rozen shoulder syndrome (FSS)is a condition of uncertain etiol-ogy characterized by a progres-sive loss of both active and passiveshoulder motion.
Clinical syn-dromes include pain, a limited rangeof motion (ROM), and muscle weak-ness from disuse.
The natural his-tory is uncertain. Some authors
have argued that adhesive capsulitisis a self-limiting disease lasting as lit-tle as 6 months, whereas other au-thors
suggest that it is a morechronic disorder causing long-termdisability. Although the pathogenesis of FSS isunknown, several authors
haveproposed that impaired shoulder movements are related to shoulder capsule adhesions, contracted softtissues, and adherent axillary recess.Cyriax
suggested that tightness in a joint capsule would result in a pat-tern of proportional motion restric-tion (a shoulder capsular pattern in which external rotation would bemore limited than abduction, which would be more limited than internalrotation). Based on the absence of asigniﬁcant correlation between joint-space capacity and restricted shoul-der ROM, contracted soft tissuearound the shoulder may be relatedto restricted shoulder ROM.
Ver-meulen and colleagues
indicatedthat adherent axillary recess hindershumeral head mobility, resulting indiminished mobility of the shoulder.Furthermore, they documented thatabnormal scapular motion existed inpatients with FSS despite improve-ment in glenohumeral motion fol-lowing a 3-month period of physicaltherapy intervention.
Apparently,impaired shoulder movements affectfunction. In longitudinal follow-upstudies lasting from 6 months to 2 years,
signiﬁcant numbers of patients with FSS demonstrated mod-erate functional deﬁcits.To regain the normal extensibility of the shoulder capsule and tight softtissues, passive stretching of theshoulder capsule and soft tissues by means of mobilization techniqueshas been recommended, but limiteddata supporting the use of thesetechniques are available.
Mid-range mobilization (MRM), end-range mobilization (ERM), and mobi-lization with movement (MWM)techniques have been advocated by Maitland,
but they did not base their suggestions on research. Addition-ally, few studies have described theuse of these techniques in patients with FSS. Due to the performance of techniques (MRM and ERM with or without interscalene brachial plexusblocks), a lack of quantitative andqualitative outcome criteria, an in-appropriate research design (casereports and clinical trials withoutcontrols), and utilization of other treatment modalities (home exer-cises and hot and cold packs), it isnot possible to draw ﬁrm conclu-sions about the efﬁcacy of mobiliza-tion in patients with FSS.The aim of our study was to investi-gate the effect of mobilization treat-ment and to determine whether adifference of treatment efﬁcacy exists among 3 mobilization tech-niques (MRM, ERM, and MWM) inpatients with FSS. The functional sta-tus and kinematic variables of three-dimensional shoulder complexmovements were included in thisstudy. The null hypothesis was thatthere would be no signiﬁcant differ-ence among the 3 mobilization tech-niques in the functional status andshoulder kinematics during armelevations.
Research Design andTreatment Assignment
A multiple-treatment trial on 2groups was carried out. Themultiple-treatment trial involves theapplication of 2 or more treatmentsin a single subject.
It is used tocompare the effects of 2 or moretreatments. We used the multiple-treatment design to leverage the po-tential to assess differences among 3different forms of mobilization with only 2 groups.In a comparison of 3 different formsof mobilization with 2 groups, theadvantages of our design were thefollowing. First, a high adherencerate was expected in our subjects.The subjects usually did not adhereto the treatment program when theeffects of treatment were not obvi-ous, leading to loss of follow-up dur-ing MRM treatment in our study. Sec-ond, the overall number of subjectsneeded to reach a level of statisticalpower was lower in our design thanin 3 different forms of mobilization with 2 groups. Third, each subjectserved as his or her own control ineach group in our design. Variability in individual differences among sub- jects was removed from the error term in each group in our design.Consenting subjects were randomly assigned by computer-generated per-muted block randomization of 5 by sequentially numbered, sealed,opaque envelopes to receive differ-ent mobilization treatments. Ingroup 1, an A-B-A-C (A
ERM, and C
MWM) multiple-treatment design was used. In group2, an A-C-A-B multiple-treatment de-sign was used. The 2 groups usedhere were intended to counterbal-ance the order effects of treatments.There were 3 weeks in each phase.The differences in outcomes acrossthe 4 phases of the study were ex-amined. Because of our mobilizationprocedures, the subjects were notmasked to the intervention. To min-imize bias, an independent trainedoutcome assessor, masked to treat-ment allocation, evaluated the partic-ipants at baseline and at 3-week in-tervals for 12 weeks.
Mobilization Techniques for Frozen Shoulder Syndrome
Physical Therapy Volume 87 Number 10 October 2007