Effect of Maitland mobilization and exercises for the treatment of shoulder adhesive capsulitis: A single-case design

A systematic review of N-of-1 trials and single case experimental designs in physiotherapy for musculoskeletal conditions

BACKGROUND

Single Case Experimental Designs (SCEDs) are especially useful for small heterogeneous samples. Their role in evaluation of physiotherapy interventions for musculoskeletal conditions has not been systematically reviewed.

OBJECTIVES

Systematically review use, purpose, and outcomes of SCEDs for physiotherapy interventions for musculoskeletal conditions.

DATA SOURCES

Electronic databases and grey literature, searched using pre-defined terms.

STUDY SELECTION OR ELIGIBILITY CRITERIA

Studies of human participants enrolled in eligible SCEDs (individual or a series).

STUDY APPRAISAL AND SYNTHESIS METHODS

We extracted study characteristics, analytic methods and results, synthesising these descriptively. We used RoBiN-T scale to assess risk of bias.

RESULTS

We included 19 SCEDs comprising 92 participants, with wide variability in design, methodology, analysis and in conditions and interventions evaluated. 95% of participants responded favourably to the tested intervention. Overall risk of bias was high, due to poor internal validity, especially regarding randomisation, blinding, inter-rater agreement and measurement of treatment adherence. Visual analysis alone was performed in 55% of studies. Assessment of provider and participant satisfaction was limited.

CONCLUSIONS AND IMPLICATIONS

of key findings: SCEDs may be well-suited to evaluation of physiotherapy interventions for musculoskeletal conditions, but the risk of bias in studies to date is high. Following SCED guidelines to minimize the risk of bias and maximise clinical usefulness is recommended.

Effectiveness of extracorporeal shockwave therapy for frozen shoulder in perimenopausal diabetic women

Study aim: To evaluate the effectiveness of extracorporeal shockwave therapy (ESWT) for frozen shoulder in perimenopausal diabetic women.

Materials and methods: A single blind randomized controlled trial was conducted on sixty-two perimenopausal women diagnosed with diabetic frozen shoulder. They were divided randomly into two groups. Group (A) received physiotherapy program in the form of maitland joint mobilization for shoulder joint, self-stretching exercises, range of motion exercises (ROM) and strengthening exercises. Sessions were held 3 times per week, for 4 weeks. Group (B) study group: received the same physiotherapy program in addition to ESWT, once per week, for 4 weeks. Visual analogue scale was used to measure pain intensity, shoulder pain and disability index (SPADI) was used to evaluate disability level, while an electrogoniometer was used to measure shoulder flexion, abduction and external rotation range of motion. All measurements were recorded pretreatment and posttreatment program.

Results: For intragroup comparison, significant improvement in all treatment outcomes was noted in both groups (P < 0.05). However, no significant differences were found between both groups regarding all outcome measures in case of intergroup comparison in the study (P > 0.05).

Conclusion: The use of ESWT have a positive effect in reducing pain and improving shoulder range of motion in perimenopausal women suffering from frozen.

Changes in glenohumeral translation, electromyographic activity, and pressure-pain thresholds following sustained or oscillatory mobilizations in stiff and healthy shoulders: Results of a randomized, controlled laboratory trial

STUDY DESIGN

Randomized Controlled Laboratory Study.

BACKGROUND

Posterior glide glenohumeral (GH) mobilizations are utilized to improve motion and decrease pain in patients with shoulder pathologies, thought to be due to capsular stretch and neurophysiologic effects. However, it remains unclear how different GH mobilizations influence mobility, rotator cuff (RC) activity, and pain processing, or if effects are different in stiff (≥15-degree loss of passive motion in any plane) rather than healthy shoulders.

OBJECTIVES

To compare the effects of oscillatory and sustained posterior GH mobilizations on translation, RC activity, and pressure pain threshold (PPT) in stiff and healthy shoulders.

METHODS

Eighty-eight participants, (44 control, 44 stiff shoulders) were randomly assigned to one of two mobilization conditions. Pre-post intervention measurements of PPT, GH translation via ultrasound imaging, and RC activity assessed via electromyography were performed. Sustained or oscillatory grade III posterior GH mobilizations were then provided to all participants. Data were analyzed using tests of difference and regression modeling.

RESULTS

Sustained glides (2.8 ± 3.3 mm) demonstrated significantly greater changes in translation compared to oscillatory glides (1.1 ± 3.9 mm), p = .028. Stiff shoulders demonstrated higher total RC activity than controls both pre (+24.51%, p = .004) and post-intervention (+23.10%, p = .01). Small changes in PPT occurred across all conditions, none reaching clinically meaningful levels.

CONCLUSION

Sustained mobilizations resulted in greater changes in GH translation. RC activity was higher in the stiff shoulder group, and remained higher post-intervention despite gains in GH translation, suggesting a mechanical rather than neurophysiologic effect. There was no meaningful difference in PPT between modes of mobilization.

LEVEL OF EVIDENCE

Therapy, Randomized Controlled Laboratory Study, Level 1b.

Comparison of two mobilization techniques in management of chronic non-specific low back pain

AIM

The aim of the study was to compare between the effects of Maitland's postero-anterior (PA glide) mobilization and Mulligan's sustained natural apophyseal glide (SNAG) on pain, mobility, muscle activation and functional disability in subjects with chronic, non-specific low back pain.

METHODS

The study was a two arm repeated measure design with random allocation of subjects (n = 33). Subjects in group 1 received Maitland's PA glide mobilization and those in group 2 received Mulligan's SNAG. Along with the respective mobilization technique, individualized exercises were common for subjects in both the groups. Subjects in both groups received treatment for 4 days a week for 4 weeks. The outcome measures were numeric pain rating scale (NPRS) scores, lumbar flexion and extension range of motion, erector spinae muscle activity and Oswestry low back pain disability questionnaire score.

RESULTS

The outcome measure scores showed statistical significance in time effect on NPRS (p = 0.001); lumbar flexion and extension range of motion (p = 0.001); erector spinae muscle activity (0.001); Oswestry low back pain disability questionnaire score (p = 0.001); group effect on lumbar flexion (p = 0.03) and extension range of motion (p = 0.05); and interaction effect (time x group) on lumbar flexion (p = 0.003) and extension range of motion (p = 0.002); and, erector spinae muscle activity (p = 0.05) at the 3rd lumbar vertebral level.

CONCLUSION

The addition of Maitland or Mulligan mobilization techniques of the spine does not show a difference in the improvement of symptoms associated with chronic non-specific low back pain.

Effects of an anteroposterior mobilization of the glenohumeral joint in overhead athletes with chronic shoulder pain: A randomized controlled trial

BACKGROUND

Passive oscillatory mobilizations are often employed by physiotherapists to reduce shoulder pain and increase function. However, there is little data about the neurophysiological effects of these mobilizations.

OBJECTIVES

To investigate the initial effects of an anteroposterior (AP) shoulder joint mobilization on measures of pain and function in overhead athletes with chronic shoulder pain.

DESIGN

Double-blind, controlled, within-subject, repeated-measures design.

METHOD

Thirty-one overhead athletes with chronic shoulder pain participated. The effects of a 9-min, AP mobilization of the glenohumeral joint were compared with manual contact and no-contact interventions. Self-reported pain, pressure pain threshold (PPT), range of movement (ROM), muscle strength, and disability were measured immediately before and after each intervention.

RESULTS/FINDINGS

No significant differences were found among the treatment conditions in any of the variables investigated. A significantly greater mean decrease in self-reported shoulder pain was observed following treatment condition [0.63 (0.12, 1.14); p = 0.01]. PPT at the affected shoulder increased significantly following both the treatment [0.23 (-0.43, 0.02); p = 0.02] and manual contact [0.28 (-0.51, 0.04); p = 0.01] conditions. Shoulder AP joint mobilization also increased PPT at a distal, non-painful site [0.42 (-0.85, 0.01); p = 0.04]. No changes were observed in shoulder ROM or muscle strength.

CONCLUSIONS

This study found no superior effects in various pain or function-related outcome measures of a passive oscillatory anteroposterior mobilization applied to the glenohumeral joint compared to manual contact and no-contact interventions in overhead athletes with chronic shoulder pain. Some ability to modulate shoulder pain and local and widespread pain sensitivity was observed in the short term after the passive oscillatory anteroposterior mobilization.

Effectiveness of Trigger Point Manual Treatment on the Frequency, Intensity, and Duration of Attacks in Primary Headaches: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

A variety of interventions has been proposed for symptomatology relief in primary headaches. Among these, manual trigger points (TrPs) treatment gains popularity, but its effects have not been investigated yet.

Objective

The aim was to establish the effectiveness of manual TrP compared to minimal active or no active interventions in terms of frequency, intensity, and duration of attacks in adult people with primary headaches.

Methods

We searched MEDLINE, COCHRANE, Web Of Science, and PEDro databases up to November 2017 for randomized controlled trials (RCTs). Two independent reviewers appraised the risk-of-bias (RoB) and the grading of recommendations, assessment, development, and evaluation (GRADE) to evaluate the overall quality of evidence.

Results

Seven RCTs that compared manual treatment vs minimal active intervention were included: 5 focused on tension-type headache (TTH) and 2 on Migraine (MH); 3 out of 7 RCTs had high RoB. Combined TTH and MH results show statistically significant reduction for all outcomes after treatment compared to controls, but the level of evidence was very low. Subgroup analysis showed a statistically significant reduction in attack frequency (no. of attacks per month) after treatment in TTH (MD −3.50; 95% CI from −4.91 to −2.09; 4 RCTs) and in MH (MD −1.92; 95% CI from −3.03 to −0.80; 2 RCTs). Pain intensity (0–100 scale) was reduced in TTH (MD −12.83; 95% CI from −19.49 to −6.17; 4 RCTs) and in MH (MD −13.60; 95% CI from −19.54 to −7.66; 2RCTs). Duration of attacks (hours) was reduced in TTH (MD −0.51; 95% CI from −0.97 to −0.04; 2 RCTs) and in MH (MD −10.68; 95% CI from −14.41 to −6.95; 1 RCT).

Conclusion

Manual TrPs treatment of head and neck muscles may reduce frequency, intensity, and duration of attacks in TTH and MH, but the quality of evidence according to GRADE approach was very low for the presence of few studies, high RoB, and imprecision of results.

EMG activity of selected rotator cuff musculature during grade III distraction and posterior glide glenohumeral mobilization: results of a pilot trial comparing painful and non-painful shoulders

OBJECTIVES

The objectives of this pilot study were to investigate rotator cuff activity that may be present during grade III distraction and posterior glide mobilization of the glenohumeral (GH) joint, as well as to examine any differences in response between painful and non-painful shoulders utilizing these techniques.

METHODS

EMG data were collected using Delsys EMGworks(®) software and Trigno(®) mini-wireless electrodes for the supraspinatus, infraspinatus and upper trapezius musculature during grade III GH distraction and posterior glide mobilization. A total of 20 shoulders (10 painful, 10 non-painful) were recruited from a sample of convenience. Submaximal voluntary dynamic contraction against gravity was used as reference for each of the three selected muscles. Participants underwent two trials of each mobilization, and the mean results for each group were assessed using descriptive statistics (mean, standard deviation) and effect size.

RESULTS

Both the painful and non-painful groups exhibited considerable levels of rotator cuff activity during each test parameter, with the painful group consistently generating higher supraspinatus and infraspinatus RMS and peak force activity. Analysis of the peak combined rotator cuff activity during distraction (d = 0.58) and posterior glides (d = 0.64) suggests moderate-to-high practical significance of the results.

DISCUSSION

GH distraction and posterior glide mobilizations have traditionally been thought of as passive treatment procedures. The results of this pilot study indicate that the supraspinatus and infraspinatus are significantly active during these techniques. Findings suggest that during these techniques, the total infra/supraspinatus EMG activity approaches the level produced while raising the arm against gravity.

LEVEL OF EVIDENCE

2b.

Comparison for efficacy of general exercises with and without mobilization therapy for the management of adhesive capsulitis of shoulder - An interventional study

OBJECTIVE

The aim of this work was to evaluate the effectiveness of exercise with manual therapy and exercise alone in adhesive capsulitis of the shoulder.

METHOD

This randomized study was conducted at institute of physical medicine and rehabilitation Dow University of Health Sciences, Karachi between January, 2014 and July, 2014. Forty four participant age between 25-40 years were recruited. Twenty two participants were allocated to exercise and manual therapy group and 22 participants were allocated to exercise only group. Exercise and manual therapy group received general exercises and Maitland mobilization on shoulder joint whereas exercise group only received general exercises. Both interventions were carried out 3 times a week for 5 consecutive weeks. Pre and post intervention scores of Visual analogue scale (VAS), range of movement and Shoulder Pain and Disability Index (SPDI) were recorded. Paired sample t-test was used to analyze the results within groups.

RESULTS

After 5 weeks of intervention both groups made significant improvements in all outcome measures (p < 0.001). Intra group analysis showed no significant difference between two groups (p > 0.05). Mean VAS and SPADI difference was 2.23 and 22 in General exercise & manual therapy group and 2.33 and 23 in General exercise group respectively.

CONCLUSION

Both exercises with manual therapy and exercises alone are equally effective in the management of adhesive capsulits of the shoulder joint.

Does adding mobilization to stretching improve outcomes for people with frozen shoulder? A randomized controlled clinical trial

OBJECTIVE

To assess the effectiveness of joint mobilization combined with stretching exercises in patients with frozen shoulder.

DESIGN

A randomized controlled clinical pilot trial.

SETTING

Department of Orthopedics and Traumatology.

SUBJECTS

Thirty patients with frozen shoulder.

INTERVENTION

All participants were randomly assigned to one of two treatment groups: joint mobilization and stretching versus stretching exercises alone. Both groups performed a home exercise program and were treated for six weeks (18 sessions).

MAIN MEASURES

The primary outcome measures for functional assessment were the Disabilities of the Arm, Shoulder and Hand score and the Constant score. The secondary outcome measures were pain level, as evaluated with a visual analog scale, and range of motion, as measured using a conventional goniometer. Patients were assessed before treatment, at the end of the treatment, and after one year as follow-up.

RESULTS

Two-by-two repeated-measures ANOVA with Bonferroni corrections revealed significant increases in abduction (91.9° [CI: 86.1-96.7] to 172.8° [CI: 169.7-175.5]), external rotation (28.1° [CI: 22.2-34.2] to 77.7° [CI: 70.3-83.0]) and Constant score (39.1 [CI: 35.3-42.6] to 80.5 [75.3-86.6]) at the one-year follow-up in the joint mobilization combined with stretching exercise group, whereas the group performing stretching exercise alone did not show such changes.

CONCLUSION

In the treatment of patients with frozen shoulder, joint mobilization combined with stretching exercises is better than stretching exercise alone in terms of external rotation, abduction range of motion and function score.

Can osteopathic manipulative treatment modify the posture in elderly people? - a single-case study

In this research, we have studied the consequences of three consecutive osteopathic manipulative sessions (OMS) on postural control by using a single-case research (SCR) design. The patient was a 77 years old woman complaining of altered balance and low-back pain. OMS were delivered by a single practitioner. The pain level was self-rated by using a visual Borg scale. The posture was monitored on a force platform. Postural parameters were deduced from the analysis of the centre of foot pressure (CoP) displacement. The statistical significance of the observed differences was established by using an SCR-related effect size indicator (i.e. Taunovlap). Our results indicate that OMS decrease the patient's pain, modify CoP mean position and decreased the length and velocity of the CoP displacement. Furthermore, modifications of the body oscillations were observed after OMS. This work indicates that OMS can improve body balance and that SCR allows the objective evaluation of the consequences of OMS.

Pain relief in a young woman with adhesive capsulitis after manual manipulation of the acromioclavicular joint for remaining symptoms after mobilisation under anaesthesia

Adhesive capsulitis is a painful condition with a prevalence of 2-5%. There is a lack of evidence for its aetiology and for conventional treatment and cost effects. This study describes the treatment effects of manual manipulation of the acromioclavicular joint for adhesive capsulitis in a young woman for persisting pain after mobilisation of the glenohumeral joint under anaesthesia. Primary outcomes were pain and physical function, measured by a visual analogue scale and the SF36 health survey. Secondary outcomes were sleep pattern, medication and perceived recovery. The mobility after manipulation under anaesthesia: elevation 55° and no improvement in pain. After manual manipulation: unrestricted elevation and significant pain relief. The patient no longer suffered from sleeping disorders and ceased all medication. Considering the lack of knowledge in aetiology and treatment, specialised manual examination of the acromioclavicular joint should be considered early in patients diagnosed with adhesive capsulitis.

Trigger point dry needling as an adjunct treatment for a patient with adhesive capsulitis of the shoulder

STUDY DESIGN

Case report.

BACKGROUND

Prognosis for adhesive capsulitis has been described as self-limiting and can persist for 1 to 3 years. Conservative treatment that includes physical therapy is commonly advised.

CASE DESCRIPTION

The patient was a 54-year-old woman with primary symptoms of shoulder pain and loss of motion consistent with adhesive capsulitis. Manual physical therapy intervention initially consisted of joint mobilizations of the shoulder region and thrust manipulation of the cervicothoracic region. Although manual techniques seemed to result in some early functional improvement, continued progression was limited by pain. Subsequent examination identified trigger points in the upper trapezius, levator scapula, deltoid, and infraspinatus muscles, which were treated with dry needling to decrease pain and allow for higher grades of manual intervention.

OUTCOMES

The patient was treated for a total of 13 visits over a 6-week period. After trigger point dry needling was introduced on the third visit, improvements in pain-free shoulder range of motion and functional outcome measures, assessed with the Shoulder Pain and Disability Index and the shortened form of the Disabilities of the Arm, Shoulder and Hand questionnaire, exceeded the minimal clinically important difference after 2 treatment sessions. At discharge, the patient had achieved significant improvements in shoulder range of motion in all planes, and outcome measures were significantly improved.

DISCUSSION

This case report describes the clinical reasoning behind the use of trigger point dry needling in the treatment of a patient with adhesive capsulitis. The rapid improvement seen in this patient following the initiation of dry needling to the upper trapezius, levator scapula, deltoid, and infraspinatus muscles suggests that surrounding muscles may be a significant source of pain in this condition.

Effectiveness of Maitland Techniques in Idiopathic Shoulder Adhesive Capsulitis

Objective. To study the effectiveness of Maitland techniques in the treatment of idiopathic shoulder adhesive capsulitis. Methods. total of 40 patients diagnosed with idiopathic shoulder adhesive capsulitis were recruited and randomly allocated into two groups. In Group A () subjects were treated with Maitland mobilization technique and common supervised exercises, whereas subjects in Group B () only received common supervised exercises. Variables. Shoulder pain and disability index (SPADI), VAS and shoulder ROM (external rotation and abduction) were variables of the study. These were recorded before and after the session of the training. Total duration of the study was four weeks. Result. Statistical analysis of the data revealed that within-group comparison both groups showed significant improvement for all the parameters, whereas between-group comparison revealed higher improvement in Group A compared to the Group B. Conclusion. The study confirmed that addition of the Maitland mobilization technique with the combination of exercises have proved their efficacy in relieving pain and improving R.O.M. and shoulder function and hence should form a part of the treatment plan.

Effective therapeutic exercise prescription: the right exercise at the right dose

The prescription of an effective therapeutic exercise program requires the right dosage of the right exercise, at the right time for that patient. The therapist must understand and apply training principles effectively in the presence of pathology, injury, or otherwise unhealthy tissue. The intervention goal is to close the gap between current performance and the desired goal or capacity. Although there may be a preferred linear path from current performance to optimal outcome, complexities of the human body, internal factors, and external variables may create barriers to this direct path. Successful programs include key program design considerations such as ensuring a stable baseline before progression, treating the right impairments and activity limitations, understanding contextual factors, considering the principles of specificity and optimal loading, and applying dosing principles. Program progression can be achieved through increases in total exercise volume and/or through manipulation of exercise challenges at the same exercise volume. Effective application of these principles will guide patients toward their goals as quickly and efficiently as possible.