Effects of two different mobilization techniques on pain, range of motion and functional disability in patients with adhesive capsulitis: a comparative study – Duke Center of Excellence in Manual and Manipulative Therapy

Author Names

Agarwal, S., Raza, S., Moiz, J. A., Anwer, S., & Alghadir, A. H.

Reviewer Name

Meera V. Bucklin, SPT

Reviewer Affiliation(s)

Duke University student of Physical Therapy

Paper Abstract

This study aimed to compare the effects of two different mobilization techniques in the management of patients with adhesive capsulitis. Thirty non-diabetic men and women with adhesive capsulitis were randomly allocated to the reverse distraction group (n=15) or Kaltenborn group (n=15). The reverse distraction technique and Kaltenborn’s caudal and posterior glides (grades III and IV) were applied 10–15 times along with conventional physical therapy for 18 treatment sessions in 6 weeks. The pain was measured with a visual analog scale, abduction, and external rotation range of motion with goniometry, hand behind back reach with inch tape, and functional disability with the Flexilevel scale of shoulder function before and after the treatment. Although all the variables improved significantly in both groups after 18 intervention sessions, reverse distraction was significantly better than Kaltenborn’s caudal and posterior glides in decreasing pain and improving abduction range of motion and functional scores. This study supports the clinical use of reverse distraction as an alternative to conventional mobilization techniques to decrease pain and improve range of motion and functional scores in patients with adhesive capsulitis.

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?

Was the method of randomization adequate (i.e., use of randomly generated assignment)?

Was the treatment allocation concealed (so that assignments could not be predicted)?

Were study participants and providers blinded to treatment group assignment?

Were the people assessing the outcomes blinded to the participants’ group assignments?

Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?

Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?

Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?

Was there high adherence to the intervention protocols for each treatment group?

Were other interventions avoided or similar in the groups (e.g., similar background treatments)?

Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?

Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?

Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?

Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?

Key Finding #1

The reverse distraction technique has a greater decrease in pain compared to the Kaltenborn mobilization technique by a significant amount (p<0.001). Both groups had significant decreases in pain by the end of 18 treatment sessions over 6 weeks.

Key Finding #2

This is the first study of this kind that compare the two techniques in patients with adhesive capsulitis. Some studies have shown the effectiveness of a reverse distraction technique in conjunction with other mobilizations or the effectiveness of reverse distraction in increasing mobility or reducing pain

Key Finding #3

There are no studies to support and explain why the reverse distraction is a better mobilization technique than the Kaltenborn. Further research is needed to explain the findings of this study.

Key Finding #4

This study states that because of capsular restrictions pain association a glenohumeral joint mobilization that is applied before a scapular mobilization can cause further pain. The study notes the need for improvement in adjoining joint mobility before getting the best effects for GH mobilization.

Please provide your summary of the paper

This study found significantly better outcomes in patients with nondiabetic adhesive capsulitis with a reverse distraction technique compared to a Kaltenborn end range lateral and posterior glides with lateral distraction. This comparative study randomly assigned 15 patients fitting inclusion criteria to either group and had a dropout rate of 1 participant per assignment leaving 28 participants total in the study. Patients were treated with their respective intervention for 3 sessions a week for 6 weeks, with a total of 18 visits. Changes in pain, ROM, and functional ability were measured before and after each intervention. The study found that active and passive abduction increased significantly in both treatment groups and pain levels decreased in both treatment groups. The reverse distraction technique had a more significant decrease in pain than the Kaltenborn. Decreases in pain are attributed to several mechanisms such as stimulation of Golgi tendons and type II mechanoreceptors, inhibition of type IV nociceptors, and reflex inhibition. There are no other studies to explain why the reverse distraction technique is better than the Kaltenborn, and further research is needed to support this study’s findings.

Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.

This study offers good evidence to support the implementation of two different manual techniques but lacks a comparison to treatment without manual therapy. While both groups had good outcomes the standardized other treatments for adhesive capsulitis with PROM, AROM, and strengthening could contribute to the progression of the client through treatment and pain. The impact on my clinical practice this article made has been my appreciation of the variety of manual therapy techniques there are- I think I was unaware of all the different techniques available for mobilization and how nuanced each can be to the point of comparative studies and significant differences in pain outcomes. I believe this study can impact how I practice knowing the research behind each individual manual technique I can best discern what technique I can use to implement with different diagnoses. In my practice there are good changes I will see a patient with adhesive capsulitis who would benefit in pain and ROM outcomes with manual techniques and knowing which one has the best outcomes can help me discern what to choose as my treatment for the best outcomes for my patients.