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The Effects of Passive Joint Mobilization on Pain and Hypomobility Associated with Adhesive Capsulitis of the Shoulder GARVICE G. NICHOLSON, MS, PT' The purpose of this investigation was to determine the effects of passive mobilization and active exercises in patients with painfully restricted shoulders.RESULTS A summary of the initial descriptive group data is presented in Table 1.The force and am- plitude of the treatment movements varied, but eventually all experimental subjects were able to tolerate grade IV oscillations (small amplitude mo- tions at the end of the range of motion) without significant discomfort.The experimental subjects performed active and resistive exercises after the passive mobilization treatments and were in- structed to perform them independently three times daily.All motions studied, except internal rotation in the control group, increased significantly from base- line levels over the 4-week period with consist- ently greater gains in the mobilizationgroup.Pain questionnaires were answered and isolated glenohumeral mobility measurements were taken initially and at weekly intervals during the 4 weeks of treatment.With the exception of internal rotation in the control groop, all motions increased'significantly from baseline in both groups.Pain scores decreased significantly from baseline in the experimental group and not in controls.Passive abduction improved significantly more in the mobilization group than in the control group.Pain scores decreased more in the mobilization group; however, the difference between the groups was not significant.Adhesive capsulitis, periarthritis, and frozen shoulder are all terms used to describe a painful stiffness of the glenohumeral joint.Twenty patients with painful glenohumeral restrictions were randomly placed in one of two groups.The experimental group received mobilization and active exercises two to three times per week for 4 weeks.The results suggest that joint mobilization and exercises are clinically effective in the treatment of painfully stiff shoulders.Table 2 shows the mean increases in glenohumeral range of motion and mean reductions in pain scores for each group.The controls received only active exercises.An

The Effects of Passive Joint
Mobilization on Pain and Hypomobility
Associated with Adhesive Capsulitis of
the Shoulder GARVICE G. NICHOLSON, MS, PT'
The purpose of this investigation was to determine the effects of passive mobilization and active exercises in patients with painfully restricted shoulders. Twenty patients with painful glenohumeral restrictions were randomly placed in one of two groups. The experimental group received mobilization and active exercises two to three times per week for 4 weeks. The controls received only active exercises. Pain questionnaires were answered and isolated glenohumeral mobility measurements were taken initially and at weekly intervals during the 4 weeks of treatment. With the exception of internal rotation in the control groop, all motions increased'significantly from baseline in both groups. Passive abduction improved significantly more in the mobilization group than in the control group. Pain scores decreased more in the mobilization group; however, the difference between the groups was not significant. The results suggest that joint mobilization and exercises are clinically effective in the treatment of painfully stiff shoulders.
Adhesive capsulitis, periarthritis, and frozen shoulder are all terms used to describe a painful stiffness of the glenohumeral joint. Reeves," in a long-term study of the natural history of frozen shoulder, concluded that the disease is self-limit- ing; however, many patients suffer for more than 3 years with an average duration of 30.1 months. A disability of this duration can obviously place severe emotional and economic hardship on the affected individual. Clinical reports of patients with adhesive capsulitis show considerable variability in methods of treatment; however, virtually all of them advocate some form of exercise to restore m~bility.',~.'~
Joint mobilization is a form of passive move- ment in a broad spectrum of exercise used to treat painful and stiff synovial joints. Several forms of mobilization exist and terminology varies among the authorities. For the purpose of this study, mobilization will refer to passive oscillatory movements of one articular surface in relation to its counterpart. The oscillatory movements will be
Department of Physical Therapy. University of Alabama Hospital, Birmingham. AL; and Division of Physical Therapy. School of Commu- nity and Allied Health, University of Alabama in Birmingham.
in the direction of the joint's accessory motions which are small spinning, gliding, rolling, or dis- tractive motionsthat occur betweenjoint surfaces and are essential for normal mobility. An example of an accessory motion at the shoulder would be movement of the humeral head inferiorly as it moves on the glenoid fossa during normal abduc- tion. This gliding motion is necessary for the greater tuberosity of the humerus to pass under the coracoacromial arch and thereby allow full elevation of the arm. Accessory motions can be demonstrated in normal, synovial joints when an examiner passively moves one articular surface while the other is stabilized.
The use of joint mobilization by physical thera- pists in the United States has proliferated as a result of the coverage this treatment has received in the many short courses offered in nonclinical settings.* Several textbooks on the examination and techniques of joint mobilization are available by such authorities as C y r i a ~K, ~altenb~rnM,~ait- land,' and Mennell;' however, very few controlled clinical trials to establish the therapeutic value of mobilization have been reported in the literature. Reasons why research in mobilization has been
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JOSPT JanlFeb 1985 THERAPY FOR SHOULDER PAIN AND STIFFNESS 239
so limited include the following: 1) joint mobiliza- tion is frequently used in combination with other physical therapy procedures, such as thermal agents and other forms of exercise; 2) the force, direction, and amplitude of the therapeutic move- ments are continually modified based on the sub- jective and objective responses of the patient; and 3) many of the parameters of manual proce- dures are difficult to quantify.
The purpose of this investigation was to deter- mine the effects of passive joint mobilization, in combination with an active exercise program, on pain and hypomobility associated with adhesive capsulitis of the shoulder. The results were com- pared with those of patients receiving only active exercise.
The importance of careful examination and se- lection of a specific course of treatment for each patient obviates the use of an identical method of treatment for all patients. Thus, the intent of this study was to assess the therapeutic value of gentle, passive joint movement as an adjunct to other aspects of a physical therapy program.
METHOD
The study ,was conducted in the Department of Physical Therapy, University of Alabama Hospital, Birmingham, Alabama. Letters and verbal com- munications describing the study were extended to various medical services in Birmingham, and subjects were considered for admission to the study as soon as they were referred from a phy- sician. The presence of shoulder pain and limited passive motion at the glenohumeraljoint were the criteria for eligibility with the following exclusions: 1) unstable fracture of the humerus, scapula, or clavicle, 2) recurrent dislocation or subluxation of the shoulder, 3) rheumatic disease, 4) advanced osteoporosis, 5) malignancy, 6) history of exten- sive steroid therapy, 7) severe pain unrelieved by resting the joint, and 8) peripheral neurological involvement in the upper extremity.
If the eligibility criteria were met and informed consent was obtained, the subjects were as- signed to either the experimental or control group, using the toss of a coin, i.e., when the first subject consented, a coin toss determined the group as- signment and the next successive subject was assigned to the opposite group. The coin toss was repeated for each odd numbered subject.
During the initial session after group assign- ment, each patient completed a pain question- naire to assess the degree and nature of the
symptoms. Also at the initial session, a history, subjective examination, and objective examina- tion relative to the involved shoulder were per- formed. The cervical spine, acromioclavicular, sternoclavicular, scapulothoracic, and elbow joints were also examined to determine if these areas were the sources of the patient's signs and symptoms.
Measurements of active internal and external rotation, active abduction and passive abduction of the shoulder were performed similarly to the method described by Lee et aL5 Active and pas- sive abduction were measured with the patient positioned supine, the scapula stabilized manually by pressing firmly against the acromion while the angle between the humerus and the lateral chest wall was determined by a goniometer (Fig. 1). Measurement of internal and external rotation was accomplished with the patient standing. A cuff, with a pointer, was attached to the patient's arm just superior to the elbow. A protractor encir- cling the elbow was placed just inferior to the pointer and the patient was instructed to rotate his arm internally and externally without protract- ing or retracting the scapula (Fig. 2 and 3). All mobility measurements were visualized and re- corded by an assistant who was unaware of the patient's group designation.
Assessment of pain and mobility was done initially before treatment started and then at weekly intervals for a period of 4 weeks; final measurements were taken following the 4-week treatment period. Subjects in both groups re- ported for treatment two to three times per week during the 4-week period. A schematic of the examination and treatment sequence is shown in Figure 4.
Fig. 1. Measurement of passive glenohumeral abduction.
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240
NICHOLSON JOSPT Vol. 6,No. 4
Fig. 2 . Measurement of active internal rotation
In addition to the weekly measurements of pain and mobility, passive motion was examined prior to each treatment to assess the degree of stiff- ness and irritability. Manual muscle testing was performed to assess strength.
These data were used to determine the treat- ment program for that session. During the treat- ment sessions, the control subjects performed active exercises in those ranges found to be restricted and additional resistive exercises if weaknesses were present. The controls were instructed to repeat the exercises three times per day independently.
In the experimental group, examination of the assessory motions determined the direction of the mobilization movements. Generally, in the early sessions gliding and distractive mobilizationtech- niques were performed with the joint near its neutral position, progressing in the later sessions to mobilization toward the end of the range of motion. During abduction, for instance, inferior glide of the humerus was performed with the shoulderinapproximately25' ofabduction;sub- sequently progressionto inferior glide at the indi- vidual's limit of abduction (Figs. 5 and 6). The decision to progress to mobilization at the end of
Fig. 3. Measurement of active external rotation.
the range of motion was based on the patient's satisfactory tolerance of mobilization within the range and a "leveling off" of progress made by the less vigorous techniques. The force and am- plitude of the treatment movements varied, but eventually all experimental subjects were able to tolerate grade IV oscillations (small amplitude mo- tions at the end of the range of motion) without significant discomfort. The experimental subjects performed active and resistive exercises after the passive mobilization treatments and were in- structed to perform them independently three times daily.
RESULTS
A summary of the initial descriptive group data is presented in Table 1. Table 2 shows the mean increases in glenohumeral range of motion and mean reductions in pain scores for each group. All motions studied, except internal rotation in the control group, increased significantly from base- line levels over the 4-week period with consist- ently greater gains in the mobilizationgroup. Pain scores decreased significantly from baseline in the experimental group and not in controls. An