Shoulder mobilization in-service BY: Devin Henry, SPT Determining the most effective mobilization to increase glenohumeral range of motion Shoulder mobilization in-service BY: Devin Henry, SPT

Why this topic? Recent evidence emerging I asked a lot of questions regarding this topic Interesting Confusing Concave-convex rule

Kaltenborn Concave-Convex Rule Concave surface moving on a stable convex surface Rolls and glides are the same Examples: tibia moving on a fixed femur Convex surface moving on a stable concave surface Rolls and glides are opposite Examples: humerus moving on a fixed scapula

Shoulder arthrokinematics Abduction: Rolls superiorly, glides inferiorly Extension & ER: Rolls posteriorly, glides anteriorly IR and Flexion: Rolls anteriorly, glides posteriorly https://s3.amazonaws.com/classconnection/63/flashcards/1254063/jpg/shoulderrollslide-1498C41FD1C7FA0DE88.jpg

Shoulder mobilizations Mobilizations are attempting to imitate the glides occurring at the joint Inferior mobs target abduction limitations Posterior mobs target internal rotation and flexion limitations Anterior mobs target external rotation and extension limitations

Brandt et al., An evidence-based review on the validity of the Kaltenborn rule as applied to the glenohumeral joint. Manual therapy 12 (2007) 3–11 2008 Impact Factor: 2.98 Article 1 PURPOSE: Determine the validity of the concave-convex rule in the GH joint 2008 Journal Impact Factor: 2.98

METHODS Systematic review that included articles with various types of clinical designs 1966-2003 Searched key terms and limited the search to English and human studies Screening process Included 25 studies that were analyzed qualitatively Assessed quality of the studies using PEDro scale

results A lot of the clinical trials were not the best quality Mean quality score: 51.27% Best evidence demonstrated Translation of the humeral head is influenced by capsulo-ligamentous structures (particularly at end range) and neuromuscular control Rotator cuff centralizes the humeral head during AROM Dysfunction of shoulder structures disrupts normal translational patterns Contradicting results with regard to translational direction during shoulder ER A/PROM in normal and reconstructed joints Only firm conclusion was normal and dysfunctional joints behave differently capsulo-ligamentous structures (particularly at end range) and neuromuscular control = ACTIVE & PASSIVE Loss or defect in above shoulder structures disrupts normal translational patterns: ie PAIN, SPASMS, LOSS OF PROPRIOCEPTION Size of humeral head could influence translation

Johnson, A et al. The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with shoulder adhesive capsulitis. J orthopaedic & sports physical therapy. 2007;37:88-99 Article ii PURPOSE: Compare the effectiveness of anterior versus posterior glide mobilization techniques to improve ER in patients with adhesive capsulitis 2008 Journal Impact Factor: 2.13

methods 20 patients with unilateral adhesive capsulitis with additional inclusion/exclusion criteria: Between ages 25-80 Normal findings on radiographs within previous 12 months No previous shoulder surgeries or manipulations to affected shoulder Restricted ER that worsened with shoulder abduction Each patient randomly assigned to anterior mobilization (AM) or posterior mobilization (PM) group Each patient also completed the following before the 1st treatment and after the last treatment VAS pain/unpleasantness 5-item self assessment function questionnaire Glenohumeral ER ROM (primary outcome measure) Groups were similar at baseline except for the side of the affected arm

Intervention Preheated targeted capsule using thermal US Joint mobilization (independent variable) Grade III “after the slack of the joint has been taken up” Held for 1 minute (no oscillations) for a total of 15 minutes of sustained stretch Progressed as subject tolerated Measured and recorded external rotation PROM UBE for 3 minutes in FW direction only *** Each subject was treated for 6 sessions 2-3x/week

results PM Group AM Group 2 subjects lost ER 1 had no change 7 showed improvement All subjects showed a significant improvement in ER

Take away Use clinical judgement and patient-centered care when choosing manual therapy

Kozono, N et al. In vivo kinematic analysis of the glenohumeral joint during dynamic full axial rotation and scapular plane full abduction in healthy shoulders. Knee surg sports traumatol arthrosc (2017) 25: 2032. 2-14 IMPACT FACTOR: 3.053 Article III PURPOSE: Evaluate the kinematics of healthy shoulders during dynamic motions 2016 Journal Impact Factor: 3.227

Methods 10 healthy male participants ages 30-37 with no previous shoulder problems Statistical analysis Subjects performed full-range ER and abduction Kinematic analysis using radiographic and computed tomography images to fine-tune the 3D model Coordinate system of humerus and scapula defined by anatomical landmarks 10 frames/sec

results EXTERNAL ROTATION ABDUCTION Plane Early Phase Translation Late Phase Frontal plane Medial Lateral Sagittal plane Superior Inferior Transverse plane Posterior Plane Early Phase Translation Late Phase Translation Frontal plane Medial Lateral Sagittal plane Superior Inferior Transverse plane Anterior Posterior Moved posteriorly 2.5mm during ER w.out holding hand weights *** This study was also the first to demonstrate that the humerus rotates 33.6 degrees externally relative to the scapula during scapular-plane abduction

Take away By assessing healthy shoulders, there is now a baseline for pathological shoulders

Some more evidence Posterior translation during ER: Dal Maso et al. 2014 Glenohumeral translations during ADLs, sports activities, and ROM movements: Dal Maso et al. 2015 Systematic review on the effectiveness of different mobilization techniques: Noten, S et al. 2016 Posterior mobilization decreases the severity of pain and improves joint function in patients with adhesive capsulitis: Gutiérrez et al. 2015

References Brandt C, Sole G, Krause MW, Nel M. An evidence-based review on the validity of the kaltenborn rule as applied to the glenohumeral joint. Manual therapy 12 (2007) 3–11 Dal Maso et al. Glenohumeral translations during range-of-motion movements, activities of daily living, and sports activities in healthy participants. Clin Biomech (Bristol, Avon). 2015 Nov;30(9):1002-7. doi: 10.1016/j.clinbiomech.2015.06.016. Epub 2015 Jun 30. Dal Maso F, Raison M, Lundberg A, Arndt A, Begon M (2014) Coupling between 3D displacements and rotations at the glenohumeral joint during dynamic tasks in healthy participants. Clin Biomech (Bristol, Avon) 29:1048–105 Gutiérrez Espinoza HJ, Pavez F, Guajardo C, Acosta M. Glenohumeral posterior mobilization versus conventional physiotherapy for primary adhesive capsulitis: a randomized clinical trial. Medwave. 2015 Sep 22;15(8):e6267. doi: 10.5867/medwave.2015.08.6267. Johnson AJ, Godges JJ, Zimmerman GJ, Ounanian LL. The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with shoulder adhesive capsulitis. J Orthopaedic & Sports Physical Therapy. 2007;37:88-99 Kaltenborn, FM. Manual mobilizations of the joints. In: The extremities, vol. I, Oslo (Norway): Norlis; 2002. Kozono, N., Okada, T., Takeuchi, N. et al. In vivo kinematic analysis of the glenohumeral joint during dynamic full axial rotation and scapular plane full abduction in healthy shoulders. Knee Surg Sports Traumatol Arthrosc (2017) 25: 2032. doi:10.1007/s00167-016-4263-2. Noten, Suzie et al. Efficacy of Different Types of Mobilization Techniques in Patients With Primary Adhesive Capsulitis of the Shoulder: A Systematic Review. Arch Phys Med Rehabil. 2016 May;97(5):815-25. doi: 10.1016/j.apmr.2015.07.025. Epub 2015 Aug 15.

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