Manual Therapy xxx (2015) 1e17

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Manual Therapy
journal homepage: www.elsevier.com/math

Systematic review

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
Steven Piper a, Heather M. Shearer b, c, *, Pierre Co
^ te
 d, e, f, Jessica J. Wong b, g, Hainan Yu b, c,
b, c, g b, g
Sharanya Varatharajan , Danielle Southerst , Kristi A. Randhawa b, c, g,
Deborah A. Sutton , Maja Stupar , Margareta C. Nordin h, i, Silvano A. Mior c, e,
b, c c, f

Gabrielle M. van der Velde j, k, l, Anne L. Taylor-Vaisey b

a
Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St., Toronto, Ontario, Canada M2H 3J1
b
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
c
Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St., Toronto, Ontario, Canada M2H 3J1
d
Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North,
Oshawa, Ontario, Canada L1H 7K4
e
Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, Ontario, Canada L1H 7K4
f
UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, 6100 Leslie St., Toronto, Ontario, Canada M2H 3J1
g
Division of Undergraduate Education, Canadian Memorial Chiropractic College, 6100 Leslie St., Toronto, Ontario, Canada M2H 3J1
h
Department of Orthopedic Surgery, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 63 Downing Street, New
York, NY 10014, USA
i
Department of Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 63 Downing Street,
New York, NY 10014, USA
j
Toronto Health Economics and Technology Assessment (THETA) Collaborative, Leslie Dan Pharmacy Building, University of Toronto, 6th Floor, Room 658,
144 College Street, Toronto, Ontario, Canada M5S 3M2
k
Faculty of Pharmacy, University of Toronto, Leslie Dan Pharmacy Building, University of Toronto, 144 College Street, Toronto, Ontario, Canada M5S 3M2
l
Institute for Work and Health, 481 University Ave., Toronto, Ontario, Canada M5G 2E9

a r t i c l e i n f o a b s t r a c t

Article history:
Background: Soft-tissue therapy is commonly used to manage musculoskeletal injuries.
Received 25 November 2014
Objective: To determine the effectiveness of soft-tissue therapy for the management of musculoskeletal
Received in revised form
29 April 2015 disorders and injuries of the upper and lower extremities.
Accepted 21 August 2015 Design: Systematic Review.
Methods: We searched six databases from 1990 to 2015 and critically appraised eligible articles using
Keywords: Scottish Intercollegiate Guidelines Network (SIGN) criteria. Evidence from studies with low risk of bias
Musculoskeletal injuries was synthesized using best-evidence synthesis methodology.
Soft-tissue therapy Results: We screened 9869 articles and critically appraised seven; six had low risk of bias. Localized
Massage relaxation massage provides added benefits to multimodal care immediately post-intervention for carpal
Systematic review tunnel syndrome. Movement re-education (contraction/passive stretching) provides better long-term
benefit than one corticosteroid injection for lateral epicondylitis. Myofascial release improves out-
comes compared to sham ultrasound for lateral epicondylitis. Diacutaneous fibrolysis (DF) or sham DF
leads to similar outcomes in pain intensity for subacromial impingement syndrome. Trigger point
therapy may provide limited or no additional benefit when combined with self-stretching for plantar
fasciitis; however, myofascial release to the gastrocnemius, soleus and plantar fascia is effective.
Conclusion: Our review clarifies the role of soft-tissue therapy for the management of upper and lower
extremity musculoskeletal disorders and injuries. Myofascial release therapy was effective for treating

* Corresponding author. UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, 6100 Leslie Street, Toronto, ON, Canada M2H 3J1. Tel.: þ1 416 482
2340.
E-mail address: heather.shearer@uoit.ca (H.M. Shearer).

http://dx.doi.org/10.1016/j.math.2015.08.011
1356-689X/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Piper S, et al., 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,
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
2 S. Piper et al. / Manual Therapy xxx (2015) 1e17

lateral epicondylitis and plantar fasciitis. Movement re-education was also effective for managing lateral
epicondylitis. Localized relaxation massage combined with multimodal care may provide short-term
benefit for treating carpal tunnel syndrome. More high quality research is needed to study the appro-
priateness and comparative effectiveness of this widely utilized form of treatment.
© 2015 Elsevier Ltd. All rights reserved.

1. Introduction treatment modality for soft-tissue injuries including lateral ankle

The Centers for Disease Control and Prevention (CDC) defines
musculoskeletal disorders as injuries or disorders of the muscles,
nerves, tendons, joints, cartilage and supporting structures of the
upper and lower limbs, neck, and lower back (Centers for Disease
Control and Prevention, 2015). These can be caused or exacer-
bated by exertion or prolonged exposure to physical factors.
Musculoskeletal disorders and injuries of the upper and lower ex-
tremities are common. In the Netherlands, the point prevalence for
musculoskeletal pain in adults for the most frequently reported sites
are: 1) 27% in the low back; 2) 21% in the shoulders; 3) 21% in the
neck; 4) 15% in the knee; 5) 12.5% in the wrist/hand; 6) 7.5% in the
elbow; and 7) 5% in the ankle (Picavet and Schouten, 2003). In the
United States, 36% and 16% of all injuries presenting to emergency
departments are sprains and/or strains of the lower and upper ex-
tremity respectively (Lambers et al., 2012; Ootes et al., 2012). In
these settings, more than 60% of shoulder and wrist injuries are
diagnosed as soft-tissue injuries (Ootes et al., 2012). Carpal tunnel
syndrome (CTS) is the most common neuropathy of the upper ex-
tremity, with a point prevalence among workers ranging from 2.6%
to 14% (Dale et al., 2013). The prevalence of lower extremity pe-
ripheral neuropathy in those over 40 years old has been reported at
14.8% among the general population and 13.3% among those
without diabetes in the United States (Gregg et al., 2004).
Musculoskeletal disorders and injuries, including sprains,
strains and neuropathies place a significant burden on individuals,
workplaces and health care systems. In Australia, individuals who
report shoulder symptoms including pain and/or stiffness have
lower health-related quality of life and are more than 2.5 times
more likely to have depressive symptoms than those without
shoulder complaints (Hill et al., 2010). Median days away from
work in the United States for occupational injuries to the upper and
lower extremity in 2013 were 10 and 12 days, respectively (Bureau
of Labor Statistics US Department of Labour, 2012). At 24 and 15
days respectively, shoulder and knee injuries account for the
largest number of lost work days (Bureau of Labor Statistics US
Department of Labour, 2012). Additionally, leg and ankle injuries
account for 18% of lost time claims, while shoulder injuries account
for 6% of lost time claims among workers in Ontario (Workplace
Safety and Insurance Board, 2014). Furthermore, two thirds of Ca-
nadians with sprains or strains experience limitations with activ-
ities of daily living and seek medical attention (Mo et al., 2013).
Patients with sprains or strains commonly seek complementary
and alternative medicine (CAM) therapy. In Canada, 18.3% of adults
over the age of 20 reported using chiropractic and massage therapy
as the main treatment for musculoskeletal disorders and chronic
arthritis (Foltz et al., 2005). Soft-tissue therapies are mechanical
forms of therapy where soft-tissue structures are pressed and
kneaded, using physical contact with the hand or a mechanical
device (Australian Acute Musculoskeletal Guidelines Group, 2004).
More than 80 types of soft-tissue therapy exist, and many
have been developed in the last 30 years (Sherman et al., 2006).
The American Physical Therapy Association recommends manual
therapy, including active and passive soft-tissue therapy, as a viable
sprains and plantar heel pain involving muscular strains (McPoil
et al., 2008; Martin et al., 2013). Although soft-tissue therapy is a
common form of treatment and often recommended, there is a
paucity of literature regarding its effectiveness for the management
of musculoskeletal disorders and injuries in the extremities.
Previous systematic reviews examined the effectiveness of soft-
tissue therapy for low back pain (Furlan et al., 2009), neck and
shoulder pain (Kong et al., 2013), tension-type headaches
(Fernandez-de-Las-Penas et al., 2006), and non-specific myofascial
pain syndrome (Vernon and Schneider, 2009). Overall, these re-
views concluded that soft-tissue therapy is effective for improving
pain symptoms, but when combined with other interventions, such
as exercise and education, it may also improve pain and function.
The reviews also reported that soft-tissue therapy may not be more
effective than other treatments such as manipulation.
Two systematic reviews focused specifically on the manage-
ment of sprains and strains of the extremities (Brosseau et al., 2002;
Ho et al., 2009). One systematic review examined the effectiveness
of deep transverse friction massage for treating tendinitis (Brosseau
et al., 2002). The authors concluded there is no short-term benefit
to adding this form of massage to other interventions for in-
dividuals with tendinitis of the iliotibial band or extensor carpi
radialis for reducing pain, and improving grip strength or func-
tional status (Brosseau et al., 2002). However, this conclusion was
based on two trials with methodological limitations (poor de-
scriptions of randomization, allocation concealment, blinding and
dropouts) and small sample sizes (Stratford et al., 1989; Schwellnus
et al., 1992). Another systematic review focused on manual therapy
interventions, which included soft-tissue therapy, for musculo-
skeletal shoulder disorders (Ho et al., 2009). It identified one ran-
domized trial that suggested massage was better than a two-week
waiting list control for improving pain, range of motion and func-
tion in those with non-specific shoulder pain (van den Dolder and
Roberts, 2003). Although this trial had a low risk of bias, there was
potential for residual confounding given the small sample size
(n ¼ 29). Therefore, the results of previous systematic reviews must
be interpreted with caution in light of their limitations. Further-
more, these systematic reviews are outdated (search dates prior to
2007) and need to be updated.
The purpose of our systematic review is to evaluate the effec-
tiveness of soft-tissue therapy compared to other interventions,
placebo/sham interventions or no intervention in improving self-
rated recovery, functional recovery, clinical outcomes and/or
administrative outcomes in patients with musculoskeletal disor-
ders and injuries of the upper and lower extremities.
2. Methods
2.1. Registration
We registered our protocol with the International Prospective
Register of Systematic Reviews (PROSPERO) on January 23, 2014
(CRD42014007306).

Please cite this article in press as: Piper S, et al., 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,
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
 S. Piper et al. / Manual Therapy xxx (2015) 1e17 3

2.2. Eligibility criteria 2.2.4. Outcomes

2.2.1. Population
We targeted studies of adults and children with musculoskeletal
disorders and injuries, including nerve injuries/neuropathies, of the
upper or lower extremities. We excluded studies involving pa-
thology (e.g., fractures, dislocations, infection, neoplasms, or sys-
temic disease). We defined musculoskeletal disorders and injuries,
based on the CDC definition, as grade IeII sprains or strains,
nonspecific shoulder, elbow, wrist, hip, knee, ankle and/or foot
pain, tendonitis, tendinopathy, tendinosis and other musculoskel-
etal disorders and injuries (including nerve injuries/neuropathies)
as informed by available evidence (Centers for Disease Control and
Prevention, 2015). Studies of grade IeIII ankle sprains and strains
were considered if a grade specific analysis was conducted or if a
trial included the same distribution of grade III injuries across
intervention groups.
2.2.2. Interventions
We based our definition of soft-tissue therapy on the Australian
Acute Musculoskeletal Pain Guidelines Group (Australian Acute
Musculoskeletal Guidelines Group, 2004). We define soft-tissue
therapy as a mechanical form of therapy where soft-tissue struc-
tures are passively pressed, kneaded, or stretched, using physical
contact with the hand or a mechanical device; it can be applied
locally to the site of injury (e.g. trigger point therapy), or in a more
general fashion dependent on the intent of the specific technique.
Furthermore, soft tissue therapy is used to promote relaxation,
release muscle spasms, induce movement, or free energy blockages
(Sherman et al., 2006). Types of soft-tissue therapy are classified
according to the taxonomy which categorizes soft-tissue therapy
techniques into one of four principal treatment goals (e.g. clinical
massage may be used to release muscle spasms, relieve pain and
improve motion; relaxation massage can be used to relax muscles,
move body fluids and diminish pain), although overlap between
categories is possible (Table 1) (Sherman et al., 2006). We defined
muscle energy techniques (movement re-education) as a soft-
tissue therapy as these involve passive stretching of soft-tissue
structures. We excluded any form of soft-tissue therapy directed
at acupuncture points (e.g., acupressure).
2.2.3. Comparison groups
We included studies that compared soft-tissue therapy to other
non-invasive interventions, placebo/sham, waiting list (wait and
see), or no intervention.
Eligible studies included one of the following outcomes: 1) self-
rated recovery; 2) functional recovery (e.g., return to activities,
work, school); 3) clinical outcomes (e.g., disability, pain intensity,
health-related quality of life); 4) administrative outcomes (e.g.,
time on disability benefits); or 5) adverse events.
2.3. Study characteristics
Eligible studies met the following criteria: 1) English language;
2) published between January 1, 1990 to February 21, 2015; 3)
randomized controlled trials (RCTs), cohort studies, caseecontrol
studies; and 4) an inception cohort of a minimum of 30 participants
per treatment arm for RCTs or 100 subjects per exposed group for
cohort or caseecontrol studies. We excluded the following: 1)
guidelines, narrative reviews, letters, editorials, commentaries,
unpublished manuscripts, dissertations, government reports,
books and book chapters, conference proceedings, meeting ab-
stracts, lectures and addresses, consensus development state-
ments, guideline statements; 2) cross-sectional studies, case
reports, case series, qualitative studies, reviews, biomechanical
studies, laboratory studies, studies not reporting on methodology;
or 3) cadaveric or animal studies.
2.4. Information sources
The review was completed in a two-step process. Initially, the
literature search and screening was completed for the lower ex-
tremity. A second literature search and subsequent screening was
completed for the upper extremity. Separate search strategies for
the upper extremity and the lower extremity were developed with
a health sciences librarian. A second librarian reviewed each search
strategy for completeness and accuracy using the Peer Review of
Electronic Search Strategies (PRESS) Checklist (McGowan et al.,
2010). We searched the following electronic databases: MEDLINE,
EMBASE, CINAHL, PsycINFO, SPORTDiscus, and Cochrane Central
Register of Controlled Trials.
The search strategies were first developed in MEDLINE and
subsequently adapted to the other bibliographic databases. The
search terms included subject headings (e.g. MeSH in MEDLINE)
specific to each database and free text words relevant to soft-tissue
therapy and sprains, strains, and other musculoskeletal injuries and
nerve injuries/neuropathies of the upper and lower extremities
(Appendix I and II).

Table 1
Taxonomy of soft tissue therapies (Sherman et al., 2006).

Principal goals Relaxation massage Clinical massage Movement re-education Energy work
of treatment

Intention Relax muscles, move body fluids, Accomplish specific goals Induce sense of freedom, Free energy
promote wellness such as releasing muscle spasms ease and lightness in body blockages
Additional goals Nourish cells, remove wastes Focus on muscle or fascia, relieve Use movement to enhance posture, Assist the flow
of treatmentb from cells, diminish pain, pain and restricted motion, body awareness, movement, or function of energy in the body
relax body use focused
therapeutic goals
Commonly used Swedish massage; Spa massage; Myofascial trigger point Proprioceptive neuro-muscular Acupressurea; Reiki;
styles (examplesc) Sports massage therapy; Myofascial release; facilitation; Strain counterstrain; Trager Polarity; Therapeutic
Strain counterstrain touch; Tuina
Commonly used Gliding; Kneading; Friction; Direct pressure; Skin rolling; Contract-relax; Passive stretching; Direction of energy;
techniques Holding; Percussion; Vibration Resistive stretching; Passive Resistive stretching; Rocking Smoothing; Direct pressure;
(examplesd) stretching; Cross-fiber friction; Holding; Rocking; Traction
a
Acupressure is excluded from this review.
b
Additional goals of treatment were retrieved from the body of the paper by Sherman et al. (2006).
c
While some styles of massage are commonly used in addressing one of the four principal treatment goals, some may be used to address several distinct treatment goals.
d
By varying the intent (or purpose) for a technique, many of them can be used in massages with different principal treatment goals.

Please cite this article in press as: Piper S, et al., 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,
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
4 S. Piper et al. / Manual Therapy xxx (2015) 1e17

2.5. Study selection
We used a two-phase screening process to select eligible
studies. In phase one, random pairs of independent reviewers
(from a pool of 11 reviewers) screened titles and abstracts and
classified citations as relevant, possibly relevant, or irrelevant. The
same reviewers independently reviewed the manuscripts of
possibly relevant studies in phase two screening to make a final
determination of eligibility. Reviewers met to resolve disagree-
ments. If consensus could not be reached, a third reviewer was
consulted.
2.6. Assessment of risk of bias
Random pairs of independent reviewers critically appraised
eligible studies (from a pool of five reviewers). Internal validity was
assessed using the Scottish Intercollegiate Guidelines Network
(SIGN) criteria (Harbour and Miller, 2001). This qualitatively eval-
uated the internal validity (selection bias, information bias, and
confounding) of studies (Table 2). All reviewers were trained to
make an informed judgment of the internal validity of appraised
studies using the SIGN criteria. We did not use a quantitative
scoring method or specific cutoff point to assess the internal val-
idity of studies (van der Velde et al., 2007). This methodology has
been previously described (Spitzer et al., 1995; Co ^ te
 et al., 2001;
Carroll et al., 2004; Hayden et al., 2006, 2013).
For RCTs, the following items were appraised: 1) clarity of
the research question; 2) randomization method; 3) concealment
of treatment allocation; 4) blinding of treatment and outcomes;
5) similarity of baseline characteristics between/among treat-
ment arms; 6) co-intervention contamination; 7) validity and
reliability of outcome measures; 8) follow-up rates; 9) analysis
according to intention to treat principles; and 10) comparability
of results across study sites (where applicable). Consensus be-
tween reviewers in each pair was reached through discussion,
with the involvement of a third reviewer where necessary. Au-
thors were contacted when additional information was needed
for the critical appraisal to be accurate and valid. After critical
appraisal, studies judged to have adequate internal validity were
deemed scientifically admissible and included in our synthesis
(Slavin, 1995).
2.7. Data extraction and synthesis of results
Two authors (SP, HMS) extracted data from studies with a low
risk of bias to build evidence tables. A third reviewer independently
checked the extracted data. We considered conducting a meta-
analysis if the studies were homogeneous. However, a qualitative
best evidence synthesis was performed if the studies were clinically
heterogeneous (Slavin, 1995).
We stratified our results according to the type of disorder,
duration [i.e. recent (<3 months) versus persistent (3 months)],
and types of soft-tissue therapy (Sherman et al., 2006).
Where available, minimal clinically important differences
(MCIDs) were used to assess differences in outcomes between
groups. The following MCIDs were established: 1) 1.4/10 cm on the
Visual Analogue Scale (VAS) (Tashjian et al., 2009); 2) 11/100 points
on the Patient-rated Forearm Evaluation Questionnaire (PRTEE)
(Poltawski, 2011); 3) 6.0 Kg for grip strength using the Jamar
Dynamometer (Nitschke et al., 1999); 4) 10.2/100 points on the
Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire
(Roy et al., 2009); 5) 0.47 on the Boston Carpal Tunnel Question-
naire Functional Capacity subscale (BFCS) (Amirfeyz et al., 2009), 6)
0.16 for the Boston Carpal Tunnel Questionnaire Symptom Severity
(BSSS) (Amirfeyz et al., 2009); 7) 10 points on the SF-36 Bodily Pain
sub-scale (Lauche et al., 2013) (assuming the threshold determined
for non-specific neck pain is applicable for upper or lower ex-
tremity pain); and 8) 7/100 for total foot function and 12/100 for
the pain sub-scale on the Foot Function Index (FFI) (Landorf and
Radford, 2008).

Table 2
Risk of bias for accepted randomized controlled trials on musculoskeletal disorders and injuries and neuropathies of the upper and lower extremities based on Scottish
Intercollegiate Guidelines Network (SIGN) criteria (Harbour and Miller, 2001).

Author, year Research Randomization Concealment Blinding Similarity at Similarity Outcome Percent Intention Comparable results
question baseline between measures drop-outa to treat between sites
arms

Ajimsha et al. Y CS N Y Y CS Y 3 months: N NA

(2012) MFR: 2.9%
Control: 5.9%
Ajimsha et al. Y CS CS Y Y CS Y 3 months: Y NA
(2014) MFR: 3%
Control: 0%
Barra Lopez et al. Y Y Y Y Y Y Y 3 months: Y CS
(2013) DF: 17.5%
Sham DF: 15%
Control: 10%
Kucuksen et al. Y Y CS Y Y CS Y 6 weeks: N CS
(2013) MET: 2.4%
CSI: 2.4%
26 weeks:
MET: 2.4%
CSI: 4.9%
52 weeks:
MET: 4.9%
CSI: 2.4%
Madenci et al. Y CS CS CS Y CS Y Post-intervention: N CS
(2012) M þ S: 5%
Splint: 5%
Renan-Ordine Y Y Y Y Y Y Y No dropouts NA NA
et al. (2011)
a
Incorporates both loss to follow-up and dropout; CS: Can't Say; CSI: Corticosteroid Injection; DF: Diacutaneous Fibrolysis; MET: Muscle Energy Technique; MFR: Myo-
fascial Release; M þ S: Massage þ Splint; N: No; NA: not applicable; Sham DF: Placebo intervention of Diacutaneous fibrolysis; Y: yes.

Please cite this article in press as: Piper S, et al., 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,
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
 S. Piper et al. / Manual Therapy xxx (2015) 1e17 5

2.8. Statistical analyses

We computed the inter-rater reliability for the screening of ar-

ticles using the kappa coefficient (k) and 95% confidence intervals
(CI) (Viera and Garrett, 2005). The percentage agreement for critical
appraisal of articles was calculated for classifying studies with high
and low risk of bias. We computed the difference in mean change
between groups and 95% CI to quantify the effectiveness of in-
terventions. The computation of the 95% CI for the difference in
mean change was based on the assumption that the pre- and post-
intervention outcomes were highly correlated (r ¼ 0.8) (Follmann
et al., 1992; Abrams et al., 2005).

2.9. Reporting

The systematic review was organized and reported based on the

Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) statement (Moher et al., 2009).

3. Results

3.1. Study selection

We screened 9869 articles and critically appraised seven

(Figs. 1 and 2). Of those, six had a low risk of bias and were
included for evidence synthesis (Renan-Ordine et al., 2011;
Ajimsha et al., 2012; Madenci et al., 2012; Barra Lopez et al.,
2013; Kucuksen et al., 2013; Ajimsha et al., 2014). The inter-rater

Fig. 2. Identification and selection of articles for the upper extremity.

agreement for the screening of articles was k ¼ 0.88 (95% CI:

0.70; 1.00) for the upper extremity and k ¼ 1.0 for the lower ex-
tremity, but this is best described as a kappa paradox caused by a
low prevalence of relevant studies (Feinstein and Cicchetti, 1990).
The percentage agreement for classifying studies into high and
low risk of bias studies was 100%.

3.2. Study characteristics

The six low risk of bias RCTs investigated the management of

Fig. 1. Identification and selection of articles for the lower extremity.
lateral epicondylitis (Ajimsha et al., 2012; Kucuksen et al., 2013),
shoulder impingement syndrome (Barra Lopez et al., 2013), carpal
tunnel syndrome (Madenci et al., 2012) and plantar fasciitis
(Renan-Ordine et al., 2011; Ajimsha et al., 2014). We did not find
any relevant studies for the management of other extremity
musculoskeletal disorders or injuries (including nerve injuries/
neuropathies). Nor did we find any studies investigating manage-
ment in children.
One study with a low risk of bias investigated the effectiveness
of a device-assisted technique (Barra Lopez et al., 2013) while the
others used manual soft-tissue therapy (Renan-Ordine et al., 2011;
Ajimsha et al., 2012; Madenci et al., 2012; Kucuksen et al., 2013;
Ajimsha et al., 2014). Localized relaxation massage and move-
ment re-education were used in one trial each (Madenci et al.,
2012; Kucuksen et al., 2013) while clinical massage was used in
the remaining four RCTs (Renan-Ordine et al., 2011; Ajimsha et al.,

Please cite this article in press as: Piper S, et al., 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,
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
6 S. Piper et al. / Manual Therapy xxx (2015) 1e17
2012; Barra Lopez et al., 2013; Ajimsha et al., 2014) (Table 1). The
studies were clinically heterogeneous and could not be pooled in a
meta-analysis.
3.3. Risk of bias
Of the six RCTs with a low risk of bias, the following criteria
were met: adequate description of randomization procedures (3/6)
(Renan-Ordine et al., 2011; Barra Lopez et al., 2013; Kucuksen et al.,
2013); adequate description of proper allocation concealment (2/
6) (Renan-Ordine et al., 2011; Barra Lopez et al., 2013); blinding
where possible (5/6); similar baseline characteristics across
intervention groups (6/6); reporting possible co-interventions (2/
6); valid and reliable outcome measures (6/6); and intention-to-
treat analysis (3/6) (Table 2). Participant follow-up rates were
80% or higher in all studies. The study with a high risk of bias had
limitations related to randomization method, allocation conceal-
ment and co-interventions (Quintana Aparicio et al., 2009). During
critical appraisal, we contacted authors of six RCTs (2/6 responded)
(Ajimsha et al., 2012; Madenci et al., 2012).
3.4. Summary of evidence
1. Musculoskeletal disorders and injuries of the upper extremity
1.1 Carpal tunnel syndrome
Evidence from one RCT suggests that adding self-massage to a
multimodal care program provides additional benefit immediately
post-intervention for persistent carpal tunnel syndrome (Madenci
et al., 2012). Madenci et al. randomized patients with carpal tun-
nel syndrome (mean duration 4 months) to: 1) six weeks of su-
pervised self-applied massage to the hand and forearm (localized
relaxation massage consisting of effleurage, petrissage, friction, and
shaking) combined with a multimodal care program (wearing a
wrist-hand splint at night for six months, tendon and nerve gliding
exercises, and analgesics when needed), or 2) multimodal care
program (as in group 1) (Madenci et al., 2012). There were clinically
significant improvements favoring massage in function [mean
change difference on BFCS (0.60, 95% CI: 0.39, 0.81)] and symptom
severity [mean change difference on BSSS (0.90, 95% CI: 0.57, 1.23)]
immediately post-intervention. There were statistically and clini-
cally significant improvements for patient- and physician-rated
global assessment of pain, and statistically significant improve-
ments for grip strength and one electroneurophysiological test fa-
voring massage (Table 3).
1.2 Lateral epicondylitis
Evidence from one RCT suggests that muscle energy technique
may provide more benefit than one corticosteroid injection in the
long-term for persistent lateral epicondylitis (Kucuksen et al.,
2013). Participants were randomized to four weeks of muscle en-
ergy technique or one injection of 1 mL of triamcinolone acetonide
(40 mg/mL) plus 1 mL of 1% lidocaine into the subcutaneous tissue
and muscle distal to the lateral epicondyle (Kucuksen et al.,
2013). The muscle energy technique (classified as movement re-
education) consisted of five repetitions twice per week for four
weeks of resisted forearm pronation from an initial maximally
supinated position to passively stretch the pronator muscles. At the
six-week follow-up, statistically significant improvements favored
corticosteroid injection therapy in pain-free grip strength [mean
change difference (7.99, 95% CI: 2.49, 13.49)] and pain with gripping
(Table 3). However, in the long term, muscle energy technique was
more effective than the corticosteroid injection with statistically
significant improvements in pain-free grip strength [mean change
Please cite this article in press as: Piper S, et al., 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,
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
difference (10.99, 95% CI: 5.53, 16.45) at 26 weeks and (16.38, 95%
CI: 9.56, 23.20), at 52 weeks], arm function and disability. Also,
there were also statistically and clinically important improvements
favoring muscle energy technique in pain with hand gripping
(Table 3).
Evidence from one RCT suggests that clinical massage using
myofascial release is effective for persistent lateral epicondylitis
(Ajimsha et al., 2012). Ajimsha et al. randomized participants to a
maximum of 12 sessions over four weeks of: 1) myofascial release
therapy to the forearm; or 2) sham ultrasound. There were statis-
tically significant and clinically important differences favoring
myofascial release compared to sham ultrasound for pain and
disability on PRTEE at four [mean change difference (47.00, 95% CI:
26.64, 67.36)] and twelve weeks [mean change difference (42.70,
95% CI: 22.03, 63.37)].
1.3 Subacromial impingement syndrome
Evidence from one RCT suggests diacutaneous fibrolysis (DF), a
myofascial release technique using a metal hook, is no more
effective than sham diacutaneous fibrolysis or multimodal care in
pain intensity for persistent subacromial impingement (Barra
Lopez et al., 2013). Barra Lopez et al. randomized participants to:
1) DF (provided six times over three weeks); 2) sham DF (a su-
perficially applied metal hook); 3) multimodal care (clinic-based
electrotherapy, therapeutic exercises and cryotherapy for three
weeks followed by three weeks of home exercises and icing) (Barra
Lopez et al., 2013). The DF and sham DF groups also received the
multimodal care. There were no statistical differences in pain in-
tensity between groups (DF vs sham DF, DF vs multimodal care,
sham DF vs multimodal care) at any follow-up (Table 3). A statis-
tically significant difference favoring DF over sham DF in function
was observed post-intervention. Statistically significant differences
favored DF, as well as sham DF over multimodal care for function,
shoulder extension and external rotation (Table 3). In addition, a
statistically significant difference between sham DF and multi-
modal care was observed for shoulder flexion. However, the MCIDs
for these outcomes have not yet been established. Patient-reported
perception of clinical improvement was 82.5% for DF, 76% for the
sham DF and 67% for multimodal care.
2. Musculoskeletal disorders and injuries of the lower extremity
2.1 Plantar fasciitis
Evidence from one RCT suggests that trigger point therapy may
provide limited or no added benefit to a self-stretching protocol in
the short-term (immediately post-intervention) for unilateral
plantar heel pain (Table 3) (Renan-Ordine et al., 2011). Renan-
Ordine et al. randomized participants to16 sessions over one
month of: 1) supervised self-stretching and trigger point soft-tissue
therapy to the gastrocnemius muscle (classified as clinical mas-
sage); or 2) supervised self-stretching alone (Renan-Ordine et al.,
2011). The authors reported statistically significant differences
post-intervention for the primary outcomes of physical functioning
(SF-36 sub-scale) [mean change difference 9.30 (95% CI: 3.70,
15.00)] and bodily pain (SF-36 sub-scale) [mean change difference
7.80 (95% CI: 2.0, 13.60)] favoring trigger point soft-tissue therapy.
However, the difference in bodily pain did not meet the MCID and
the MCID of physical functioning is unknown. The mean change
differences for the secondary outcomes of pressure pain thresholds
and the remaining SF-36 sub-scales, except for vitality, social
function and mental health, were statistically significant favoring
trigger point soft-tissue therapy (Table 3). However, the effect sizes
were small and the clinical importance of these outcomes is not
clear due to unknown MCIDs.
 Table 3
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
injuries of the upper and lower extremities: A systematic review by the Ontario Protocol for Traffic Injury management (OPTIMa) collaboration,
Please cite this article in press as: Piper S, et al., The effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and
Evidence table for accepted randomized controlled trials on soft tissue therapy for musculoskeletal disorders and injuries of the upper and lower extremities.
Author(s), year Setting and subjects, number
(n) enrolled
Ajimsha et al. Computer professionals (20
(2012),c e40 y.o.) using a computer or
equivalent device 50% of
work day with persistent (3
months) LE in the mouse-
operating arm, presenting to
a myofascial treatment
center in India.
Case definition: diagnosis of
lateral epicondylitis based on
Southhampton examination
criteria.
(n ¼ 68)
Ajimsha et al. Adults (20e50 y.o.)
(2014),d presenting with a primary
complaint of persistent
unilateral plantar heel pain
(mean duration ¼ 4 months)
referred to the Myofascial
Therapy and Research
foundation, Kerala, India.
Case definition: 1) insidious
onset sharp pain under
plantar heel surface upon
weight bearing after a period
of rest; 2) increasing plantar
heel pain with first steps
in morning; and 3)
decreasing symptoms
with slight activity.
(n ¼ 66)
Interventions, number (n) of
subjects
Myofascial Release (MFR):
Therapist completes 3
procedures over 30 min
(3/week for 4 weeks):
1) Therapist treats common
extensor tendon to wrist
extensor retinaculum using
fingertip contact to engage
periosteum along this region,
while patient slowly flexes/
extends the wrist (2 reps.
for 5 min each).
2) Therapist's knuckles
remain static over ulnar
periosteum while patient
alternates
ulnar and radial deviation of
the wrist (2 reps. for
5 min each).
3) Therapist contacts the head
of the ulna with finger pads of
one hand and the dorsal
tubercle of radius with the
pads of the other. A line of
tension in a lateral and distal
direction is applied with
intent to spread bones apart
(2 repetitions for 5 min
each). (n ¼ 34)
Myofascial Release (MFR):
Physiotherapist certified in
MFR completes treatment
over 30 min (3/week with a
minimum one day gap for 4
weeks), patient prone for all
treatment:
1) Gastrocnemius: a) patient's
feet hanging off end of table
as therapist's flexed elbow
(90 ) tensions Achilles
tendon in superior direction
as ankle is dorsiflexed (5 min,
1 rep.); b) therapist's index
and middle fingers bilaterally
contact gastrocnemii tendons
at the femoral insertions and
tensioned inferiorly into
fibrous muscle as ankle is
dorsiflexed (5 min, 1 rep.); c)
therapist's fingers bilaterally
contact medial & lateral
calcaneus with inferior
tension as patient moves
ankle from plantar to
Comparisons, number (n) of
subjects
Control: Sham ultrasound
therapy (quartz crystal
removed) over extensor
aspect of the forearm in same
locations as intervention
group (10 min per location)
(3/week for 4 weeks).
(n ¼ 34)
Control: Sham ultrasound
therapy (quartz crystal
removed) over gastrocnemii,
soleus and plantar fascia in
same areas as intervention
group (30 min per session)
(3/week with a minimum of
one day gap for 4 weeks).
(n ¼ 32)
Follow-up Outcomes
Post-intervention Primary outcome:
(4 weeks), 12 weeks. Pain and disability
(PRTEE, 0e100)
Adverse events.
Post-intervention Pain, disability & activity
(4 weeks), 12 weeks. restriction (FFI, 0e100); PPT
(pressure algometer,
pressure ¼ approximately 0.1
kg/cm2/s. [Baseline FPK 20]).
Adverse events.
Key findingsa
Difference in mean change
(MFR-Control) for PRTEEb:
4 weeks: 47.0 (95% CI:
26.64, 67.36)
12 weeks: 42.70 (95% CI:
22.03, 63.37).
No serious adverse events
reported.
MFR: 14.7% (5/34) increased
pain post-treatment initiation
subsiding within one week.
S. Piper et al. / Manual Therapy xxx (2015) 1e17
Difference in mean change
(MFR-Control) post
intervention:
FFI: 41.09 (95% CI:
39.38, 42.80)
PPT Gastrocnemius: 0.90 (95%
CI: 0.67, 1.13)
PPT Soleus: 1.10 (95% CI:
0.86, 1.34)
PPT Calcaneus: 1.10 (95% CI:
0.81, 1.39)
Difference in mean change
(MFR-Control) 12 weeks:
FFI: 36.97 (95% CI:
35.00, 38.94)
PPT Gastrocnemius: 0.70 (95%
CI: 0.57, 0.83)
PPT Soleus: 0.80 (95% CI:
0.60, 1.00)
PPT Calcaneus: 0.90 (95% CI
0.65, 1.15)
No serious adverse events
reported in either groups
based on patient diary.
(continued on next page)
7
 Table 3 (continued )
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
injuries of the upper and lower extremities: A systematic review by the Ontario Protocol for Traffic Injury management (OPTIMa) collaboration,
Please cite this article in press as: Piper S, et al., The effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and
Author(s), year Setting and subjects, number
(n) enrolled
Barra Lopez Adults (18 y.o.) presenting
et al. (2013),e with subacromial
impingement of varied
duration to 2 public health
centers in Spain.
Case definition: Subacromial
impingement syndrome
diagnosed with 1) Positive
Neer impingement sign and
2) HawkinseKennedy signs.
(n ¼ 120)
Interventions, number (n) of
subjects
dorsiflexed position 3 times
(5 min, 1 rep.);
2) Soleus: knee in resting
10e15 flexed position, ankle
is dorsiflexed as therapist's
elbow tensions Achilles
tendon in superior direction
as ankle is dorsiflexed
(5 min, 1 rep.);
3) Plantar myofasciae:
therapist's knuckles placed
anterior to calcaneus with
tension applied, working into
deep layers as toes are
flexed/extended.
(n ¼ 34)
Diacutaneous Fibrolysis (DF)
treatment (6 sessions/3
weeks) provided by a
physiotherapist; application
of metal hook-based
instrument as deeply as
possible to the intermuscular
septum between the muscles
of the cervicoscapular and
shoulder in a centripetal
direction towards the site of
pain; provided in addition to
control group protocol.
(n ¼ 40)
Comparisons, number (n) of
subjects
Sham DF (6 sessions/3 weeks)
provided by physiotherapist;
same as treatment except
metal hook-based instrument
was applied superficially;
provided in addition to
control group protocol.
(n ¼ 40)
Control: Therapeutic
exercises, analgesic
electrotherapy and
cryotherapy (5 sessions/week
for 3 weeks) provided by
physiotherapist. Patients
instructed to continue home
exercises and cryotherapy
after 3 weeks of treatment.
(n ¼ 40)
Follow-up Outcomes
Post-intervention Primary outcome: Pain
(3 weeks), 3 months. intensity (VAS, 0e100 mm).
Secondary outcomes:
Functional status (Constant-
Murley score, 0e75); active
shoulder ROM (universal
double-armed goniometer,
degrees); patient perception
of results (5 pt. Likert scale of
much better to much worse).
8
Key findingsa
Difference in mean change for
DF-Sham (post-intervention):
Pain (VAS): 3.60 (95% CI:
S. Piper et al. / Manual Therapy xxx (2015) 1e17
7.34, 14.54)
Function (CMS): 3.70 (95% CI:
0.37, 7.03)
(3 month follow-up):
Pain (VAS): 1.5 (95% CI:
11.11, 14.11)
Difference in mean change
DF-Control (post-
intervention):
Pain (VAS): 7.40 (95% CI:
2.44, 17.24)
Function (CMS): 5.70 (95% CI:
2.07, 9.33)
Flexion: 9.80 (95% CI:
1.58, 18.02)
Extension: 7.00 (95% CI:
3.35, 10.64)
External rotation: 6.50 (95%
CI: 2.34, 10.66)
Difference in mean change
DF-Control (3 month
follow-up):
Pain (VAS): 0.20 (95%
CI: 10.54, 10.14)
Extension: 5.10 (95% CI
1.25, 8.95)
External rotation: 6.10 (95%
CI: 0.89, 11.31)
Difference in mean change
Sham-Control (post-
intervention):
Pain (VAS): 3.80 (95% CI:
8.14, 15.14)
Extension: 4.60 (95% CI:
1.12, 8.08)
External rotation: 5.30 (95%
CI: 0.49, 10. 11)

Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
injuries of the upper and lower extremities: A systematic review by the Ontario Protocol for Traffic Injury management (OPTIMa) collaboration,
Please cite this article in press as: Piper S, et al., The effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and
Kucuksen et al. Adults (18e70 y.o.) referred
(2013),f to the physical medicine and
rehabilitation outpatient
clinic of Necmettin Erbakan
University Hospital, Turkey
between April 2011eOctober
2011.
Case definitions:
Persistent unilateral LE 1)
tenderness on/near
Muscle energy technique
(MET) (2 sessions/week for 4
weeks): Physician stabilizes
patient's distal humerus
while supinating the patient's
forearm until resistance/
discomfort felt. Patient then
pronates forearm against
resistance for 5 sec, followed
by slight increase in
Corticosteroid injection (CSI):
1 mL of triamcinolone
acetonide (40 mg/mL) plus
1 mL of 1% lidocaine (10 mg/
ml) injected deep into
subcutaneous tissue and
muscle, 1 cm distal to the
lateral epicondyle, aiming
toward area of maximum
6 weeks, 26 weeks Primary outcome: Pain-free
and 52 weeks. grip strength (PFGS,
dynamometer)
Secondary Outcomes:
Pain with hand gripping (VAS
10 cm); arm function and
disability (DASH)
Adverse events
Difference in mean change
Sham-Control (3 months):
Pain (VAS): 4.40 (95% CI:
8.69, 17.49)
Function (CMS): 4.50 (95% CI:
0.56, 8.44)
Extension: 3.80 (95% CI:
0.13, 7.47)
No statistical difference in
mean change between any
group at any follow-up for
pain intensity, shoulder
abduction, or the hand-
behind-back test.
No difference in mean change
between DF and Sham post
intervention for flexion,
extension, external rotation
and at 3 months for
functional status, flexion,
extension, external rotation.
No difference in mean change
S. Piper et al. / Manual Therapy xxx (2015) 1e17
between DF and Control at 3
months for functional status
and flexion.
No difference in mean change
between Sham and Control
post-intervention for
functional status and flexion,
and at 3 months for
functional status, flexion,
external rotation
Subjective improvement:
DF:
82.5% improved
8% no change
3% felt worse
Sham:
76% improved
22% no change
3% felt worse
Control:
67% improved
28% no change
6% felt worse
Differences in mean change at
6 weeks (MET-CSI):
Grip strength (PFGS): 7.99
(95% CI: 13.49, 2.49)
Pain with gripping
(VAS): 1.18 (95%
CI: 1.91, 0.45)
Differences in mean change at
26 weeks (MET-CSI):
Grip strength (PFGS): 10.99
(continued on next page)
9
 Table 3 (continued )
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
injuries of the upper and lower extremities: A systematic review by the Ontario Protocol for Traffic Injury management (OPTIMa) collaboration,
Please cite this article in press as: Piper S, et al., The effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and
Author(s), year Setting and subjects, number
(n) enrolled
lateral epicondyle,
2) pain with 2/3 pain
provocation tests; 3)
unilateral elbow pain >3
months, pain severity
50 mm/100 mm VAS.
(n ¼ 82)
Madenci et al. Adults (31e65 y.o.) with
(2012),g carpal tunnel syndrome
presenting to the Physical
Therapy and Rehabilitation
Department of the Medical
School of Gaziantep
University, Turkey, between
2009 and 2010.
Case definition: Carpal tunnel
syndrome diagnosed by:
1) pain, paresthesia, and/or
vasomotor symptoms
>6 weeks in
median nerve
distribution of the
hand; 2)
positive test for at least one
of: Tinel, Phalen, Buda, and
Carpal compression tests; 3)
median motor distal latency
and median sensory nerve
conduction velocity deficits.
(n ¼ 84)
Interventions, number (n) of
subjects
supination to resistance
position. Procedure
performed 5 times with 5 sec
of relaxation intermittently.
(n ¼ 41)
Splint and massage: Same
protocol as splint only group
with the additions of daily
self-applied “Madenci” hand
massage technique taught by
physiotherapist or
rehabilitation physician
(30 sec effleurage massage,
60 sec friction massage,
30 sec petrissage massage,
30 sec shaking, 30 sec
effleurage) for 6 weeks;
tendon and nerve gliding
exercises daily; analgesic
drugs (paracetamol, 1 g/day)
as needed.
(n ¼ 42)
Comparisons, number (n) of
subjects
tenderness.
(n ¼ 41)
Splint only: Wrist-hand splint
worn nightly for 6 months,
tendon and nerve gliding
exercises daily; analgesic
drugs (paracetamol, 1 g/day)
as needed.
(n ¼ 42)
Follow-up Outcomes
Immediately Symptom severity and
post-intervention functional capacity (Boston
(6 weeks). Carpal Tunnel Questionnaire,
BSSS and BFCS subscales);
Pain intensity (Patient global
evaluation (PGA), physician
global evaluation (MDPGA));
Hand grip strength (Jamar
dynamometer);
Electroneuro-physiological
testing: median motor distal
latency, median sensory
nerve conduction velocity
and, median nerve motor
conduction velocity
10
Key findingsa
(95% CI: 5.53, 16.45)
Pain with gripping (VAS):
1.51 (95% CI: 0.76, 2.56)
Disability (DASH): 5.16, (95%
CI: 0.56, 9.76)
Differences in mean change at
52 weeks (MET-CSI):
Grip strength (PFGS): 16.38
(95% CI: 9.56, 23.20)
Pain with gripping (VAS):
1.89 (95% CI: 1.02, 2.76)
Disability (DASH): 5.57 (95%
CI: 0.32, 10.82)
No statistically significant
difference between groups
for disability at 6 weeks.
Adverse events:
MET: no significant adverse
events reported.
S. Piper et al. / Manual Therapy xxx (2015) 1e17
7.3% (3/41) participants
experienced adverse events
in the CSI group:
2.4% (1/41) pain lasting 5 days
post injection;
4.9% (2/41) with loss of
skin pigment;
2.4% (1/41) with
subcutaneous atrophy.
Difference in mean change
(Splint with Massage e
Splint):
Symptom severity (BSSS): 0.9
(95% CI: 0.57, 1.23)
Functional capacity (BFCS):
0.60 (95% CI: 0.39, 0.81)
Grip strength (Kg)
Right: 2.4 (95% CI: 0.70, 4.10)
Left: 2.1 (95% CI: 1.23, 2.98)
Pain intensity perception:
PGA: 2.1 (95% CI: 1.78, 2.42)
MDPGA: 2.3 (95% CI:
2.07, 2.53)
Median nerve motor latency:
Right: 0.50 (95%
CI: 0.70, 0.30)
Difference in mean between
groups for median nerve
sensory conduction
(bilaterally), median nerve
motor conduction
(bilaterally), and median
nerve motor latency (left)
were not statistically
significant.
 Renan-Ordine Adults (18e60 y.o.) with Trigger point soft tissue Self-stretching (St) prescribed Post-intervention Primary outcome: Difference in mean change
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
injuries of the upper and lower extremities: A systematic review by the Ontario Protocol for Traffic Injury management (OPTIMa) collaboration,
Please cite this article in press as: Piper S, et al., The effectiveness of soft-tissue therapy for the management of musculoskeletal disorders and

et al. (2011),h unilateral plantar heel pain
presenting to physical
therapy clinic in Brazil.
Case definition: 1) insidious
onset of sharp pain under the
plantar heel surface upon
weight bearing after a period
of non-weight bearing;
2) plantar heel pain that
increases in the morning with
the first steps after waking
up;
3) symptoms decreasing with
slight levels of activity, such
as walking. (n ¼ 60)
therapy þ self-stretching
(Trp) provided by
physiotherapist (16 sessions/
4 weeks): Manual pressure to
gastrocnemius muscle for
90 sec (3 repetitions);
therapist's thumb was used to
provide slow, moderated
pressure, longitudinal strokes
in a caudal-cranial direction
over taut bands. Provided in
addition to a supervised self-
stretching program
(comparison group). (n ¼ 30)
and supervised by
physiotherapist (16 sessions/
4 weeks): 9 min protocol of
standing calf muscles stretch
and plantar fascia specific
stretches; performed
intermittently (20 sec stretch
then 20 sec rest, total of
3 min/stretch, twice daily).
(n ¼ 30)
(4 weeks) Physical function and bodily
pain subscales (SF-36, 0e100)
Secondary outcomes:
Physical role, general health,
vitality, social function,
emotional role, mental
health(SF-36 sub-scales, 0
e100);
Pressure pain threshold (kg/
cm2).
Adverse events.
post-intervention (Trp-St)b:
Physical functioning
(SF-36 0e100):
9.3 (95% CI: 3.7, 15.0)
Bodily pain (SF-36 0e100):
7.8 (95% CI: 2.0, 13.6)
Physical role (SF-36 0e100):
11.9 (95% CI: 1.4, 22.4)
General health (SF-36 0
e100):
5.4 (95% CI: 0. 1, 10.7)
Emotional role (SF-36 0
e100):
19.9 (95% CI: 8.1, 31.8)
Gastrocnemius PPT(kg/cm2):
0.9 (95% CI: 0.7, 1.1)
Soleus PPT (kg/cm2):
0.8 (95% CI: 0.6, 1.0)
Calcaneous PPT (kg/cm2):
1.2 (95% CI: 0.8, 1.6)
No statistically significant

S. Piper et al. / Manual Therapy xxx (2015) 1e17

difference in mean change
between groups post-
intervention for vitality,
social function and mental
health SF-36 sub-scales.
Adverse events:
Transient, mild soreness after
initial two treatments for the
trigger point therapy group
[13% (4/30)] and stretching
only group [7% (2/30)].

Acronyms: BFCS: Boston functional capacity scale; BSSS: Boston symptom severity scale; CSI: corticosteroid injection; CMS: Constant-Murley Score; DASH: Disabilities of the Arm, Shoulder and Hand; FFI: foot function index; LE:
lateral epicondylitis; MET: muscle energy technique; MFR: myofascial release; PFGS: pain-free grip strength; PRTEE: Patient-related tennis elbow evaluation questionnaire; Reps: repetitions; ROM: range of motion; Sec:
seconds; VAS: visual analogue scale; y.o.: years old.
a
Clinical or statistical significant differences only reported.
b
Adjusted for multiple comparisons of group and time: least significant difference (equivalent to no adjustments).
c
Ajimsha MS, Chithra S and Thulasyammal RP. Effectiveness of myofascial release in the management of lateral epicondylitis in computer professionals. Arch Phys Med Rehabil. 2012; 93: 604e9.
d
Ajimsha MS, Binsu D and Chithra S. Effectiveness of myofascial release in the management of plantar heel pain: a randomized controlled trial. Foot. 2014; 24: 66e71.
e
Barra Lopez ME, Lopez de Celis C, Fernandez Jentsch G, Raya de Cardenas L, Lucha Lopez MO and Tricas Moreno JM. Effectiveness of Diacutaneous Fibrolysis for the treatment of subacromial impingement syndrome: A
randomised controlled trial. Man Ther. 2013; 18: 418e24.
f
Kucuksen SY, H.; Salli, A.; Ugurlu, H. Muscle energy technique versus corticosteroid injection for management of chronic lateral epicondylitis: randomized controlled trial with 1-year follow-up. Arch Phys Med Rehabil. 2013;
94: 2068e74.
g
Madenci EA, O.; Koca, I.; Yilmaz, M.; Gur, A. Reliability and efficacy of the new massage technique on the treatment in the patients with carpal tunnel syndrome. Rheumatol Int. 2012; 32: 3171e9.
h
Renan-Ordine R, Alburquerque-Sendín F, Rodrigues De Souza DP, Cleland JA and Fern ~ as C. Effectiveness of Myofascial Trigger Point Manual Therapy Combined With a Self-Stretching Protocol for the
andez-De-Las-Pen
Management of Plantar Heel Pain: A Randomized Controlled Trial. J Orthop Sports Phys Ther. 2011; 41: 43e50.

11
12 S. Piper et al. / Manual Therapy xxx (2015) 1e17
Evidence from one RCT suggests that myofascial release is effec-
tive for the management of persistent plantar heel pain (Table 3)
(Ajimsha et al., 2014). Ajimsha et al. randomized adults with uni-
lateral planter heel pain (mean duration >4 months) to 12 (30 min)
sessions over four weeks of: 1) myofascial release for gastrocnemius,
soleus and plantar fascia by physiotherapists; or 2) sham ultrasound
therapy over the gastrocnemii, soleus and plantar fascia (no sound
wave produced) (Ajimsha et al., 2014). There were statistically sig-
nificant and clinically important differences for foot function (Foot
Function Index) favoring myofascial release at the four and 12 week
follow-ups [mean change difference on the Foot Function Index:
41.09/100 (95% CI: 39.38, 42.80) and 36.97/100 (95% CI: 35.00, 38.94),
respectively]. There were statistically significant differences favoring
myofascial release compared to sham ultrasound in pressure pain
threshold at both follow-up periods; however, the minimal clinically
important difference is unknown (Table 3).
3.5. Adverse events
Four of the six studies reported on adverse events (Renan-
Ordine et al., 2011; Ajimsha et al., 2012; Kucuksen et al., 2013;
Ajimsha et al., 2014). No serious adverse events were reported.
Transient adverse events (increased pain post-treatment) were
reported by 14.7% of participants randomized to myofascial release
therapy for the management of lateral epicondylitis (Ajimsha et al.,
2012). In one trial, 7.3% of those randomized to a corticosteroid
injection reported temporary pain, loss of skin pigment or subcu-
taneous atrophy (Kucuksen et al., 2013). Seven percent of the self-
stretching-only group and 13% of the trigger point therapy group
reported temporary soreness following the initial two treatments
(Renan-Ordine et al., 2011).
4. Discussion
4.1. Summary of evidence
Limited evidence with low risk of bias exists on the effectiveness
of soft-tissue therapy for the management of musculoskeletal
disorders and injuries in the upper and lower extremities.
Our systematic review identified six studies that investigated
clinical massage, localized relaxation massage, and movement re-
education for the management of persistent lateral epicondylitis,
subacromial impingement, carpal tunnel syndrome and plantar
heel pain. The evidence suggests that clinical massage (myofascial
release) and movement re-education (muscle energy technique)
may benefit patients with persistent lateral epicondylitis. Clinical
massage (diacutaneous fibrolysis) was not effective for managing
subacromial impingement. Finally, relaxation massage (self-mas-
sage to the hand/forearm with the intent to relax muscles, move
body fluids, and reduce pain) combined with multimodal care may
provide short-term benefits to patients with persistent carpal
tunnel syndrome. For plantar heel pain related to a gastrocnemius
strain, the evidence suggests that clinical massage (manual trigger
point therapy) may provide minimal added benefit when combined
with a self-stretching protocol. However, clinical massage (myo-
fascial release) to the gastrocnemius, soleus and plantar fascia was
effective in improving foot function in patients with plantar heel
pain. No studies were found examining the effectiveness of soft-
tissue therapy for other musculoskeletal disorders or injuries of
the lower extremity.
4.2. Comparison of results to other systematic reviews
Two systematic reviews previously examined the effectiveness
of soft-tissue therapy for the management of injuries in the
Please cite this article in press as: Piper S, et al., 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,
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
extremities (Brosseau et al., 2002; Ho et al., 2009). These reviews
included studies that did not meet our eligibility criteria (sample
size too small or inability to isolate the effect of the intervention).
For instance, Brosseau et al. reported no benefit to adding a form of
clinical massage (deep transverse friction massage) to ultrasound
or phonophoresis for the management of lateral epicondylitis
(Brosseau et al., 2002). Our results differ from these showing there
may be benefit in using clinical massage (myofascial release) for
this condition. Thus, comparing the results of these previous sys-
tematic reviews to this review is tenuous because: 1) the type of
clinical massage differs; 2) the true effect of the massage could not
be isolated from the other interventions provided in past reviews;
and 3) in past reviews the intervention groups were not compared
to a sham or placebo; thus absolute effectiveness cannot be re-
ported. Instead, we can only conclude there was no difference in
outcomes between the provided interventions.
4.3. Future research directions
Soft-tissue therapy is commonly used by manual therapists
(Australian Acute Musculoskeletal Guidelines Group, 2004). Cana-
dians often seek out CAM providers that use soft-tissue therapy as
part of a treatment plan for musculoskeletal disorders (Foltz et al.,
2005). Despite being widely used, only six RCTs examining the
effectiveness of soft-tissue therapy for upper and lower extremity
musculoskeletal disorders and injuries had a low risk of bias and
were deemed admissible for our systematic review. The assessment
of internal validity clearly highlighted shortcomings in this body of
literature. The most common flaws include failures to report or use
appropriate randomization techniques, allocation concealment,
blinding when possible, and intention-to-treat analyses. Addition-
ally, many published studies have small sample sizes and are thus
liable to type II error and residual confounding (Carroll et al., 2008).
Future studies should also provide details on the frequency,
duration of treatment, and intensity of pressure applied. This may
help elucidate the effectiveness of soft-tissue therapy. In addition,
longer follow-up periods to evaluate the long-term effectiveness of
soft-tissue therapy should be considered. Specifically, two of the
five admissible studies only examined outcomes immediately post-
intervention.
There are challenges to synthesizing the evidence on the
effectiveness of soft-tissue therapy for extremity injuries. There are
many types of soft-tissue therapies that have different treatment
intentions and techniques (Sherman et al., 2006). The combination
of all soft-tissue techniques into one category when synthesizing
evidence would likely combine heterogeneous interventions. It is
more appropriate to categorize the types of soft-tissue therapies
based on an established taxonomy (Sherman et al., 2006) and
stratify the evidence accordingly. Furthermore, soft-tissue therapy
is often studied as a component of a multimodal program of care
(Ho et al., 2009; Almeida et al., 2013). As such, its treatment
effectiveness cannot be isolated. We have attempted to address
these challenges in our review.
4.4. Strength and limitations
The strengths of this review include: 1) a rigorous literature
search in six databases; 2) detailed inclusion and exclusion criteria;
3) use of a clearly defined taxonomy of terms categorizing soft-
tissue techniques; and 4) a standardized methodology for critical
appraisal of relevant studies.
This review also has limitations. The literature search was
limited to journal articles in English. We may have missed some
potentially relevant non-English studies, although previous
research indicates the risk of bias is low given the majority of
 S. Piper et al. / Manual Therapy xxx (2015) 1e17 13

studies are published in English (Moher et al., 1996; Sutton et al., 13. Vibration/tu [Therapeutic Use]
2000; Juni et al., 2002; Moher et al., 2003; Morrison et al., 2012). 14. active release.ab,ti.
There is also potential bias during the critical appraisal process as 15. acupressure.ab,ti.
reviewer judgment is involved. However, this is likely minimized 16. “Alexander technique*”.ab,ti.
by standardized training for critical appraisal. This review 17. “Anma massage*”.ab,ti.
assessed trials using quantitative outcome measures and there- 18. Aston patterning.ab,ti.
fore a more qualitative experience with soft-tissue therapy is not 19. “Ayurvedic massage*”.ab,ti.
represented. 20. bodywork.ab,ti.
21. Chih Ya.ab,ti.
5. Conclusions 22. cranial release.ab,ti.
23. (cranio-sacral and (massage or therap*)).ab,ti.
Our review helps clarify the role of soft-tissue therapy for the 24. (craniosacral and (massage or therap*)).ab,ti.
management of upper and lower extremity musculoskeletal dis- 25. Cyriax friction.ab,ti.
orders and injuries. Our results suggest that clinical massage 26. “deep tissue therap*”.ab,ti.
(myofascial release) is effective for the management of plantar heel 27. Feldenkrais method.ab,ti.
pain and lateral epicondylitis but not for subacromial impingement 28. “friction massage*”.ab,ti.
syndrome. Furthermore, trigger point therapy may provide limited 29. Graston.ab,ti.
to no benefit for plantar heel pain. Movement re-education (muscle 30. Gua Sha.ab,ti.
energy technique) is effective for managing persistent lateral epi- 31. Guasha.ab,ti.
condylitis and localized relaxation massage may provide short term 32. Hakomi method.ab,ti.
benefit for treating carpal tunnel syndrome when combined with 33. “Hot stone massage*”.ab,ti.
multimodal care. Based on our review, the effectiveness of most 34. (instrument assisted and (massage* or soft tissue or soft
types of soft tissue therapies does not appear to have been tissue)).ab,ti.
adequately investigated. More high quality studies are needed to 35. (instrument-assisted and (massage* or soft tissue or soft
study the appropriateness and comparative effectiveness of this tissue)).ab,ti.
widely utilized form of treatment. 36. Jin Shin.ab,ti.
37. “manual therap*”.ab,ti.
Acknowledgments 38. “massage*”.ab,ti.
39. “muscle energy technique*”.ab,ti.
The authors acknowledge the invaluable contributions to this 40. myofascial release.ab,ti.
review from: Arthur Ameis, Robert Brison, J. David Cassidy, Douglas 41. “neuromuscular therap*”.ab,ti.
Gross, Murray Krahn, Michel Lacerte, Gail Lindsay, Patrick Loisel, 42. Nimmo.ab,ti.
Shawn Marshall, Mike Paulden, Roger Salhany, John Stapleton, and 43. “Pfrimmer therap*”.ab,ti.
Angela Verven and Leslie Verville. The authors also thank Trish 44. “polarity therap*”.ab,ti.
Johns-Wilson at the University of Ontario Institute of Technology 45. ((post isometric or post-isometric) and relaxation).ab,ti.
for her review of the search strategy. 46. “pressure point* therap*”.ab,ti.
This study was funded by the Ontario Ministry of Finance and 47. proprioceptive neuromuscular facilitation.ab,ti.
the Financial Services Commission of Ontario (RFP No.: 48. reflexology.ab,ti.
OSS_00267175). The funding agency was not involved in the 49. “reflexotherap*”.ab,ti.
collection of data, data analysis, interpretation of data, or drafting of 50. Reiki.ab,ti.
the manuscript. This research was undertaken, in part, thanks to 51. Rolfing.ab,ti.
funding from the Canada Research Chairs program to Dr. Pierre 52. Shiat?u.ab,ti.
Co^ te
, Canada Research Chair in Disability Prevention and Rehabil- 53. (soft tissue and (mobili?ation or therap*)).ab,ti.
itation at the University of Ontario Institute of Technology. 54. (soft tissue and (mobili?ation or therap*)).ab,ti.
55. “sports massage*”.ab,ti.
Appendix I. MEDLINE search strategy on soft tissue therapy 56. “Swedish massage*”.ab,ti.
on musculoskeletal disorders and injuries of the lower 57. TCM.ab,ti.
extremity. 58. “Thai massage*”.ab,ti.
59. “therapeutic touch*”.ab,ti.
Searched February 21, 2015 in Ovid Technologies MEDLINE to 60. Thumper.ab,ti.
February Week 3 2015; in Ovid MEDLINE In-Process & Other Non- 61. traditional Chinese medicine.ab,ti.
Indexed Citations February 20, 2015. 62. Trager psychophysical.ab,ti.
63. “trigger point* therap*”.ab,ti.
1. Acupressure/ 64. Tui Na.ab,ti.
2. Complementary Therapies/ 65. Tuina.ab,ti.
3. Manipulation, Chiropractic/ 66. “vibration therap*”.ab,ti.
4. Manipulation, Orthopedic/ 67. Vibromax.ab,ti.
5. Manipulation, Osteopathic/ 68. VMTX.ab,ti.
6. Massage/ 69. Zhi Ya.ab,ti.
7. Muscle Stretching Exercises/ 70. “Zone therap*”.ab,ti.
8. Musculoskeletal Manipulations/ 71. functional range release.ab,ti.
9. Physical Therapy Modalities/ 72. functional range release.ab,ti.
10. Reflexotherapy/ 73. or/1e72
11. Therapeutic Touch/ 74. Randomized Controlled Trials as Topic/
12. exp Medicine, Chinese Traditional/ 75. Controlled Clinical Trials as Topic/

Please cite this article in press as: Piper S, et al., 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,
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
14 S. Piper et al. / Manual Therapy xxx (2015) 1e17

76. Clinical Trials as Topic/ 140. “patellar tendon*”.ab,ti.

77. exp CaseeControl Studies/ 141. popliteus.ab,ti.
78. exp Cohort Studies/ 142. pubofemoral.ab,ti.
79. Double-Blind Method/ 143. “quadricep*”.ab,ti.
80. Single-Blind Method/ 144. soleus.ab,ti.
81. Placebos/ 145. talocrural.ab,ti.
82. randomized controlled trial.pt. 146. “tarsal*”.ab,ti.
83. controlled clinical trial.pt. 147. tendinosis.ab,ti.
84. comparative study.pt. 148. tendinopathy.ab,ti.
85. (meta analys* or meta-analys* or metaanalys*).ab,ti. 149. plantar fasciitis.ab,ti.
86. (cohort and (study or studies or analys*)).ab,ti. 150. tibialis.ab,ti.
87. (random* and (control* or clinical or allocat*)).ab,ti. 151. or/95e150
88. (case adj control*).ab,ti. 152. 73 and 94 and 151
89. ((double or single) and blind*).ab,ti. 153. limit 152 to (human and english language and
90. “placebo*”.ab,ti. yr ¼ “1990e2015”)
91. (comparative and (study or studies)).ab,ti.
92. (case adj control*).ab,ti. Appendix II. MEDLINE search strategy on soft tissue therapy
93. (meta analys* or meta-analys* or metaanalys*).ab,ti. on musculoskeletal disorders and injuries of the upper
94. or/74e93 extremity.
95. exp Lower Extremity/
96. exp Hip Injuries/ Searched February 21, 2015 in Ovid Technologies MEDLINE to
97. exp Leg Injuries/ February Week 3 2015; in Ovid MEDLINE In-Process & Other Non-
98. exp Knee Injuries/ Indexed Citations February 20, 2015.
99. exp Foot/
100. exp Toes/in [Injuries] 1. exp Upper Extremity/
101. exp Knee Joint/ 2. Shoulder Pain/
102. exp Foot Bones/ 3. exp “Sprains and Strains”/
103. Anterior Cruciate Ligament/ 4. exp Cumulative Trauma Disorders/
104. Posterior Cruciate Ligament/ 5. exp Median Neuropathy/
105. exp Collateral Ligaments/ 6. Shoulder Impingement Syndrome/
106. Ankle Injuries/ 7. exp Arm Injuries/
107. Ankle Joint/ 8. exp Hand Injuries/
108. Ankle/ 9. Rotator Cuff/in [Injuries]
109. Lateral Ligament, Ankle/in [Injuries] 10. exp Tendinopathy/
110. Fasciitis, Plantar/ 11. Radial Neuropathy/
111. (lower and (extremit* or limb* or injur*)).ab,ti. 12. exp Ulnar Neuropathies/
112. (ankle* and (sprain* or strain* or injur*)).ab,ti. 13. exp Brachial Plexus/
113. ((talofibular or calcaneofibular or calcaneotibial or tibio*) 14. Bursitis/
and (sprain* or strain* or injur*)).ab,ti. 15. Thoracic Outlet Syndrome/
114. (deltoid and ankle*).ab,ti. 16. carpal tunnel syndrome.ab,ti.
115. (fibularis and strain*).ab,ti. 17. (medial adj (epicondylitis or epicondylosis or
116. ((peroneal or peroneus) and strain*).ab,ti. epicondylopathy)).ab,ti.
117. (tibialis and strain* and (anterior or posterior)).ab,ti. 18. (lateral adj (epicondylitis or epicondylosis or
118. (band syndrome and (illiotibial or IT)).ab,ti. epicondylopathy)).ab,ti.
119. achilles.ab,ti. 19. (shoulder* and (sprain* or strain*)).ab,ti.
120. (ACL or LCL or MCL or PCL).ab,ti. 20. (forearm* and (sprain* or strain*)).ab,ti.
121. “adductor muscle*”.ab,ti. 21. (arm* and (sprain* or strain*)).ab,ti.
122. “collateral ligament*”.ab,ti. 22. (wrist* and (sprain* or strain*)).ab,ti.
123. gastrocnemius.ab,ti. 23. (hand* and (sprain* or strain*)).ab,ti.
124. (gluteus or gluteal).ab,ti. 24. tennis elbow.ab,ti.
125. “hamstring*”.ab,ti. 25. (forearm and (injur* or pain)).ab,ti.
126. “hip flexor*”.ab,ti. 26. (wrist and (injur* or pain)).ab,ti.
127. “hoffa* syndrome”.ab,ti. 27. peritendinitis.ab,ti.
128. iliofemoral.ab,ti. 28. (rotator cuff and (injur* or disorder*)).ab,ti.
129. impingement.ab,ti. 29. (median adj neuropath*).ab,ti.
130. (buttock* and (injur* or pain*)).ab,ti. 30. (radial adj neuropath*).ab,ti.
131. (foot and (injur* or pain*)).ab,ti. 31. “De Quervain's tenosynovit*”.ab,ti.
132. (hip* and (injur* or pain*)).ab,ti. 32. (shoulder and (tendonitis or impingement or capsulitis)).ab,ti.
133. (knee* and (injur* or pain*)).ab,ti. 33. frozen shoulder.ab,ti.
134. (leg* and (injur* or pain*)).ab,ti. 34. “thoracic outlet syndrome*”.ab,ti.
135. (thigh* and (injur* or pain*)).ab,ti. 35. brachial plexus.ab,ti.
136. (toe* and (injur* or pain* or turf)).ab,ti. 36. bursitis.ab,ti.
137. ischiofemoral.ab,ti. 37. “shoulder impingement syndrome*”.ab,ti.
138. “metatars*”.ab,ti. 38. “upper extremit* injur*”.ab,ti.
139. “patellofemoral pain syndrome*”.ab,ti. 39. ((radial or ulnar) adj neuropath*).ab,ti.

Please cite this article in press as: Piper S, et al., 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,
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
 S. Piper et al. / Manual Therapy xxx (2015) 1e17 15

40. (hand* and (injur* or pain)).ab,ti. 103. (soft tissue and (mobili?ation or therap*)).ab,ti.
41. (arm* and (injur* or pain)).ab,ti. 104. “sports massage*”.ab,ti.
42. (forearm* and (injur* or pain)).ab,ti. 105. “Swedish massage*”.ab,ti.
43. (wrist* and (injur* or pain)).ab,ti. 106. TCM.ab,ti.
44. (shoulder* and (injur* or pain)).ab,ti. 107. “Thai massage*”.ab,ti.
45. “cumulative trauma disorder*”.ab,ti. 108. “therapeutic touch*”.ab,ti.
46. “cubital tunnel syndrome*”.ab,ti. 109. Thumper.ab,ti.
47. “overuse syndrome*”.ab,ti. 110. traditional Chinese medicine.ab,ti.
48. (repetit* and (strain* or sprain* or injur* or disorder*)).ab,ti. 111. Trager psychophysical.ab,ti.
49. or/1e48 112. “trigger point* therap*”.ab,ti.
50. Acupressure/ 113. Tui Na.ab,ti.
51. Complementary Therapies/ 114. Tuina.ab,ti.
52. Manipulation, Chiropractic/ 115. “vibration therap*”.ab,ti.
53. Manipulation, Orthopedic/ 116. Vibromax.ab,ti.
54. Manipulation, Osteopathic/ 117. VMTX.ab,ti.
55. Massage/ 118. Zhi Ya.ab,ti.
56. Muscle Stretching Exercises/ 119. “Zone therap*”.ab,ti.
57. Musculoskeletal Manipulations/ 120. or/50e119
58. Physical Therapy Modalities/ 121. Randomized Controlled Trials as Topic/
59. Reflexotherapy/ 122. Controlled Clinical Trials as Topic/
60. Therapeutic Touch/ 123. Clinical Trials as Topic/
61. exp Medicine, Chinese Traditional/ 124. exp CaseeControl Studies/
62. Vibration/tu [Therapeutic Use] 125. exp Cohort Studies/
63. active release.ab,ti. 126. Double-Blind Method/
64. acupressure.ab,ti. 127. Single-Blind Method/
65. “Alexander technique*”.ab,ti. 128. Placebos/
66. “Anma massage*”.ab,ti. 129. randomized controlled trial.pt.
67. Aston patterning.ab,ti. 130. controlled clinical trial.pt.
68. “Ayurvedic massage*”.ab,ti. 131. comparative study.pt.
69. bodywork.ab,ti. 132. (meta analys* or meta-analys* or metaanalys*).ab,ti.
70. Chih Ya.ab,ti. 133. (cohort and (study or studies or analys*)).ab,ti.
71. cranial release.ab,ti. 134. (random* and (control* or clinical or allocat*)).ab,ti.
72. (cranio-sacral and (massage or therap*)).ab,ti. 135. (case adj control*).ab,ti.
73. (craniosacral and (massage or therap*)).ab,ti. 136. ((double or single) and blind*).ab,ti.
74. Cyriax friction.ab,ti. 137. “placebo*”.ab,ti.
75. “deep tissue therap*”.ab,ti. 138. (comparative and (study or studies)).ab,ti.
76. Feldenkrais method.ab,ti. 139. (case adj control*).ab,ti.
77. “friction massage*”.ab,ti. 140. (meta analys* or meta-analys* or metaanalys*).ab,ti.
78. Graston.ab,ti. 141. or/121e140
79. Gua Sha.ab,ti. 142. 49 and 120 and 141
80. Guasha.ab,ti. 143. limit 142 to (english language and humans and
81. Hakomi method.ab,ti. yr ¼ “1990e2015”)
82. “Hot stone massage*”.ab,ti.
83. (instrument assisted and (massage* or soft tissue or soft Ethics or Institutional review board approval
tissue)).ab,ti.
84. (instrument-assisted and (massage* or soft tissue or soft Not required for systematic review.
tissue)).ab,ti.
85. Jin Shin.ab,ti. Funding
86. “manual therap*”.ab,ti.
87. “massage*”.ab,ti. This study was funded by the Ontario Ministry of Finance
88. “muscle energy technique*”.ab,ti. and the Financial Services Commission of Ontario (RFP No.:
89. myofascial release.ab,ti. OSS_00267175). The funding agency was not involved in the
90. “neuromuscular therap*”.ab,ti. collection of data, data analysis, interpretation of data, or drafting of
91. Nimmo.ab,ti. the manuscript. This research was undertaken, in part, thanks to
92. “Pfrimmer therap*”.ab,ti. funding from the Canada Research Chairs program to Dr. Pierre
93. “polarity therap*”.ab,ti. Co^ te
, Canada Research Chair in Disability Prevention and Rehabil-
94. ((post isometric or post-isometric) and relaxation).ab,ti. itation at the University of Ontario Institute of Technology.
95. “pressure point* therap*”.ab,ti.
96. proprioceptive neuromuscular facilitation.ab,ti. Conflicts of interest
97. reflexology.ab,ti.
98. “reflexotherap*”.ab,ti. All authors have no potential conflicts of interest to disclose.
99. Reiki.ab,ti.
100. Rolfing.ab,ti. Systematic review registration number
101. Shiat?u.ab,ti.
102. (soft tissue and (mobili?ation or therap*)).ab,ti. CRD42014007306.

Please cite this article in press as: Piper S, et al., 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,
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
16 S. Piper et al. / Manual Therapy xxx (2015) 1e17

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Please cite this article in press as: Piper S, et al., 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,
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011
 S. Piper et al. / Manual Therapy xxx (2015) 1e17 17

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Please cite this article in press as: Piper S, et al., 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,
Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.08.011