Joint mobilization versus self-exercises for limited glenohumeral joint mobility: randomized controlled study of management of rehabilitation

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1 Clin Rheumatol (2010) 29: DOI /s BRIEF REPORT Joint mobilization versus self-exercises for limited glenohumeral joint mobility: randomized controlled study of management of rehabilitation Kazunari Tanaka & Ryuichi Saura & Noriyo Takahashi & Yuko Hiura & Remi Hashimoto Received: 15 February 2010 /Revised: 23 May 2010 /Accepted: 9 June 2010 /Published online: 29 June 2010 # Clinical Rheumatology 2010 Abstract To clarify the optimal management of rehabilitative intervention for limited glenohumeral joint mobility (LGHM) arising from adhesive capsulitis, particularly focusing on the frequency of sessions for joint mobilization and the self-exercise compliance, the functional results of 120 patients with LGHM were prospectively investigated as follows: Differences in improved angle of the shoulder joint (IA) and the time required to reach the range of motion plateau point (T) were compared by (1) age, (2) gender, (3) handedness, (4) duration before rehabilitative intervention, (5) frequency of sessions for joint mobilization by physical therapists in the hospital setting, and (6) self-exercise compliance in the home setting. The lengths of therapy and follow-up were 4.6 and 5.9 months, respectively. IA significantly decreased in the 71-year-old and above group. There were no significant differences in IA between male and female. IA of the dominant-handed group was significantly higher than that of the nondominant-handed group. There were no significant differences in T in each item. IA of the group that had experienced more than 7 months of the condition was significantly low. Although the frequency of joint mobilization by physical therapists in the hospital setting showed no relationship with IA or T, IA was significantly higher and T was significantly shorter in the group that performed self-exercise every day than in the groups that performed less. In conclusion, early intervention and self-exercise in the home setting are more important factors than session K. Tanaka (*) : R. Saura : N. Takahashi : Y. Hiura : R. Hashimoto Department of Rehabilitation Medicine, Division of Comprehensive Medicine, Osaka Medical College, 2-7, Daigaku-machi, Takatsuki, Osaka , Japan reh030@poh.osaka-med.ac.jp frequency of joint mobilization in the hospital setting for the successful management of rehabilitation for LGHM. Keywords Frozen shoulder. Joint mobilization. Limited glenohumeral joint mobility. Management. Randomized controlled trial. Rehabilitation. Self-exercise Introduction Limited glenohumeral joint mobility (LGHM) arises from adhesive capsulitis and frequently develops into frozen shoulder (FS) [1]. Although it is common and the patients typically demonstrate characteristic clinical presentations (pain and stiffness of the shoulder), its still unclear etiology has led to its poor understanding and unclear opinions on its appropriate treatment. Despite FS being generally considered to resolve spontaneously within 1 or 2 years [2], Shaffer et al. [3] demonstrated in their long-term follow-up study that 50% of patients will experience pain or some mild restriction of movement, whereas 11% will experience some residual disability even several years after treatment. Consequently, the treatment protocol is very important. Many clinical trials on treatments have been reported [4 6]. However, the response of patients to these treatments has been mixed and has not been proven clearly. Although rehabilitation is considered as the initial non-operative treatment [7], there is no standardized management protocol [8 10]. While various rehabilitative interventions are performed depending on the institution, the optimal use of common physical therapies (e.g., modalities, exercise, and joint mobilization) and the frequency and timing of session criteria have not yet been established [11]. Moreover, the cost effectiveness of the protocol has not been clarified also. Hauzeur [12]

2 1440 Clin Rheumatol (2010) 29: concluded in his review that rehabilitation could be useful but that the data were too preliminary to lead to any definitive conclusions. The purpose of this study was to clarify the preferable management of physical therapy for LGHM, focusing on the frequency of sessions for joint mobilization and the selfexercise compliance. Materials and methods This study was approved by the local research ethics committee. Following the explanation of the purpose of the study, protection of privacy, and use of personal information, written informed consent was obtained from all the patients in accordance with the Declaration of Helsinki. Participants Among patients who consulted our institute with the complaint of shoulder pain, patients who fulfilled the following inclusion criteria were requested to participate in this study: unremarkable medical history and no clinical or radiological findings that could explain the decrease in shoulder motion. Patients receiving corticosteroidal injections into the joint during the intervention were excluded from the study because of the possibility of affecting the improvement of the symptom. Study design We performed a randomized, placebo-controlled, participant and single assessor-blinded trial. From the frequency of sessions for joint mobilization by physical therapists in the hospital setting, the patients were divided randomly into the high-frequency session group (HF group, more than two times a week), moderate-frequency session group (MF group, once a week), and low-frequency session group (LF group, less than once a week). Interventions In the hospital setting, patients received the same standardized intervention including joint mobilization of the shoulder joint by physical therapists for 40 min per day (it is the usual duration of physiotherapy in Japan) and instruction on self-exercises to be performed in the home setting. Mobilization techniques were used in this study as described by Vermeulen et al. [13], which are performed in the end-ranges of limited joint mobility. Self-exercises included Codman s or pendulum exercises (circumduction) [2] and passive stretching exercises such as climbing the wall exercise (i.e., facing a wall about three quarters of an arm s length away and raising the affected arm up to the shoulder level using only one s fingers without using shoulder muscles). The patients were instructed to perform these exercises within the painless range, two to three times each day. Investigated items The point in time at which improvement in the range of motion (ROM) of the shoulder joint had plateaued for more than 1 month was defined as the ROM plateau point. The functional outcome was investigated in terms of improved angle of the shoulder joint (IA: defined as the value obtained by subtracting the affected shoulder joint angle at baseline from the angle of the ROM plateau point) and the time required to reach the ROM plateau point (T). IA and T were compared in terms of the following items: (1) age, (2) gender, (3) handedness, (4) duration before rehabilitative intervention, (5) frequency of sessions for joint mobilization by physical therapists in the hospital setting, and (6) self-exercise compliance in the home setting. Self-exercise compliance was assessed using a questionnaire at the time of the final evaluation. Angle measurements The angle of joints was evaluated in terms of active abduction angle at which the capsular pattern of FS characteristically causes the most restriction [14]. Angle was assessed using a large handheld goniometer. Abduction angle was evaluated with the patient in the supine position to limit the contribution of scapulothoracic motion. ROM was measured every week by one examiner who was not informed of the group designation of patients. Measurement was performed three times, and their average angle was applied. Statistical analysis We focused on IA and T. Descriptive data are presented as mean ± SD. For baseline angle, one-factor analysis of variance (ANOVA) was used with respect to items 1 and 5, and the Wilcoxon Mann Whitney test was used with respect to items 2 and 3. Linear regression analysis was used for the evaluation of correlations of IA and T with items 1 and 4. Differences between paired groups of data were evaluated using the Wilcoxon Mann Whitney test (items 2 and 3). One-factor ANOVA and the Bonferroni test for multiple comparisons were used for IA and T with respect to items 1 and 4 6. Differences were considered significant when the p value was <0.05. Statistical analyses were performed using SPSS 13.0J for Windows (SPSS Japan Inc., Tokyo, Japan). Results Among 475 patients (men, 211; women, 264) who were years of age and consulted us with the complaint of shoulder pain, 137 patients who fulfilled the inclusion

3 Clin Rheumatol (2010) 29: criteria were requested to participate in this study. We recruited 120 patients with their written informed consent. The mean age (±SD) of the participants was 63.7±9.1 years; the numbers of affected shoulders were 60 for the dominant side and 50 for the non-dominant side. The results of ten patients (men, 7; women, 3) were excluded from the data analysis because they received corticosteroidal injections during this study. Finally, 110 patients (men, 52; women, 58) were enrolled in this study (Fig. 1). The average length of therapy was 4.6±1.2 months and the follow-up time was 5.9±1.3 months. The demographics of the participants are shown in Table 1. Age, gender, handedness, and duration before rehabilitative intervention Linear regression analysis showed a weak correlation between IA and age (y= x , R 2 =0.1043). In particular, IA significantly decreased in the 71-year-old and above group (95% CI , p=0.001; Table 2). There were no significant differences in IA between male and female. With regard to handedness, the IA of the dominant-handed group was significantly higher than that of the non-dominant-handed group (95% CI , p=0.010). There were no significant differences in T for each item. Regarding the relationship between the duration before rehabilitative intervention and outcome, IA of the group that had experienced more than 7 months of the condition was significantly low (95% CI , p=0.018). However, linear regression analysis did not indicate a relationship of the duration with IA or T (y= x , R 2 = ; y= x , R 2 =0.0023, respectively). Frequency of sessions for joint mobilization and compliance of self-exercise Although the frequency of joint mobilization by physical therapists in the hospital setting showed no relationship with IA or T, IA was significantly higher and T was significantly shorter in the group that performed selfexercise every day. The levels of self-exercise compliance in the home setting in each group were as follows: LF group, 55.6% (every day, 12; several times/week, 8; not done, 16); MF group, 40% (every day, 7; several times/ week, 7; not done, 21); and HF group, 61.5% (every day, 13; several times/week, 11; not done, 15; Table 3). Discussion The adhesion of the shoulder joint capsule is reversible in the acute stage; however, in the chronic stage, ROM restoration is minimal [15]. From the current findings, if Patients who consulted the outpatient clinic of our institute with the complaint of shoulder pain n=475 Patients were classified as having LGHM (n=137) Enrollment (n=120) Excluded (n=17) No consent from patients Randomization (n=120) HF group (n=40) MF group (n=40) LF group (n=40) Excluded (n=1) received corticosteroidal injections Excluded (n=4) received corticosteroidal injections HF group (n=39) LF group (n=36) Excluded (n=5) received corticosteroidal injections MF group (n=35) LGHM = Limited glenohumeral joint mobility; HF = high-frequency session; MF = moderate-frequency session, LF = lowfrequency session. Fig. 1 Flowchart of participants. LGHM limited glenohumeral joint mobility, HF high-frequency session, MF moderate-frequency session, LF low-frequency session

4 1442 Clin Rheumatol (2010) 29: Table 1 Demographics for each item (age, gender, handedness, frequency of sessions) Baseline abduction angle (95% CI) a (deg) p value Age b 50 and below (n=11) 20.9±38.1 ( ) s (n=27) 114.6±21.4 ( ) 60s (n=51) 107.1±29.1 ( ) 71 and above (n=21) 108.8±32.1 ( ) Gender c Male (n=52) 118.5± Female (n=58) 103.6±25.6 Handedness c Dominant (n=60) 104.3± Non-dominant (n=50) 118.3±31.3 Frequency of sessions for joint LF group (n=36; male, 17; female, 19) 106.1±36.4 ( ) mobilization in hospital setting b MF group (n=35; male, 17; female, 18) 112.1±22.9 ( ) HF group (n=39; male, 18; female, 21) 113.5±26.3 ( ) Values are mean ± SD 95% CI 95% confidence interval, LF group low-frequency session group, MF group moderate-frequency session group, HF group high-frequency session group a The abduction angle on first admission to the clinic b One-factor ANOVA c Wilcoxon Mann Whitney test Table 2 Comparison of parameters (IA and T) for each item (age, gender, handedness, duration of the condition) Values are mean ± SD 95% CI 95% confidence interval a IA: The value obtained by subtracting affected shoulder joint angle at baseline from the angle of the ROM plateau point with the significant values (p<0.05) in bold b T: The time required to reach the ROM plateau point at which improvement in ROM of the shoulder joint had plateaued for more than 1 month c Bonferroni test d Wilcoxon Mann Whitney test e The duration of the condition before rehabilitative intervention IA (95% CI) a (deg) p value T (95% CI) b (months) p value Age c 50 and below (n=11) 69.5±14.6 ( ) 4.45±1.13 ( ) 50s (n=27) 54.1±22.2 ( ) NS 4.56±1.09 ( ) NS 60s (n=51) 54.0±26.7 ( ) NS 4.55±0.92 ( ) NS 71 and above (n=21) 34.0±21.8 ( ) ±1.64 ( ) NS 50s (n=27) 54.1±22.2 ( ) 4.56±1.09 ( ) 60s (n=51) 54.0±26.7 ( ) NS 4.55±0.92 ( ) NS 71 and above (n=21) 34.0±21.8 ( ) ±1.64 ( ) NS 60s (n=51) 71 and above (n=21) 34.0±21.8 ( ) ±0.92 ( ) Gender d 5.10±1.64 ( ) NS Male (n=52) 55.8±23.9 NS 4.53±1.01 NS Female (n=58) 47.3± ±1.29 Handedness d Dominant (n=60) 59.3± ±1.29 NS Non-dominant (n=50) 42.8± ±0.97 Duration of the condition c,e Less than a month (n=37) 47.7±26.5 ( ) 4.76±0.83 ( ) Less than 3 months (n=39) 56.7±22.8 ( ) NS 4.67±1.42 ( ) NS Less than 6 months (n=21) 60.0±20.4 ( ) NS 4.48±1.12 ( ) NS More than 7 months (n=13) 35.8±30.7 ( ) NS 4.54±1.15 ( ) NS Less than 3 months (n=39) 56.7±22.8 ( ) 4.67±1.42 ( ) Less than six months (n=21) 60.0±20.4 ( ) NS 4.48±1.12 ( ) NS More than 7 months (n=13) 35.8±30.7 ( ) ±1.15 ( ) NS Less than 6 months (n=21) 60.0±20.4 ( ) 4.48±1.12 ( ) More than 7 months 35.8±30.7 ( ) ±1.15 ( ) NS

5 Clin Rheumatol (2010) 29: Table 3 Comparison of the parameters (IA and T) for each item (frequency of sessions for joint mobilization in hospital setting; self-exercise compliance in home setting) IA (95% CI) a (deg) p value T (95% CI) b (months) p value Frequency of sessions for joint mobilization in hospital setting c LF group (n=36) 49.3±28.1 ( ) 4.61±0.84 ( ) MF group (n=35) 49.9±24.2 ( ) NS 4.77±0.97 ( ) NS HF group (n=39) 56.4±24.0 ( ) NS 4.56±1.52 ( ) NS MF group (n=35) 49.9±24.2 ( ) 4.77±0.97 ( ) HF group (n=39) 56.4±24.0 ( ) NS 4.56±1.52 ( ) NS Self-exercise compliance in home setting (frequency of self-exercise) c Every day (n=32) 63.9±19.5 ( ) 3.97±0.95 ( ) Several times/week (n=26) 55.0±21.7 ( ) ±0.93 ( ) Not done (n=52) 38.4±27.2 ( ) < ±1.24 ( ) <0.001 Several times/week (n=26) 55.0±21.7 ( ) 4.80±0.93 ( ) Not done (n=52) 38.4±27.2 ( ) ±1.24 ( ) NS Values are mean ± SD 95% CI 95% confidence interval, LF group low-frequency session group, MF group moderate-frequency session group, HF group high-frequency session group a IA: The value obtained by subtracting affected shoulder joint angle at baseline from the angle of the ROM plateau point with the significant values (p< 0.05) in bold b T: The time required to reach the ROM plateau point at which improvement in ROM of the shoulder joint had plateaued for more than 1 month c Bonferroni test the condition persists for an extended duration, the improved angle of the shoulder joint likely decreases significantly. This suggests the importance of early intervention. However, patients often do not consult a physician when their shoulder joint contractures are not yet severe (flexion, 60 ; abduction, 90 ; external rotation, 60 ; internal rotation, 45 ) [16]. This is due to the fact that patients with the shoulder joint affected only unilaterally can live independently by compensation movement of the trunk and shoulder girdle [17]. That is, by the time the limitation of ROM in the shoulder joint causes disabilities in activity of daily living, the contracture is already severe and difficult to treat. Therefore, education on LGHM as a cause of FS and information on the effectiveness of early intervention are important for successful management. Non-operative treatment is typically prescribed initially. Many authors reported their high rate of successful nonoperative treatment [18, 19]. In non-operative treatment, there is no doubt that physical therapy is the key treatment [20]. Joint mobilization, education, and instruction on selfexercise are generally indicated. The joint mobilization technique is considered to selectively stress certain parts of the joint capsule [6]. However, although many investigators advocate joint mobilization for pain reduction and ROM improvement [9, 21], there has been insufficient evidence to demonstrate its efficacy even now [6]. On the other hand, exercises based on a strategy of stretching structural stiffness are another key [22]. The patients receive instructions on its methods from a therapist and are required to perform on their own in the home setting. Several exercises, such as Codman s exercise and climbing the wall exercise, have been well known and recommended. However, there is no study in which the optimal management of exercise (type and frequency) was investigated scientifically. Diercks et al. [23] compared the effects in an intensive physical therapy group with those in a supervised neglect group (pendulum exercises and active exercises within the painless range). They reported that the supervised neglect group made significant improvements in ROM and pain. They concluded that aggressive stretching beyond the pain threshold could be detrimental to recovery. Kelly et al. [6] reported that three factors should be considered when calculating the dose or total amount of stress applied to a tissue: intensity, frequency, and duration. They proposed that the tensile stress dose applied while stretching should be based on the patient s irritability classification. Our results indicated that the effectiveness of selfexercise depends on its frequency. Significant improvements observed in the dominant-handedness group, in which patients would likely use the affected shoulder in everyday life, also support this hypothesis. However, the self-exercise compliance may become another problem. The results showed poor compliance in performing selfexercise (more than 47% of the patients were classified into the not done group). Another important goal may be to increase the compliance level. The treatment course of LGHM is long and arduous at times. Compliance with the

6 1444 Clin Rheumatol (2010) 29: exercise program is vital and leads to the successful maintenance of an appropriate self-exercise program [24]. Patients should be educated on the importance of self-exercise and thus be encouraged to develop self-responsibility in the management of their physical problems [6]. The finding that the compliance level in the HF group is highest suggests that a high frequency of sessions in the hospital setting may be effective to increase the compliance level. However, a high frequency of sessions implicates high costs. Therefore, further research focusing on the balance between self-exercise compliance and the frequency of sessions with consideration of cost effectiveness is necessary. Finally, we used ROM as the endpoint because the Japanese health insurance system requires improvement determination by numerical comparison when we prescribe the continuation of rehabilitative intervention. However, the International Classification of Functioning and/or questionnaires (e.g., SRQ and SDQ) are considered to be more sensitive in assessing the function level and health-related quality of life. Further study of activity-related outcomes is also required. Disclosures References None 1. Matsen FA, Chebli CM, Lippitt SB (2007) Principles for the evaluation and management of shoulder instability. Instr Course Lect 56: Codman EA (1934) The shoulder. Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Thomas Todd, Boston 3. Shaffer B, Tibone J, Kerlan R (1992) Frozen shoulder. A longterm follow-up. J Bone Joint Surg Am 74: Bell S, Coghlan J, Richardson M (2003) Hydrodilatation in the management of shoulder capsulitis. Australas Radiol 47: Hamdan T, Al-Essa KA (2003) Manipulation under anesthesia for the treatment of frozen shoulder. Int Orthop 27: Kelley MJ, McClure PW, Leggin BG (2009) Frozen shoulder: evidence and a proposed model guiding rehabilitation. J Orthop Sports Phys Ther 39: Finnoff JT (2006) Musculoskeletal problem of the upper limb. In: Braddom RL (ed) Physical medicine and rehabilitation, 3rd edn. Saunders, Philadelphia, pp Grubbs N (1993) Frozen shoulder syndrome: a review of literature. J Orthop Sports Phys Ther 18: Green S, Buchbinder R, Hetrick S (2003) Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev, Art. no. CD Anton HA (1993) Frozen shoulder. Can Fam Physician 39: Nicholson GC (1985) The effects of passive joint mobilization on pain and hypomobility associated with adhesive capsulitis of the shoulder. J Orthop Sports Phys Ther 6: Hauzeur JP (2004) Conservative treatment of the painful shoulder. Rev Méd Brux 25: Vermeulen HM, Obermann WR, Burger BJ, Kok GJ, Rozing PM, van den Ende CH (2000) End-range mobilization techniques in adhesive capsulitis of the shoulder joint: a multiple-subject case report. Phys Ther 80: Cyriax J (1978) Textbook of orthopedic medicine, vol 1: diagnosis of soft tissue lesions, 7th edn. Macmillan, New York 15. Mao CY, Jaw WC, Cheng HC (1997) Frozen shoulder: correlation between the response to physical therapy and follow-up shoulder arthrography. Arch Phys Med Rehabil 78: Darlene H, Randolph MK (1996) The shoulder and shoulder girdle. In: Darlene H, Randolph MK (eds) Management of common muscloskeletal disorders physical therapy principles and methods, 3rd edn. Lippincott Williams & Wilkins, Baltimore, pp Fayad F, Hanneton S, Lefevre-Colau MM, Poiraudeau S, Revel M, Roby-Brami A (2008) The trunk as a part of the kinematic chain for arm elevation in healthy subjects and in patients with frozen shoulder. Brain Res 1191: Griggs SM, Ahn A, Green A (2000) Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am 82: Levine WN, Kashyap CP, Bak SF, Ahmad CS, Blaine TA, Bigliani LU (2007) Nonoperative management of idiopathic adhesive capsulitis. J Shoulder Elbow Surg 16: Owen H (1997) Frozen shoulder. In: Donatelli RA (ed) Physical therapy of the shoulder. Churchill Livingstone, New York, pp Vermeulen HM, Rozing PM, Obermann WR, le Cessie S, Vliet Vlieland TP (2006) Comparison of high-grade and low-grade mobilization techniques in the management of adhesive capsulitis of the shoulder: randomized controlled trial. Phys Ther 86: Mueller MJ, Maluf KS (2002) Tissue adaptation to physical stress: a proposed physical stress theory to guide physical therapist practice, education, and research. Phys Ther 82: Diercks RL, Stevens M (2004) Gentle thawing of the frozen shoulder: a prospective study of supervised neglect versus intensive physical therapy in seventy-seven patients with frozen shouler syndrome followed up for twoyears. J Shoulder Elbow Surg 13: Harrast MA, Rao AG (2004) The stiff shoulder. Phys Med Rehabil Clin N Am 15: