Author Names
Johnson, A. J., Godges, J. J., Zimmerman, G. J., & Ounanian, L. L
Reviewer Name
Marie-Adelaide Robinson, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
Study Design: Randomized clinical trial. Objective: To compare the effectiveness of anterior versus posterior glide mobilization techniques for improving shoulder external rotation range of motion (ROM) in patients with adhesive capsulitis. Background: Physical therapists use joint mobilization techniques to treat motion impairments in patients with adhesive capsulitis. However, opinions of the value of anterior versus posterior mobilization procedures to improve external rotation ROM differ. Methods and Measures: Twenty consecutive subjects with a primary diagnosis of shoulder adhesive capsulitis and exhibiting a specific external rotation ROM deficit were randomly assigned to 1 of 2 treatment groups. All subjects received 6 therapy sessions consisting of application of therapeutic ultrasound, joint mobilization, and upper-body ergometer exercise. Treatment differed between groups in the direction of the mobilization technique performed. Shoulder external rotation ROM measured initially and after each treatment session was compared within and between groups and analyzed using a 2-way ANOVA, followed by paired and independent t tests. Results: There was no significant difference in shoulder external rotation ROM between groups prior to initiating the treatment program. A significant difference between groups (P = .001) was present by the third treatment. The individuals in the anterior mobilization group had a mean improvement in external rotation ROM of 3.0° (SD, 10.8°; P = .40), whereas the individuals in the posterior mobilization group had a mean improvement of 31.3° (SD, 7.4°; P<.001). Conclusions: A posteriorly directed joint mobilization technique was more effective than an anteriorly directed mobilization technique for improving external rotation ROM in subjects with adhesive capsulitis. Both groups had a significant decrease in pain.
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
- Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Cannot Determine, Not Reported, or Not Applicable
- Were study participants and providers blinded to treatment group assignment?
- Yes
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- No
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- No
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Cannot Determine, Not Reported, or Not Applicable
- Was there high adherence to the intervention protocols for each treatment group?
- Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- 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?
- No
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- Cannot Determine, Not Reported, or Not Applicable
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
- Yes
Key Finding #1
The use of a posterior GH glide proved more effective to increase shoulder external rotation ROM in patients with adhesive capsulitis than an anterior GH glide.
Key Finding #2
The joint capsule plays an important role in the translation of the humeral head during movement.
Key Finding #3
In contrary to the convex-concave rules, tension in the capsular tissues controls the translatory movements of the humeral head, as tension increases the more the arm is elevated, it causes a reduction in posterior and inferior translation of the humeral head.
Key Finding #4
A tight rotator cuff interval found in adhesive capsulitis limits ROM and can produced unwanted anterosuperior translation, which diminishes posterior translation of the humeral head.
Please provide your summary of the paper
This study shows that posterior mobilizations (PM) of the GH joint had more effect in increasing external rotation of the shoulder than anterior mobilizations (AM) in patients with adhesive capsulitis. Each patient underwent thermal ultrasound to alter the viscoelastic properties of the capsule to maximize the intervention followed by immediate anterior or posterior sustained mobilization for 15 minutes at a grade 3 stretch mobilization, each held for a minute long. Each patient was put at their end range of abduction and ER before lateral traction and the mobilization was applied. Following treatment, each patient exercised on an upper body ergometer in the forward position only for 3 minutes in their pain-free range to limit soreness. After 6 sessions, the patients that underwent AM, 2 lost ER ROM, 1 had no change, and 7 improved. In contrast, all patients increased ROM in ER with posterior mobilizations. It is important to note that the improvements in ROM in the AM group did not exceed 18 degrees, whereas in the PM group, the improvements were in the 22-45 degree range. Overall, the findings of this study provide a different perspective on mobilizations to increase ER in patients with adhesive capsulitis. The concave-convex rules are based on joint geometry, therefore, as the GH is concave and the humeral head is convex, an anterior mobilization would theoretically be more beneficial to increase external rotation.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Overall, the findings prove that contrary to concave-convex rules of the glenohumeral joint, posterior mobilizations had better outcomes in increasing external rotation in patients with adhesive capsulitis. This finding will be important in the treatment of patients that are limited in external rotation due to adhesive capsulitis. Knowing where the capsule has the most tension is key. The more the arm is elevated, the tension in the capsule increases, therefore, decreased the posterior and inferior translation of the humeral head. Furthermore, a tight rotator cuff interval can place the humeral head in a more anterosuperior position, diminishing the posterior translation.
