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Int J Physiother Res 2013;01(5):227-37. ISSN 2321-1822 227

Original Article

COMPARITIVE EFFECT OF GONG’S MOBLISATION VERSUSMULLIGAN’S MOBILISATION ON PAIN AND SHOULDERABDUCTION MOBILITY IN FROZEN SHOULDERMehta Bryna Pankaj 1 , Vinod Babu. K *2, Sai Kumar. N 3, Asha D 4.1 Post Graduate MPT student 2012-2014, *2 Assistant Professor in Physiotherapy, 3 Principal,4 Associate Professor.K.T.G. College of Physiotherapy and KTG Hospital. Bangalore. India.

Background and introduction: The purpose is to compare the effect of gong’s mobilization versus mulligan’smobilization on improving pain and shoulder abduction mobility for subjects with frozen shoulder.Method: 30 subjects with unilateral frozen shoulder whose abduction ROM was limited to 120 degree or lesswere selected and randomized 15 subjects each into Gong’s and MWM group. Gong’s group received Gong’smobilization with conventional therapy while MWM group received movement with mobilization andconventional therapy for duration of five sessions per week for 3 weeks. A goniometer to measure shoulderabduction ROM and VAS to measure pain were used.Results: Analysis using Independent ‘t’ test and Mann Whitney U test found that there is no statistically significantdifference (p<0.05) between Gong’s mobilization and MWM on improving shoulder abduction ROM and pain,however the percentage of change in improvement was greater in MWM group.Conclusion: The present study concludes that both MWM with conventional therapy and Gong’s mobilizationwith conventional therapy are effective on improving pain and shoulder abduction mobility for subjects withFrozen shoulder.KEYWORDS: Gong’s mobilization; MWM; Frozen shoulder; Shoulder mobility; Pain; ROM; Conventional therapy.

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International Journal of Physiotherapy and ResearchISSN 2321- 1822

www.ijmhr.org/ijpr.html

Received: 30-10-2013 Accepted: 05-11-2013

Published: 11-12-2013

ABSTRACT

INTRODUCTION

Address for correspondence: Vinod Babu.K, Assistant Professor, K.T.G. College of Physiotherapyand K.T.G. Hospital, Bangalore-560 091, India. Email: [email protected]

International Journal of Physiotherapy and Research,Int J Physiother Res 2013, Vol1(5):227-37. ISSN 2321-1822

Peer Review: 30-11-2013

Frozen shoulder or adhesive capsulitis ischaracterized by an insidious and progressiveloss of active and passive mobility in theglenohumeral joint presumably due to capsularcontracture.1

Clinical symptoms include pain, a limited rangeof motion (ROM), altered scapulohumeralrhythm and muscle weakness from disuse.2,3,4

The prevalence of frozen shoulder is slightlygreater than 2% in the general population,affecting persons older than 40 years.Approximately 70% of patients presenting withadhesive capsulitis are women, and 20% to 30%

of those affected develop adhesive capsulitis inthe opposite shoulder.5

A variety of interventions are used byphysiotherapist to reduce pain which includesexercises and electrotherapy techniques withmobilization techniques to decrease pain and toimprove mobility.6,7 But there is no un animousdecision in the selection of these treatmentpatterns and it is been found that mobilizationare integral part of frozen shoulder.8,9

Mulligan incorporated Kaltenborn’s principles ofpassive mobilization. They are thought toachieve painless movement by restoring thereduced accessory glide. Similar principles can


Mehta Bryna Pankaj et al., Comparitive effect of Gong’s moblisation versus Mulligan’s mobilisation on pain and shoulder abduction mobility inFrozen shoulder.

be applied to the treatment of peripheral mus-culoskeletal disorders and are termedMobilisation With Movement.10,11

In essence, the limited painful physiologicalmovement is performed actively while thetherapist applies a sustained accessory glide atright angles or parallel to the joint aiming torestore a restricted, painful movement to a pain-free and full range state.11,12 MWMs provide apassive pain-free end-range corrective joint glidewith an active movement. It superimposesaccessory movement on the patients activephysiological movement with the aim ofoverriding the obstruction and re-establishingcorrect alignment. The accessory movementtakes the joint through what would be thenormal physiological movement of the joint andit has been found to correct the shoulder malalignment thus inhibiting pain and this leads toincreased ROM.13,14

Gong’s mobilization is a technique in which acorrective AP or longitudinal caudal glide on thehead of the humerus can be sustained while thepatient actively abducts the arm. The therapist’sopposite hand fixates the scapula so that theglide of the humerus is relative to the scapula.It is important to ensure that the AP glide isapplied at right angles to the plane of theglenohumeral joint. The resulting movementmust be pain-free. The patient can also beencouraged to activate specific muscles.15

Joint mobilization techniques are assumed toinduce various beneficial effects includingneurophysiological, biomechanical andmechanical effects. Mobilization have a positiveeffect on treatment of frozen shoulder.16

Pathological changes of the joint capsule causehigh intra-articular pressure, which is associatedwith pain intensity, restriction of the jointcapsule reduces joint motion and shoulderfunction. The aim of manual therapy is to reduceintra-articular pressure by increasing mobility ofthe joint capsule and its surrounding soft tissue.This results in a reduction of pain and increasedrange of motion (ROM) and shoulder function.Therefore, beneficial effects of manual therapycan be expected in patients with relatively highpain intensity, strongly reduced ROM and severelimitation of shoulder function.17

In the treatment of Frozen shoulder, Maitlandmobilization aims to improve the ROM bybreaking adhesion and stretching of capsule18,19

while MWM technique attempt to improve ROMand also corrects the scapulohumeral rhythm byrestoration of correct physiological tracking16 andGong’s mobilization aims to decrease pain andimprove ROM.15

Wontae Gong. et. al concluded that Gong’sMobilization applied to the shoulder joint forshoulder medial rotation was more effectivethan Antero- posterior glides in increasing ROMsince it is an end range mobilization techniquewhich even maintains shoulder joints in normalposition.20 Wontae Gong. et. al also found effectof Gong’s Mobilization increasing shoulderabduction ROM and this technique is better thanAP glides and that Gong’s Mobilization is a usefultreatment in clinical setting because of itsimmediate effects.15

Jing-lan Yang, et al found that the end-rangemobilization/scapular mobilization treatmentapproach (EMSMTA) is more effective onimprovement ROM, disability score, shouldercomplex kinematics than a standardized physicaltherapy program in a subgroup of subjects withfrozen shoulder syndrome(FSS).21 Guler- Uysal,et al found that mobilization increased ROMafter two weeks when comparison to earlyresponse to Cyriax approach of deep frictionmassage in rehabilitation of frozen shoulder.22

Shrivastava Ankit, et al found that the treatmenttechniques Maitland and Mulligan’s improvedthe pain VAS score, shoulder range of motion andShoulder Pain and Disability Index (SPADI) scorebut response to Mulligan’s was better in subjectswith frozen shoulder.23 Jing-lan Yang, et alcompared the use of End range Mobilization,Mid range Mobilization and MWM and foundthat movement strategies in terms ofscapulohumeral rhythm improved after 3 weeksof MWM in subjects with Frozen ShoulderSyndrome (FSS).14 Aimie F. Kachingwe, et al whencompared the effectiveness of four physicaltherapy interventions supervised exercise only,supervised exercise with glenohumeralmobilizations, supervised exercise with am o b i l i za t i o n - w i t h - m o v e m e n t ( M WM )technique, and a control group receiving onlyphysician advice in the treatment of primary


shoulder impingement syndrome found thatMWM group had the highest percentage ofchange in AROM.24

Pamela Teys, Leanne Bisset et al. found that thethere is an initial effects of MWM technique onshoulder ROM in the plane of scapula and PainPressure Threshold (PPT) in subjects withanterior shoulder pain and in subjects withpainful limitation of shoulder movement.13 BangM, Deyle G et al. found that supervised exercisecombined with manual therapy was better thansupervised exercise alone in the treatment ofshoulder impingement.25 Hsu et al. studied onjoint position during mobilization on 11 cadavers,found that the application of an anterior–posterior glide towards the end of range ofabduction was effective in improving the rangeof glenohumeral abduction.26

Despite of many studies, there are no studiesfound in the literature on effect of Gong’sMobilization compared with MWM for subjectswith Frozen shoulder. There is a need to knowwheather there is a difference in effect of Gong’sMobilization versus MWM on improving painand shoulder abduction mobility for subjectswith Frozen shoulder.Hence, the purpose of the study is to find thecomparative effect of gong’s mobilization versusmulligan’s mobilization on pain and shoulderabduction mobility for subjects with frozenshoulder. The objectives of this study were toevaluate the effect of Gong’s Mobilization bymeasuring pre and post intervention pain andshoulder abduction ROM in subjects with Frozenshoulder, to evaluate the effect of Mulligan’sMobilization by measuring pre and postintervention pain and shoulder abduction ROMin subjects with Frozen shoulder, to find thecomparative effect of Gong’s Mobilization versusMulligan’s Mobilization by comparing pain andshoulder ROM measurement pre and postintervention. It was hypothesized that there willbe a significant difference between Gong’sMobilization versus Mulligan’s Mobilization onimproving pain and shoulder abduction mobilityfor subjects with Frozen shoulder.MATERIALS AND METHODSAn Experimental study design with two group-Gong’s group and MWM group. Subject wereincluded with age of 40 to 50 years6 both male

and female subjects. Unilateral Primary Frozenshoulder.27 Subjects having a painful stiffshoulder for at least 3 months.21 Subjects havinglimited Active ROM of a shoulder abductionlimited beyond 120 degree or less.15 Subjectswere excluded with Diabetes mellitus, 21 historyof surgery on the particular shoulder,14

Rheumatoid arthritis,21 painful stiff shoulderafter a severe trauma,16 history of fracturearound shoulder complex,16 rotator cuffrupture,21 Tendon calcification.28

As this study involve human subjects the EthicalClearance has been obtained from the HumanEthical Committee of KTG College ofPhysiotherapy, Bangalore as per the ethicalguidelines for Bio-medical research on humansubjects. The subjects were recruited fromvarious hospitals and physiotherapy clinics,Bangalore and the study was conducted at KTGHospital.Procedure:Randomized into Groups:Individually informed consent was taken from allthe 30 subjects selected for the study on thebasis of inclusion and exclusion criteria. TheGong’s group consists of 15 subjects. The MWMgroup consists of 15 subjects. Randomizationwas done by using thirty pieces of paper with15 pieces having the words Gong’s Mobilizationwritten on them, 15 pieces having the wordsMWM Mobilization. All pieces of paper weretightly folded and placed in a box. After shakingthe box thoroughly, piece of paper waswithdrawn, each piece of paper individuallyhaving the group name on it would be added toa list that corresponded with patient numbersfrom 1-30.Gong’s mobilization:The subjects sat on knee-high chairs with noback support with the spine in a neutral positionand comfortably extended both their arms.Therapist stood on the side opposite to theaffected side. The therapist pushed the scapulaof the affected side in a posterior to anteriordirection with one hand, and pushed thehumeral head in an anterior to posteriordirection parallel to joint plane with the otherhand. This restored the humeral head whichhave been pushed forward, to its normal position.



Simultaneously, the subject was asked to quicklyand powerfully perform shoulder abduction withno external rotation, with elbow flexion incoronal plane, and with palm facing inside andthe back of the hand facing outside. During thistime, the hands of the therapist kept facing thehumeral head with long axis of the palm alongwith the long axis of the humerus. The therapistfollows the subjects performing shoulderabduction, at the same speed while maintaininga little distraction, and adding acceleration in theend range. The procedure was performed Threesets of 10 repetitions, with 1 minute restbetween sets. The same procedure will beperformed 5 session in a week for 3 weeks.15

Fig 1: Gong’s mobilization Fig 2: Movement withmobilization

Fig3: Isometeric ScapularRetraction.

Fig4: Horizontal abductionexercise with thera band

MWM mobilization:The MWM technique was performed on theinvolved shoulder as described by Mulligan. Withthe subject in a relaxed sitting position, aMulligan belt was placed around the head of thehumerus to glide the humerus headappropriately, as the therapist’s hand was usedover the appropriate aspect of the head of thehumerus. A counter pressure also was appliedto the scapula with the therapist’s other hand.

The glide was sustained during slow activeshoulder movements to the end of the pain-freerange and released after return to the startingposition. The procedure was performed Threesets of 10 repetitions, with 1 minute restbetween sets. The same procedure wasperformed 5 session in a week for 3 weeks.14

Conventional Therapy for both the groups:It includes-Pendular exercise- Subject was asked leanforward with unaffected forearm supported ona table or bench. Keeping back straight andshoulder relaxed, gently swing your armforwards and backwards until you feel a mild tomoderate stretch, gently swing your arm incircles clockwise until you feel a mild tomoderate stretch. Repeat the exercise swingingyour arm counter clockwise. Repeat 10 timesprovided the exercise is pain free.14

Isometeric Scapular Retraction- Tie the middleof a thera band to a doorknob and hold the ends.Subject was asked move back away from thedoor until the band is taut, then extend arms infront of the chest with palms facing downward.Flexing the elbows and pull them behind theback as far as possible, squeezing the shoulderblades together. Hold this position for fiveseconds or more.30

Strengthening Rotator cuff- Prone horizontalabduction in which subject was prone with armhanging over side of table and the thumb facingforward. Slowly raise arm straight out to the sideand stop when arm is parallel to the body. Thisexercise was performed 3 sets with 15repetition.30

Horizontal abduction exercise with thera bandin which subject will face towards theattachment site of the thera band, with the armextended straight out in front. Slowly pull armbackwards and out to the side, keeping the armat shoulder height. Row with thera band in whichsubject was asked to extend the arm straightholding thera band and perform rowing motionbackwards, keeping elbows elevated at least 60°away from body. 30

Scapular stabilization exercise- In which subjectwas asked to perform wall and floor push-upswithout bending the elbow. Scapularstabilization with exercise ball in upright standing



position where subject will place the exerciseball against wall and will press the exercise ballkeeping the arm straight.29

Fig 5: Prone horizontal abduction

Fig 6: Scapular stabilization exercise with exercise ball

Fig 7: Row with theraband

Fig 8: Wall push ups

Total duration of treatment was 3 weeks, 5sessions per week.Outcome measuresThe subject’s VAS for pain, active and passiveROM of shoulder abduction mobility weremeasured in both the groups before interventionand after three weeks of intervention. Pain wasmeasured using Visual Analogue Scale (VAS) incm during active shoulder abduction. Shoulderabduction mobility was measured usingGoniometer for active and passive shoulderabduction ROM in degrees.

RESULTS AND TABLES

Statistical Methods:Descriptive statistical analysis has been carriedout in this study. Out Come measurements aremeasured for pain using Visual analog scale incentimeters and Active and passive shoulderabduction ROM and presented as mean ± SD.Significance is assessed at 5 % level ofsignificance with p value 0.05 less than this isconsidered as statistically significant difference.Pearson Chi-Square test and has been used toanalyze the significant of basic characteristic ofgender, age and side distribution of the subjectsstudied. Paired ‘t’ test as a parametric andWilcoxon signed rank test as a non-parametrictest have been used to analysis the variables pre-intervention to post-intervention withcalculation of percentage of change.Independent ‘t’ test as a parametric and MannWhitney U test as a non-parametric test havebeen used to compare the means of variablesbetween groups with calculation of percentageof difference between the means.The Statistical software namely SPSS 16.0, Stata8.0, MedCalc 9.0.1 and Systat 11.0 were usedfor the analysis of the data and Microsoft wordand Excel have been used to generate graphs,tables etc.

The study was carried on total 30 subjects inGong’s Group there were 15 subjects with meanage 43.93 years and there were 7 males 8females were included in the study. In MWMGroup there were 15 subjects with mean age44.93 years and were 8 males 7 females wereincluded in the study. There is no significantdifference in mean ages between the groups. Inboth the groups there were 8 right sided and 7left sided subjects with no significant differencebetween the side distribution between thegroups.Comparison of means of pain and Shoulderabduction ROM between Gong’s Group andMobilization Groups shows that there is nostatistically significant difference in means ofVisual analogue score for pain and shoulderabduction AROM and PROM when preintervention means and post intervention meanswere compared between the groups. There is ano clinical significant difference in post means



with small effect size.Analysis of pain and functional disability withinGong’s and MWM Group shows that in both thegroups there is a statistically significant changein means of Visual analog score and Shoulderabduction AROM and PROM in degrees when

means were analyzed from pre intervention topost intervention within the groups with p<0.000with negative percentage of change showingthat there is decrease in the post means. Thereis clinical significant improvement with largeeffect size in both the groups.

Gong's Group MWM Group

Between the groups

Significancea

15 15 --

43.93± 3.47 44.93± 3.03

(40-50) (40-50)

Males 7 8

Females 8 7

Right 8 8

Left 7 7Side P=1.000 (NS)

Basic Characteristics of the subjects d studied

Number of subjects studied (n)

Age in years(Mean± SD)

p= 0.414 (NS)

Gender P=0.751(NS)

a-Pearson Chi-SquareTable 1: Basic Characteristics of the subjects studied

Significance

(2-tailed)( Non parametric) ( Parametric) P value Lower

Upper

7.23± 1.46 7.64 ± 1.49 Z= -.872 0.13

(5.2- 9.3) ( 5.1 - 9.5 ) P=0 .383 (Small)96.20 ± 21.42 88.33± 16.69 Z= -1.038 0.2

( 61 - 132 ) (65- 122) P=0.299 (Small)107.47 ±

20.5396.60± 16.92 0.27

( 69 - 140 ) (73- 131) (Small)

5.26±1.41 5.61 ± 1.18 Z= -.643 0.13

(3.2-7.4) ( 3.1 - 7.3 ) P=0.520 -1.32 0.62 (small)

122.87 ± 8.22123.47±

15.74 Z=-.062 0.02

( 84 -155) (103-152) P=0.950 (Small)

133.27 ± 22.00 132.87± 14.96

Z=-.083 0.01

( 93 - 165 ) (112-159) P=0.934 (Small)

13.5

Shoulder abduction PROM in degrees

-0.30% 0.058 P =0.954 (NS) -13.7 14.5

Shoulder abduction AROM in degrees

0.97% -0.087 P =0.931 (NS) -14.7

-3.2 24.9

POST INTERVENTION

Visual analog scale score in cm

6.43% -0.742 P =0.465 (NS)


-10.65% Z=-1.495 P=0.135

0.125 P =0.125 (NS)

0.7


-8.52% 0.272 P =0.272 (NS) -6.5 22.2


5.51% 0.458 P =0.458 (NS) -1.51

Percentage of difference

95% Confidence interval of the difference

Effect Size r

PREINTERVENTION

Gong's Group (Mean±SD)

min-max

MWM Group (Mean±SD) min-max

Z valueb t value a

Lower Upper

7.23± 1.46 5.26±1.41 -3.422 0.56

(5.2- 9.3) (3.2-7.4) P <0.001** ( Large)

96.20 ± 21.42

122.87 ± 8.22 -3.415** 0.63

( 61 - 132 ) ( 84 -155) P <0.001** (Large )

107.47 ± 20.53

133.27 ± 22.00

-3.415** 0.51

( 69 - 140 ) ( 93 - 165 ) P <0.001** (Large )

7.64 ± 1.49 5.61 ± 1.18 -3.922 0.6

( 5.1 - 9.5 ) ( 3.1 - 7.3 ) P <0.000** ( Large )

88.33± 16.69

123.47± 15.74

0.73

(65- 122) (103-152) ( Large)96.60± 16.92

132.87± 14.96

-3.413 0.75

(73- 131) (112-159) P <0.000** ( Large)

-36.35 -33.91


37.54% -33.445 P <0.000** -38.59 -33.94


39.78%-3.420P

<0.000**-61.863 P <0.000**

-22.77

MWM Group


-26.57% 12.27 P <0.000** 1.67 2.38


24.00% -18.278 P <0.000** -28.82

2.35


27.72% -32.055 P <0.000** -28.45 -24.88

Visual analog scale score in cm -27.24% 11.09 P <0.000** 1.59

Perecntage change

95%Confidence interval of the difference Effect Size (r)

Gong's Group

Parametric Significance

(2-tailed) P value

t value a (Parametric)

Z value b (Non

parametric significance)

Post intervention (Mean±SD)

min-max

Pre intervention (Mean±SD)

min-max

** Statistically Significant difference p<0.05; NS- Not significant a. Independent t test b. Mann-Whitney TestTable 2: Comparison of means of pain and Shoulder abduction ROM between Gong’s Group and MobilizationGroups (PRE and POST INTERVENTION COMPARISION)

** Statistically Significant difference p<0.05; NS- Not significant; a. Pared t test. b. Wilcoxon Signed Ranks TestTable 3: Analysis of pain and functional disability within Gong’s and MWM Group (Pre to post test analysis)



Graph 1a: Comparison of means of VAS between Gong’sGroup and MWM Group (PRE AND POST INTERVENTION)The above graph shows that there is nostatistically significant difference in means ofVisual analogue scores for pain when pre-intervention and post-intervention means werecompared between Gong’s Group and MWMGroup.

0

20

40

60

80

100

120

140

MWM Group:AROMMWM Group:PROM

Me

an

s o

f S

ho

uld

er

abd

uct

ion

R

OM

in d

eg

ree

s

Preintervention

Post intervention

Preintervention

Post intervention

Graph 2c: Analysis of AROM and PROM within MWMGroup (Pre to post test analysis)

Graph 1b: Comparison of means of SHOULDER ABDUC-TION AROM Gong’s Group and MWM Group (PRE ANDPOST INTERVENTION)The above graph shows that there is no statisti-cally significant difference in means of shoulderAROM when pre-intervention means werecompared between Gong’s Group and MWMGroup.

Graph 1c: Comparison of means of SHOULDER ABDUC-TION PROM Gong’s Group and MWM Group (PRE ANDPOST INTERVENTION)The above graph shows that there is nostatistically significant difference in means ofshoulder PROM when pre-intervention meanswere compared between Gong’s Group andMWM Group.

Graph 2a: Analysis of pain within Gong’s and MWMGroup (Pre to post test analysis)

The above graph shows that there is astatistically significant reduction in means of VAScore when analyzed from pre intervention topost intervention within Gong’s Group andMWM Group.

The above graph shows that there is astatistically significant increase in means ofactive and passive ROM shoulder abduction indegrees when analyzed from pre intervention topost intervention within MWM Group.

Graph 2b: Analysis of Shoulder abduction AROM andPROM within Gong’s (Pre to post test analysis)The above graph shows that there is astatistically significant increase in means ofactive and passive ROM shoulder abduction indegrees when analyzed from pre intervention topost intervention within Gong’s Group.



DISCUSSIONIn this study finding from the analysis found thatthere is no statistically and clinically significantdifference between MWM mobilization andGong’s mobilization on improvement of pain andshoulder mobility after 3 weeks of programmefor subjects with Frozen shoulder. Jointmobilization is a manual therapy that appliespassive traction and gliding motion to thearticular surface to maintain the free mobilityof joints or to restore the normal condition ofjoints. Joint mobilization can be effectively usedto reduce pain and also to improve jointmobility.1,14 The manual therapy like mobilizationhas been shown significantly greaterimprovements in outcome in patients.31 Itproduces a treatment-specific initial hypoalgesicand sympathoexcitatory effect beyond that ofplacebo or control.32 Furthermore, mobilizationtechniques are supposed to increase or maintainjoint mobility by inducing rheologic changes insynovial fluid, enhanced exchange betweensynovial fluid and cartilage matrix, and increasedsynovial fluid turnover.In Gong’s group, the analysis of pain andshoulder mobility within the group shows thatthere is a statistically significant change in meansof VAS and ROM when analyzed from pre-intervention to post intervention. In this studythe increase in shoulder abduction range ofmotion occurred because with Gong’sMobilization, the abduction of the shoulder jointoccurs when the humeral head was in normalposition and the normal muscular contractionoccurs with the rolling and sliding occurring atthe articular surface when the tension ofposterior joint capsule is reduced. The mainadvantage of Gong’s Mobilization is that it canbe done in sitting position, and it providesimmediate effect and it does not require externalrotation to improve abduction which can behelpful in frozen shoulder patient where markedlimitation of external rotation is present. HenceGong’s Mobilization can be considered as auseful manual therapy tool in the managementof frozen shoulder. Joint mobilization is a passivemovement applied to the joint surfaces, soshoulder mechanics under passive conditionsneed to be considered. The joint glides thataccompany glenohumeral motions support the

clinical practice of restoring translationalmovement to restore full physiological motionin the shoulder joint, even though care must betaken in attributing joint translations to externalmobilizing glides. Wontae Gong. et. al carried outa study on the effects of Gong’s Mobilizationapplied to the shoulder joint on shoulder medialrotation on 40 subjects and gave Antero-posterior glides in 20 and Gong’s Mobilizationin 20 subjects. They concluded that Gong’sMobilization was more effective in increasingROM since it is an end range mobilizationtechnique which even maintains shoulder jointsin normal position.20 Vermeulen et al studied tocompare the effectiveness of high-grademobilization techniques (HGMT) with that oflow-grade mobilization techniques (LGMT) insubjects with adhesive capsulitis of the shoulderand HGMTs appear to be more effective inimproving glenohumeral joint mobility andreducing disability than LGMTs.33 Nicholsonstudied on the effect of passive joint mobilizationon pain and hypomobility associated withadhesive capsulitis of the shoulder. He mobilizedin a gentle way in the anatomical neutralposition, progressing in later sessions toward theend of the ROM and concluded that only thepassive glenohumeral abduction in theexperimental group increased after 4 weeks, andpain scores did not differ between groups.34

In MWM group, analysis of pain and shouldermobility within the group who received MWMwith conventional therapy shows that there is astatistically significant change in means of VASand ROM when analyzed from pre interventionto post intervention within the group.MWM improve the normal extensibility of theshoulder capsule and stretch the tightened softtissues to induce beneficial effects. It alsoindicates that the adhesive capsule and associ-ated contracted periarticular structures can onlybe stretched by MWM. Normalization ofscapulohumeral rhythm, however, was achievedwith MWM techniques in subjects, however inour study the changes in scapulohumeral rhythmwas not measures. Furthermore, improvedmobility & functional ability also were observedafter MWM treatment in various studies. Thesefindings suggest that MWM could increase mo-bility and improve motor strategies with regard



to the scapulohumeral rhythm in people withFrozen shoulder. Wright et al. has postulated thatthe mechanisms responsible for manual therapytreatment effects in the increases in ROM mayfeasibly involve changes in the joint, muscle, painand motor control systems.35 Joint mobilizationtechniques are assumed to induce variousbeneficial effects. The neurophysiologic effect isbased on the stimulation of peripheral mechan-oreceptors and the inhibition of nociceptors. Thebiomechanical effect manifests itself whenforces are directed toward resistance but withinthe limits of a subject’s tolerance. The mechani-cal changes may include breaking up of adhe-sions, realigning collagen, or increasing fiberglide when specific movements stress thespecific parts of the capsular tissue. Due to thecause of positional faults it has been suggestedas changes in the shape of articular surfaces,thickness of cartilage, orientation of fibers of liga-ments and capsules, or the direction and pull ofmuscles and tendons. MWMs correct this byrepositioning the joint, causing it to tracknormally. Mulligan originally postulated a “posi-tional fault” to explain the results gained throughhis techniques. Such a concept would seem moreapplicable to pain experienced during rest whilethe major benefit of MWMs is the restorationof mobility and/or the alleviation of pain withmovement or functional activities. The mecha-nisms behind the effectiveness of MWMs arebased on mechanical dysfunction and thereforepositional fault further mechanisms and effectsthat may underpin MWM techniques, includinghypoalgesic and sympathetic nervous system(SNS) excitation effects.The study shows that Gong’s Group and MWMGroup have shown statistically and clinicallyshown significant improvement in pain andshoulder abduction mobility following 3 weeksof intervention. The MWM Group subjects foundclinically greater improvement in comparison toGong’s Group. Subjects in MWM Group showedreduced pain level by a VAS of -26.57% and-27.24% in Gong’s Group. The participant’sshoulder abduction AROM was increased by39.78% in MWM Group and 27.72% in Gong’sGroup. The participant’s shoulder abductionPROM was increased by 37.54% in MWM Groupand 24.00% in Gong’s Group.

The results indicate significant differences in VASand shoulder abduction AROM and PROM withgreater percentage of change both variableswhich were found to be greater in the MWMGroup. The difference in improvements can bevariables as the baseline parameters when preintervention comparison of means of VAS scoreand ROM between the Gong’s group and MWMgroup found that there is no statisticallysignificant difference with small effect size.Therefore this may also interfere with the postintervention means.Both the groups received conventional therapyconsisting mobility and strengthening exercisesthat includes pendular exercise, isometricscapular retraction, horizontal abductionexercise, scapular stabilization exercise,strengthening rotator cuff exercise.Improvement in the outcome parameters alsocould be due to conventional exercises.Therefore the study is lacking with control groupwho received only conventional exercises, it isalso lacking to find the effect with otherconventional exercises such as combinedUltrasound therapy, pain reliving methods.The study was found that the small effect sizewith wider range 95% CI between the groupsshowing small sample size that might haveshown no difference between the groups. Thefindings in this study are based on the subjectswith age of 40 to 50 years 5 having painful stiffshoulder for at least 3 months,16 limited Activeshoulder abduction ROM beyond 120 degree orless was selected.15 Therefore effects cannot begeneralized with other age groups, severity,secondary frozen shoulder. Based on thepurpose of the study standardized outcomemeasures such as pain and shoulder abductionmobility were measured but not consideredchanges in other ROM and functional activities.Moreover the study was carried for three weekslong term effects of both mobilizationtechniques cannot be predictable.Hence based on the analysis and findings, thepresent study found that 3 weeks of MWMmobilization and Gong’s mobilization foundstatistically no significant difference onimprovement of pain and shoulder mobility forsubjects with frozen shoulder. Therefore thestudy accepts null hypothesis.



CONCLUSIONThe present study concludes that the 3 weeksof combined MWM with conventional exercisesand Gong’s mobilization with conventionalexercise found statistically and clinicallysignificant effect on improving pain, active andpassive shoulder abduction ROM for subjects forfrozen shoulder but there is no significantdifference between both kind of mobilization onimproving pain and ROM. However, clinicallyMWM Group was found to be more effectivethan Gong’s Group.It is clinically important to consider combinedMWM with conventional exercises and Gong’smobilization with conventional exercise areeffective for patients with frozen shoulderaffected with abduction mobility.Limitations of the study1. Subjects with small range group between 40to 50 years of age were considered for the study,thus results cannot be generalized to other agegroups.2. Follow-up was not done therefore long termeffects were not known.3. Only abduction ROM and pain were measured.4. Sample size is less.Recommendations for future research1. Further study is lacking with control groupwho received only conventional exercise.2. Study on long term effects of bothmobilization techniques needed.3. Further study should also be done to find theeffect with other conventional exercise such ascombined ultrasound therapy, pain, relivingmethods with the mobilization technique.4. Further study should needed measuring effecton other outcome measurements.ACKNOWLEDGMENTAuthors were expressing their sense ofgratitude’s to the people who helped andencouraged them for the guidance andcompletion of this study.

REFERENCESConflicts of Interest: None


1. Vermeulen HM, Obermann WR, Burger BJ, Kok GJ,Rozing PM, van Den Ende CH. End-rangemobilization techniques in adhesive capsulitis of the

shoulder joint: a multiple-subject case report.Phys Ther. 2000; 80: 1204-1213.

2. Neviaser RJ, Neviaser TJ. The Frozen shoulder:diagnosis and management. Clinical Orthop. 1995;223: 59-64.

3. Vermeulen HM, Obermann WR, Burger BJ, Kok GJ,Rozing PM, van Den Ende CH. End-rangemobilization techniques in adhesive capsulitis of theshoulder joint: a multiple-subject case report. PhysTher. 2000; 80: 1204-1213.

4. Vermeulen HM, Stokdijk et al. Measurement of 3dimensional shoulder movement patterns withelectromagnetic tracking device in patient withFrozen shoulder. Ann Rbeum DIS. 2002; 61: 115-120.

5. Uhthoff H, Boileau P: Primary frozen shoulder: aglobal capsular stiffness versus localizedcontracture. Clin Orthop 2007; 456:79Y84.

6. Carette S, Moffet FN, Tardif J, et al. Intraarticularcorticosteroids, supervised Physiotherapy or acombination of the two in the treatment ofAdhesive capsulitis of the shoulder. Arthritis andRheumatism. March 2003; 48(3): 829-838.

7. Mao. Et al. Frozen shoulder; correlation betweenresponse to Physiotherapy and follow up shoulderArthrography, Archives of Physical Medicine andRehabilitation. 1997; 78: 857-9.

8. Mao. Et al. Frozen shoulder; correlation betweenresponse to Physiotherapy and follow up shoulderArthrography 1999; 78: 855-8.

9. Guler- Uysal F, Kozanoglu E. Comparision of theearly response of two methods of rehabilitation inadhesive capsulitis. Swiss Med Wkly. 2004 Jan 12;134(23-34): 355-8.

10. Mulligan BR 1993 Mobilisations with movement.Journal of Manual and Manipulative Therapy 1(4):154–156.

11. Mulligan BR. Manual Therapy ‘Nags’, ‘Snags’, ‘PRP’s’etc., 3rd edn Plane View Services, Wellington, NewZealand 1995.

12. V icenzino B, Wright A . Effects of a novelmanipulative physiotherapy technique on tenniselbow: a single case study. Manual Therapy 1995;1(1):30–35.

13. Pamela Teys, Leanne Bisset, Bill Vicenzino. Theinitial effects of a mulligan’s mobilization withmovement technique on range of movement andpressure pain threshold in pain limited shoulders.Manual Therapy 2006 July.

14. Yang J, Chang C, Chen S, Wang SF, Lin J. Mobilizationtechniques in subjects with frozen shouldersyndrome: Randomized multiple-treatment trial.Physical Therapy 2007;87:1307-15.

15. Wontae Gong, Hyunmin Lee, Yoonmi Lee, Effects ofGong’s Mobilization Applied to Shoulder Joint onShoulder Abduction. J. Phys. Ther. Sci 2011; 23: 391-393.



16. Irem Duzgun, Gul Baltaci, Ozgur Ahmet. ManualTherapy is an effective treatment for Frozenshoulder in Diabetics: An Observational study.Eklem Hastalik Cerrahisi 2012; 23(2): 94-99.

17. Duthrie R, Bentley G. Mercer’s Orthopaedic Surgery,9th edn. Oxford, UK: Oxford University Press, 1996.

18. Ellen Hengeveld, Kevin Banks.“maitland’s peripheralmanipulation” 4th edition 2002.

19. Carolyn Kisner and Lynn Allen Colby. “TherapeuticExercise” 4th edition 2002.

20. Wontae Gong, Hyunja Jeong, Eunyoung Kim. Effectsof Gong’s Mobilization Applied to Shoulder Jointon Shoulder Medial Rotation. J. Phys. Ther. Sci2012; 24: 279-281.

21. Jing-lan Yanga, Mei-Hwa Janb, Chein-wei Changa,Jiu-jenq Linb. Effectiveness of the end-rangemobilization and scapular mobilization approachin a subgroup of subjects with frozen shouldersyndrome: A randomized control trial. ManualTherapy 2012;vol 17: 47-52.

22. Guler- Uysal, Kozanoglu. Comparison of the earlyresponse to two methods of rehabilitation inadhesive capsulitis. Swiss Med Wkly, 2004; 134:353-358.

23. Shrivastava Ankit, Shyam Ashok K, Sabnis Shaila,Sancheti Parag. Randomised Controlled Study ofMulligan’s v/s Maitland Mobilization Technique inAdhesive Capsulitis of Shoulder joint. Indian Journalof Physiotherapy and Occupational Therapy 2011,vol : 5, 12-15.

24. Millar AL, Jasheway PA, Eaton W, Christensen F. Aretrospective, descriptive study of shoulderoutcomes in outpatient physical therapy. J OrthopSports Phys Ther 2006; 36:403–414.

25. Bang M, Deyle G. Comparison of supervised exercisewith and without manual physical therapy forpatients with shoulder impingement syndrome.Journal of Orthopaedic & Sports Physical Therapy2000;30:126–37.

26. Bang M, Deyle G. Comparison of supervised exercisewith and without manual physical therapy forpatients with shoulder impingement syndrome.Journal of Orthopaedic & Sports Physical Therapy2000;30:126–37.

27. Andrea J. Johnson, DPTSc , Joseph J. Godges, DPT,Grenith J. Zimmerman, PhD, Leroy L. Ounanian, MDThe Effect of Anterior Versus Posterior Glide JointMobilization on External Rotation Range of Motionin Patients With Shoulder Adhesive Capsulitisjournal of orthopaedic & sports physical therapyvolume 37 No. 3 march 2007, 89-99.

28. Rundquist PJ, Anderson DD, Guanche CA andLudewig PM. Shoulder Kinematics in subjects withFrozen shoulder. Archives of Physical Medicine andRehabilitation 2003; 84:1473-9.

29. Derya Celik. Comparison of the outcomes of twodifferent exercise program on Frozen shoulder. ActaOrthop Traumatol Turc 2010;44(4):285-292.

30. Marc Bernier. Exercise to strengthen the Rotatorcuff muscles in the shoulder. 25th Feb 2005.

31. Caroline Gillot.Text book of bone deformities,Garhwalprakashan: maharastra , 1998; 96 -99.

32. Jean-Jacques Abitbol, MD (Orthopedic Surgeon)leading Causes of Sciatica 2010; 72:556-8Cleland J,Childs J, Palmer J, Eberhart S. 2006.

33. Henricus M Vermeulen, Piet M Rozing, Wim ROberman. Comparison of High grade and Low gradeMobilization technique in the management ofadhesive capsulitis of shoulder: RandomizedControlled Trial. Physical Therapy. 2006; vol 86no3:355-68.

34. Nicholson GG. The effect of passive jointmobilization on pain and hypomobility associatedwith adhesive capsulitis of the shoulder. J OrthopSports Phys Ther. 1995;6:238 –246.

35. Wright A. Hypoalgesia post manipulative therapy:a review of a potential neurophysiologicalmechanism. Manual Therapy 1995;1:11–6.

How to cite this article:Mehta Bryna Pankaj, Vinod Babu. K, Sai Kumar. N, Asha D. Comparitiveeffect of Gong’s moblisation versus Mulligan’s mobilisation on pain andshoulder abduction mobility in Frozen shoulder. Int J Physiother Res2013;05:227-37.

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