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PHYS THER-2007-Yang-1307-15

PHYS THER-2007-Yang-1307-15

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Published by: Terapia Manual Perú on Aug 02, 2013
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doi: 10.2522/ptj.20060295Originally published online August 7, 20072007; 87:1307-1315.
PHYS THER.
Shwu-Fen Wang and Jiu-jenq LinJing-lan Yang, Chein-wei Chang, Shiau-yee Chen,
TrialMultiple-TreatmentShoulder Syndrome: RandomizedMobilization Techniques in Subjects With Frozen
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Mobilization Techniques in SubjectsWith Frozen Shoulder Syndrome:Randomized Multiple-Treatment Trial
Jing-lan Yang, Chein-wei Chang, Shiau-yee Chen, Shwu-Fen Wang, Jiu-jenq Lin
Background and Purpose
The purpose of this study was to compare the use of 3 mobilization techniques—end-range mobilization (ERM), mid-range mobilization (MRM), and mobilization with movement (MWM)—in the management of subjects with frozen shoulder syndrome(FSS).
Subjects
Twenty-eight subjects with FSS were recruited.
Methods
 A multiple-treatment trial on 2 groups (A-B-A-C and A-C-A-B, where
ϭ
MRM, B
ϭ
ERM,and C
ϭ
MWM) was carried out. The duration of each treatment was 3 weeks, for atotal of 12 weeks. Outcome measures included the functional score and shoulder kinematics.
Results
Overall, subjects in both groups improved over the 12 weeks. Statistically significantimprovements were found in ERM and MWM. Additionally, MWM correctedscapulohumeral rhythm significantly better than ERM did.
Discussion and Conclusion
In subjects with FSS, ERM and MWM were more effective than MRM in increasingmobility and functional ability. Movement strategies in terms of scapulohumeralrhythm improved after 3 weeks of MWM.
J Yang, PT, MS, is Physical Thera-pist, Department of Physical Med-icine and Rehabilitation, NationalTaiwan University Hospital, Taipei,Taiwan.C Chang, MD, is Professor, De-partment of Physical Medicineand Rehabilitation, National Tai-wan University Hospital.S Chen, PT, MS, is PhysicalTherapist, Department of In-ternal Medicine, Taipei MedicalUniversity–Municipal Wan FangHospital, Taipei, Taiwan.SF Wang, PT, PhD, is AssociateProfessor, School and GraduateInstitute of Physical Therapy, Col-lege of Medicine, National TaiwanUniversity.J Lin, PT, PhD, is Lecturer, Schooland Graduate Institute of PhysicalTherapy, College of Medicine, Na-tional Taiwan University, Floor 3,No. 17, Xuzhou Rd, ZhongzhengDistrict, Taipei City 100, Taiwan. Address all correspondence to Dr Lin at: lxjst@ha.mc.ntu.edu.tw.[Yang JI, Chang C, Chen S, et al.Mobilization techniques in sub-jects with frozen shoulder syn-drome: randomized multiple-treatment trial.
Phys The
.2007;87:1307–1315.]© 2007 American Physical Therapy Association
Research Report
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October 2007 Volume 87 Number 10 Physical Therapy
f
1307
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F
rozen shoulder syndrome (FSS)is a condition of uncertain etiol-ogy characterized by a progres-sive loss of both active and passiveshoulder motion.
1–3
Clinical syn-dromes include pain, a limited rangeof motion (ROM), and muscle weak-ness from disuse.
1,2,4
The natural his-tory is uncertain. Some authors
5,6
have argued that adhesive capsulitisis a self-limiting disease lasting as lit-tle as 6 months, whereas other au-thors
7–9
suggest that it is a morechronic disorder causing long-termdisability. Although the pathogenesis of FSS isunknown, several authors
10–13
haveproposed that impaired shoulder movements are related to shoulder capsule adhesions, contracted softtissues, and adherent axillary recess.Cyriax
10
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.
11
 Ver-meulen and colleagues
3,12
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.
13
 Apparently,impaired shoulder movements affectfunction. In longitudinal follow-upstudies lasting from 6 months to 2 years,
3,12–15
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.
3,16–23
Mid-range mobilization (MRM), end-range mobilization (ERM), and mobi-lization with movement (MWM)techniques have been advocated by Maitland,
17
Kaltenborn,
18
and Mulli-gan,
19,20
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 efficacexists 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.
Method
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.
24,25
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 (
ϭ
MRM,B
ϭ
ERM, and C
ϭ
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
1308
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Physical Therapy Volume 87 Number 10 October 2007
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