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  • Does Passive Mobilization of ShoulderRegion Joints Provide Additional BenefitOver Advice and Exercise Alone forPeople Who Have Shoulder Pain andMinimal Movement Restriction?A Randomized Controlled TrialRoss Yiasemides, Mark Halaki, Ian Cathers, Karen A. Ginn

    Background. Passive mobilization of shoulder region joints, often in conjunctionwith other treatment modalities, is used for the treatment of people with shoulderpain and minimal movement restriction. However, there is only limited evidencesupporting the efficacy of this treatment modality.

    Objective. The purpose of this study was to determine whether passive mobili-zation of shoulder region joints adds treatment benefit over exercise and advice alonefor people with shoulder pain and minimal movement restriction.

    Design. This was a randomized controlled clinical trial with short-, medium- andlonger-term follow-up.

    Setting. The study was conducted in a metropolitan teaching hospital.

    Patients. Ninety-eight patients with shoulder pain of local mechanical origin andminimal shoulder movement restriction were randomly allocated to either a controlgroup (n51) or an experimental group (n47).

    Intervention. Participants in both groups received advice and exercisesdesigned to restore neuromuscular control at the shoulder. In addition, participantsin the experimental group received passive mobilization specifically applied toshoulder region joints.

    Measurements. Outcome measurements of shoulder pain and functionalimpairment, self-rated change in symptoms, and painful shoulder range of motionwere obtained at 1, 3, and 6 months after entry into the trial. All data were analyzedusing the intention-to-treat principle by repeated-measures analyses of covariance.

    Results. No statistically significant differences were detected in any of the out-come measurements between the control and experimental groups at short-,medium-, or longer-term follow-up.

    Limitations. Therapists and participants were not blinded to the treatmentallocation.

    Conclusion. This randomized controlled clinical trial does not provide evidencethat the addition of passive mobilization, applied to shoulder region joints, toexercise and advice is more effective than exercise and advice alone in the treatmentof people with shoulder pain and minimal movement restriction.

    R. Yiasemides, Discipline of Phys-iotherapy, Faculty of Health Sci-ences, Sydney Medical School,The University of Sydney, Sydney,New South Wales, Australia.

    M. Halaki, PhD, is Lecturer, Disci-pline of Exercise and Sport Sci-ence, Faculty of Health Sciences,The University of Sydney.

    I. Cathers, PhD, is Senior Lecturer,Discipline of Exercise and SportScience, Faculty of Health Sci-ences, The University of Sydney.

    K.A. Ginn, PhD, is Associate Pro-fessor, Discipline of BiomedicalScience, Sydney Medical School,The University of Sydney, Sydney,New South Wales, Australia.Address all correspondence toAssociate Professor Ginn at:

    [Yiasemides R, Halaki M, Cathers I,Ginn KA. Does passive mobiliza-tion of shoulder region joints pro-vide additional benefit over adviceand exercise alone for people whohave shoulder pain and minimalmovement restriction? A random-ized controlled trial. Phys Ther.2011;91:178189.]

    2011 American Physical TherapyAssociation

    Research Report

    Post a Rapid Response tothis article

    178 f Physical Therapy Volume 91 Number 2 February 2011

  • Shoulder pain is a common com-plaint, with the prevalenceranging from 20% to 33% in theadult population.14 It has beenreported that shoulder pain is thethird most frequent musculoskeletalcomplaint, after back and knee pain,in the general community.4 In 2007,the US Bureau of Labor Statisticsreported that injuries to the shoulderin the workforce required the mostnumber of days off work, with amedian of 18 days to recuperate.With the exception of the knee andwrist, the shoulder took at leasttwice the median time to recovercompared with all other body parts.5

    Nocturnal disturbance, the inabilityto sleep on the affected side, func-tional disability, and a reduction inthe overall quality of life are com-mon complaints resulting fromshoulder pain.68

    Manual therapy in the form of pas-sive joint mobilization is used byphysical therapists for the manage-ment of pain, including shoulderpain, and often is used in conjunc-tion with other treatment modalities,including exercise therapy.911 Forthe management of shoulder pain,mobilization techniques are com-monly applied to the joints of theshoulder region (glenohumeral,acromioclavicular, and sternoclavic-ular joints), to the scapula, to thejoints of the cervicothoracic verte-bral column, and to the ribs. Passivejoint mobilization aims to manageshoulder pain by physiologicalmechanisms (eg, inducing hypoanal-gesia)12,13 or by mechanical mecha-nisms (eg, restoring normal biome-chanical relationships by addressingrelated joint stiffness).14

    Clinical trials that have investigatedthe effectiveness of passive jointmobilization therapy, whichincluded mobilization of the cervico-thoracic vertebral column and ribs,for the management of painful shoul-der dysfunction indicate that this

    form of mobilization therapy ismore effective than other therapymodalities. Winters et al15 demon-strated greater, more rapid de-crease in pain in patients withacute and chronic shoulder painwho received manipulation andmobilization of vertebral column,ribs, or shoulder region joints thanthose who received massage, exer-cises, and electrotherapy. Inaddition, patients with chronicshoulder pain demonstrated addedtreatment benefit (greater decreasein pain intensity and functional lim-itation) when passive mobilizationof vertebral column or shoulder re-gion joints were added to exercis-es.16 In the only clinical trial thathas investigated mobilization andmanipulation therapy specificallyapplied to the vertebral columnand ribs for the management ofshoulder pain, patients who re-ceived the manual therapy in addi-tion to usual care reported signifi-cantly greater overall improvementand decrease in pain.17

    Despite their common use, littleevidence is available to support thecontribution of passive mobilizationapplied specifically to shoulder regionjoints in the management of painfulshoulder conditions. Indeed, the re-sults of a recent well-powered ran-domized controlled trial (RCT)indicate that this form of manual ther-apy is not more effective than exer-cises and advice from a physical ther-apist in the management of thepainfully restricted shoulder.18 Theseresults support the findings of anotherstudy of a small sample of participantsin which passive mobilizations ofshoulder region joints were found tobe ineffective in the management ofadhesive capsulitis.19 Only one RCTthat examined the effects of passivemobilization of shoulder region jointsin patients diagnosed with impinge-ment syndrome showed limited evi-dence in support of the benefit of thistreatment modality.20

    Although the evidence indicating noadditional benefit of passive mobili-zations of shoulder region jointsabove exercise and advice in painful,restricted shoulder conditions18,19 ismounting, little information is avail-able regarding the effectiveness ofthis modality for the treatment ofpeople with shoulder pain and min-imal movement restriction. There-fore, a clear clinical rationale for theuse of mobilization therapy appliedto shoulder region joints for the man-agement of nonrestricted painfulshoulder conditions has not beenestablished. As passive joint mobili-zation therapy is most commonlyused in conjunction with other treat-ment modalities and with increasingevidence to support the efficacy ofexercise therapy in the managementof painful shoulder conditions,2126

    the specific aim of the study was todetermine whether low-velocity pas-sive joint mobilization therapy spe-cifically applied to shoulder regionjoints (glenohumeral, acromioclavic-ular, and sternoclavicular joints) andpassive mobilization of the scapulaadd benefit over exercise and advicealone in the treatment of peoplewith shoulder pain and minimalmovement restriction.

    MethodDesign OverviewThis RCT compared passive mobili-zation of shoulder region joints,exercise, and advice with exerciseand advice alone for the treatment ofpeople with shoulder pain and min-imal movement restriction. Prior to

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    Passive Mobilization of Shoulder Joints

    February 2011 Volume 91 Number 2 Physical Therapy f 179

  • group allocation, baseline outcomemeasurements were obtained. Fol-lowing measurements of pain, func-tional ability, and painful activerange of motion (AROM), partici-pants were randomly allocated to anexperimental or control group basedon a concealed assignment schedulethat had been generated by an inves-tigator who was not involved withrecruitment, treatment, or outcomemeasure assessment in the study.Primary outcome measurements ofpain, functional impairment, andself-rated improvement wereobtained from participants whowere not blinded to treatment groupallocation at 1, 3, and 6 months afterrandomization. Secondary outcomemeasurements of painful AROMwere obtained by a researcher (R.Y.)blinded to group allocation at thesame time points.

    Setting and ParticipantsAll patients referred to the outpa-tient physical therapy department ata large metropolitan governmenthospital with painful active flexion

    or abduction shoulder movements ofgreater than 1 months duration andminimal shoulder movement restric-tion were eligible to particip