PT Classroom - Utiliztion of Joint Mobilization Techniques to Treat Adhesive Capsulitis of the Shoulder ׀ by Jennifer Hill, MPT, CSCS & Chai Rasavong, MPT, MBA

 

Adhesive capsultis is also known as periarthritis or frozen shoulder syndrome and is characterized by diffuse shoulder pain and loss of motion. It usually involves regional tightness in the anteroinferior joint capsule which primarily compromises external rotation, followed by loss of abduction and, less often internal rotation and flexion (1). The exact pathogenesis of adhesive capsulitis is unclear (2,3,4) but Yang et al (3) revealed that several authors have proposed that impaired shoulder movements are related to shoulder capsule adhesions, contracted soft tissues, and adherent axillary recess.

Patients with adhesive capsulitis are treated conservatively with nonsteroidal anti-inflammatory drugs, intra-articular cortisocosteriod injections and physical therapy (4). Should conservative treatment methods prove ineffective more aggressive methods such as hydrodilation, arthroscopic release, or manipulation under anesthesia can be performed (4).

In the physical therapy setting, physical therapists utilize a variety of interventions to treat patients with adhesive capsulitis. These interventions can include and are not limited to: active/passive range of motion exercises, stretching, soft tissue mobilization, myofascial release, proprioceptive-neuromuscluar techniques, ultrasound, electrical stimulation, hot packs, ice packs and joint mobilization techniques.

In this article we will focus on joint mobilization for the treatment of adhesive capsulitis of the shoulder. A leading researcher in joint mobilization technique is Geoffrey Maitland. He reported that joint mobilization is most effective when directed to restoring structures within a joint to their normal positions or pain-free positions so as to allow a full-range painless movement; stretching a stiff painless joint to restore range, and relieving pain by using special techniques (5). Maitland classifies joint mobilization techniques into five grades:

Intensity of Mobilization Techniques According to Maitland 5-Grade Classification System (5)
Grade I: Small amplitude at the beginning of the range of motion (ROM)
Grade II: Large amplitude not reaching the end of the ROM
Grade III: Large amplitude reaching the limited ROM
Grade IV: Small amplitude at the end of the limited ROM
Grade V: Small amplitude and high velocity at the end of limited ROM (manipulation or thrust)


Joint mobilization is an often used intervention by physical therapists to treat patients with adhesive capsultis. Yang et al (3) conducted a study that compared the use of three mobilization techniques – end-range mobilization, mid-range mobilization, and mobilization with movement in the management of 28 subjects with adhesive capsulitis. Their study concluded that there was improvement in mobility and functional ability at 12 weeks in subjects treated with the three mobilization techniques. When comparing the effectiveness of the three treatment strategies in subjects with unilateral adhesive capsultis, they found that end-range mobilization and mobilization with movement were more effective than mid-range mobilization in increasing mobility and functional ability.

In a preliminary study by Vermeulen et al (6) published in 2000, they conducted a study on four men and three women with adhesive capsulitis who were treated with end-range mobilization techniques, twice a week for 3 months. Their study found that after 3 months of treatment, there were increases in both active range of motion and passive range of motion. However, their study didn’t include a control group and they recommended that further investigation in the form of controlled studies is warranted to compare the therapeutic effect of these mobilizations with the natural course of the disease or other treatment regimes.

In a later study by Vermeulen et al (4) published in 2006, they conducted a study on 100 subjects with unilateral adhesive capsulitis who were randomly divided into two groups and were treated with either high-grade mobilization techniques or low-grade mobilization techniques. Their study found that high-grade mobilization techniques proved to be more effective than low-grade mobilization techniques with improving glenohumeral joint mobility and reducing disability, with the overall differences between the two interventions being small.

Despite the positive findings with the above mentioned studies, the inclusion of a control group where no treatment is received by patients with adhesive capsulitis was not included in any of the studies. Because the natural course of this condition remains a matter of dispute future studies involving a control group and a larger sample population are recommended (4).

 

A review of some shoulder mobilization techniques to the Glenohumeral (GH) joint can be found below (7) (please note that there are alternative methods to performing these mobilizations):

Anterior Glide of the GH Joint - While supporting the patient's forearm between your upper arm and trunk, apply a grade I traction at the GH joint with the guiding hand while the mobilizing hand glides the humerus in an anterior direction.

 

Posterior Glide of the GH Joint - While supporting the patient's forearm between your upper arm and trunk, apply a grade I traction to the GH joint with the guiding hand while the mobilizing hand glides the humerus in a posterior direction.

 

Inferior Glide of the GH Joint - While supporting the patient's forearm between your upper arm and trunk, apply a grade I traction to the GH joint with the guiding hand while the mobilizing hand glides the humerus in an inferior direction.

 

Distraction of the GH Joint - While supporting the patient's forearm between your upper arm and trunk, grip the proximal humerus as close to the axilla as possible from the medial and lateral side with both hands and move the humeral head lateral, anterior and inferior, perpendicular to the glenoid joint surface.

Last revised: November 15, 2009
by Jennifer Hill, MPT, CSCS & Chai Rasavong, MPT, MBA

 

References
1. Goodman, C & Boissonnault W. Pathology: Implications for the Physical Therapist. Philadelphia, PA: WB Saunders, 1998.
2. Wadsworth, C. Frozen Shoulder. Physical Therapy. 1986;66(12): 1878-1883.
3. Yang J., et al. Mobilization Techniques in Subjects with Frozen Shoulder Syndrome: Randomized Multiple-Treatment Trial. Physical Therapy. 2007;87(10): 1307-1315.
4. Vermeulen H., et al. Comparison of High-Grade and low-Grade Mobilization Techniques in the Management of Adhesive Capsultis of the Shoulder: Randomized Controlled Trial. Physical Therapy. 2006;86(3): 355-368. 
5  Maitland GD. Peripheral Manipulation. Boston, MA: Butterworth Publishers; 1977.
6. Vermeulen H, et al. End-Range Mobilization Techniques in Adhesive Capsultis of the Shoulder Joint: A Multiple-Subject Case Report. Physical Therapy. 2000;80(12): 1204-1213.
7. Edmond, S. Joint Mobilization/Manipulation - Extremity and Spinal Techniques Second Edition. St. Louis, MO: Mosby Elsevier, 2006.  


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