1. 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

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

3. 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

4. Shoulder arthrokinematics
Abduction: Rolls superiorly, glides inferiorly
Extension & ER: Rolls posteriorly, glides anteriorly
IR and Flexion: Rolls anteriorly, glides posteriorly

5. 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

6. 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

7. METHODS
Systematic review that included articles with various types of clinical designs
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

9. 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

10. 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

11. 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

13. 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

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

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

16. 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

17. Methods
10 healthy male participants ages 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

18. 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

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

22. 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
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

23. 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) Nov;30(9): doi: /j.clinbiomech 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 Sep 22;15(8):e6267. doi: /medwave 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; 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: doi: /s 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 May;97(5): doi: /j.apmr Epub 2015 Aug 15.

24. Questions?? @