EVALUATION OF MULLIGAN S TECHNIQUE FOR ADHESIVE CAPSULITIS OF THE SHOULDER

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1 J Rehbil Med 2013; 45: ORIGINAL REPORT EVALUATION OF MULLIGAN S TECHNIQUE FOR ADHESIVE CAPSULITIS OF THE SHOULDER Gokhn Doner, PT, MSc 1, Zeynep Guven, MD 2, Ayçe Atly, MD 2 nd Reyhn Celiker, MD 2 From the 1 Özel Acdemic Hospitl, Nuh Kuyusu Cd Bğlrbşı, Üsküdr nd 2 Acibdem University, Fculty of Medicine, Deprtment of Physicl Medicine nd Rehbilittion, İstnbul, Turkey Objective: To evlute Mullign s technique for relieving pin nd improving functionl cpcity of the shoulder in ptients with dhesive cpsulitis in the stiffness phse. Design: Rndomized controlled study. Methods: A totl of 40 subjects were rndomly llocted into 2 groups: (i) group 1 (n = 20) were treted with hot pck, trnscutneous electricl nerve stimultion, nd pssive stretching exercises; (ii) group 2 (n = 20) were treted with hot pck, trnscutneous electricl nerve stimultion nd Mullign s technique. Mullign s technique combines the sustined ppliction of mnul gliding force to joint, with the im of repositioning bone positionl fults while enbling concurrent physiologicl (osteo-kinemtic) motion of the joint. All cses were evluted using visul nlogue scles for pin, pssive nd ctive rnge of motion, Constnt score, Shoulder Disbility Questionnire, nd ptient nd therpist stisfction t bseline, fter completion of tretment sessions nd t the end of 3 months of follow-up. Results: Mrked improvement ws noted in both groups fter completion of tretment sessions nd t the third month of follow-up compred with bseline. The improvements in outcome mesures, nmely pin, rnge of motion, shoulder scores, nd ptient nd physiotherpist stisfction, were significntly greter in subjects in group 2, who were treted with Mullign s technique. Conclusion: Mullign s technique nd pssive stretching exercises re both effective in reducing pin, nd restoring rnge of motion nd function. However, compred with stretching exercises, Mullign s technique led to better improvements in terms of pin, rnge of motion, shoulder scores, nd ptient nd physiotherpist stisfction. Key words: dhesive cpsulitis; hot pck; Mullign s technique; shoulder pin. J Rehbil Med 2013; 45: Correspondence ddress: Zeynep Guven, Gülsuyu Mh. Fevzi Çkmk Cddesi, Divn sokk No. 1, Mltepe, Istnbul. E- mil: zeynep.guven@cibdem.edu.tr Submitted Mrch 3, 2012; ccepted July 4, 2012 INTRODUCTION Adhesive cpsulitis leds to pin nd functionl disbility s result of the limited rnge of motion (ROM) of the shoulder girdle. Although the nturl history of dhesive cpsulitis is not completely understood (1), ptients experience the following stges of the condition; freezing or pinful stge, followed by stiffness, frozen or trnsitionl phse, nd finlly thwing phse, chrcterized by incresed ROM (2, 3). Tretments dvocted for dhesive cpsulitis include rehbilittion s the initil conservtive mesure, nti-inflmmtory drugs, intrrticulr corticosteroids, cpsulr distension injections, nd surgicl interventions in refrctory cses. Vrious tretments, including mobiliztion nd mnipultion techniques, hve been dvocted for restortion of pin-free stte nd norml use of the upper extremity. Mnul nd mnipultive tretment options for this condition include high-velocity, low mplitude mnipultion, end-rnge mobiliztion, mid-rnge mobiliztion, nd mobiliztion with movement of the shoulder only nd/ or of the shoulder girdle (4). The rehbilittive interventions performed depend on the institution. The optiml use of common physicl therpies nd the frequency nd timing of session criteri hve not yet been estblished (5). Mullign s technique for peripherl joints combines sustined mnul ppliction of gliding force to joint, with the im of repositioning bone positionl fults with concurrent physiologicl (osteo-kinemtic) motion of the joint, either performed ctively by the subject or pssively by the therpist (6). It hs been shown tht Mullign s technique cn produce concurrent hypolgesic effects during nd following its ppliction, s well s ltering sympthetic nervous system function (7). The im of this study ws to investigte the effects of Mullign s technique for relieving pin nd improving the functionl cpcity of the shoulder in ptients with dhesive cpsulitis in the stiffness phse compred with ptients treted with conventionl pssive stretching exercises. MATERIAL AND METHODS Subjects A totl of 40 subjects with shoulder pin of t lest 3 months durtion, dignosed s dhesive cpsulitis in the stiffness phse ccording to physicl exmintion in the outptient clinic of the Physicl Medicine nd Rehbilittion Deprtment were recruited. Adhesive cpsulitis ws defined s 50% loss of pssive movement of the shoulder joint reltive to the non-ffected side, in 1 or more of 3 movement directions (i.e. bduction in the frontl plne, forwrd flexion, or externl rottion in 0º of bduction) similr to Vermeulen et l. (8). They were exmined by the sme physitrist for their suitbility for inclusion in the study 2013 The Authors. doi: / Journl Compiltion 2013 Foundtion of Rehbilittion Informtion. ISSN J Rehbil Med 45

2 88 G. Doner et l. nd rdiologicl exmintions were crried out ccordingly. The study ws pproved by the ethics committee (No: MAR-YC ). Exclusion criteri were: previous tretments other thn mediction, contrindictions for physicl therpy (infections or mlignncies in the shoulder region, severe hypertension, severe crdic filure, uncontrolled dibetes mellitus, neurologicl deficits, skin lesions involving the shoulder region, post-trumtic cses). Ptients with coexisting neck pin nd rdiculopthies were lso excluded. Study design A totl of 40 subjects were rndomized using tble of rndom numbers. They were llocted into two groups. Group 1 (n = 20) ws treted with hot pck (HP), trnscutneous electricl nerve stimultion (TENS), nd pssive stretching exercises in 4 directions (flexion, bduction, internl nd externl rottion). Group 2 (n = 20) received HP, TENS nd Mullign s technique. The ptients were followed for 3 months. Tretment procedures Hot pcks were used to deliver superficil heting. HPs were used before stretching or Mullign s technique to increse the extensibility of the collgen. The temperture ws djusted to comfortble level for the ptients throughout the tretment. Ech tretment session lsted 20 min. After ppliction of HP, stretching ws pplied. Conventionl pssive stretching included bduction in the scpulr plne, flexion with the ptient in the supine position, nd rottions during bduction (the degree of bduction ws incresed ccording to the ptient s progress nd tolernce level). Ech stretch ws mintined for 30 s, with 15 s rest between stretches. TENS sessions lsted 20 min. The frequency of TENS ws set to 100 Hz nd pulse durtion ws set to pproximtely ms. Ptients remined in seted position with their shoulders in neutrl position. The intensity of the current ws incresed to the point of observtion of no contrctions, but with light tingling senstion, while ensuring the ptient ws comfortble. Group 2 received HP, TENS nd Mullign s technique. Mullign s technique ws pplied in flexion, elevtion nd internl rottion. Three sets of 10 repetitions were pplied, with rest intervl of 30 s between ech set. Ptients were treted for 5 dys per week for 3 weeks. All cses were informed bout dily cre for the shoulders. They were dvised to use the ffected shoulder in dily ctivities whenever possible. All ptients were instructed to perform pendulum exercises nd ctive shoulder exercises twice dy. In previous studies concerning mnul nd mnipultive tretments for dhesive cpsulitis of the shoulder pendulum exercises were lso included in ddition to specific interventions (8, 9). All cses were evluted using visul nlogue scle (VAS) for pin, pssive nd ctive ROM, Constnt score, Shoulder Disbility Questionnire (SDQ), nd ptient nd therpist stisfction, t bseline, fter completion of tretment sessions nd the end of 3 months of follow-up. Outcome mesures The tretment outcomes used in this study were: VAS, goniometric ROM exmintion, Constnt score, SDQ, nd stisfction of the ptient nd the physiotherpist. Pin during rest nd during movement ws evluted seprtely using 10-cm horizontl VAS line. nd pssive shoulder ROM during flexion, bduction, internl nd externl rottion were noted for both shoulders. Shoulder flexion nd bduction were noted s 0 180º nd internl nd externl rottion s 0 90º. The Constnt score hs the benefits of including vrious mesures, including pin, functionl ssessment, ROM nd strength mesures. Constnt score hs been widely used for the ssessment of vrious shoulder disorders. It hs been specificlly vlidted for dhesive cpsulitis nd is currently the gold stndrd (10, 11). This mesure hs 100-point scoring system, with 100 points being the best score (12). SDQ covers 16 items iming to evlute functionl limittion in ptients with shoulder disorders. SDQ is dvntgeous for use in physiotherpy units, since the items of the SDQ were generted from the routine history of the ptients with shoulder disorders in physiotherpy (13). The Turkish version of the SDQ hs been shown to be relible nd vlid (14). It hs been demonstrted previously tht SDQ is useful instrument to ssess functionl disbility in longitudinl studies (15). In the SDQ, the best score is 0, while the worst is 100 (13). Ptient nd physiotherpist stisfction ws grded s 1 = worse, 2 = sme, 3 = slightly better, 4 = better, nd 5 = full recovery. Dt nlysis Sttisticl nlysis ws performed with NCSS 2007&PASS 2008 Sttisticl Softwre. In ddition to descriptive sttistics for vribles with norml distribution we used Student s t-test for group comprison, vrince nlysis for repeted mesures, nd pired smple t-test for intrgroup comprisons. Vribles tht were not normlly distributed were nlysed with Mnn-Whitney U test for group comprison, Friedmn test for repeted mesures nd Wilcoxon test for intrgroup comprisons. For vribles tht were not normlly distributed, Friedmn test ws used for repeted mesures, Wilcoxon sign test ws used for intrgroup comprisons. For ordinl vribles χ 2 test, Fischer s exct χ 2 test nd McNemr test were pplied. The confidence intervl ws ccepted s 95% nd p-vlue less thn 0.05 ws tken s sttisticlly significnt. RESULTS A totl of 40 ptients; 31 (77.5%) femles nd 9 (22.5%) mles, ge rnge yers, were included in the study. The men ge of the study group ws yers (stndrd devition (SD) 8.77). The tretment groups were similr in terms of ge, sex, involved shoulder, dominnt shoulder nd ccompnying medicl diseses (p > 0.05) (Tble I). Pin In both groups, ptients improved significntly in terms of pin t rest nd during ctivity between bseline, fter tretment nd follow-up t third month (p < 0.01). Pin t rest ws similr between the tretment groups t bseline nd fter tretment Tble I. Bseline chrcteristics of the study group Chrcteristics Group 1 p-vlue Age, yers, men (SD) c (8.57) (9.17) Sex, n (%) d Femle 18 (90.0) 13 (65.0) Mle 2 (10.0) 7 (35.0) Affected shoulder, n (%) d Right Left 5 (25.0) 15 (75.0) 10 (50.0) 10 (50.0) Dominnt shoulder, n (%) d Right Left Accompnying medicl disorder, n (%) d Present Absent 19 (95.0) 1 (5.0) 13 (65.0) 7 (35.0) 20 (100.0) 0 (0) 15 (75.0) 5 (25.0) Group 1: hot pck, trnscutneous electricl nerve stimultion (TENS), stretching; b Group 2: hot pck, TENS, Mullign s technique; c Student s t-test; d χ 2 or Fischer s exct test. SD: stndrd devition. J Rehbil Med 45

3 Mullign s technique for dhesive cpsulitis 89 (p > 0.05). However, ptients in group 2 reported significntly lower pin t rest compred with group 1 t the third month (p < 0.05). In ddition, ptients in group 2 reported significntly less pin during ctivity fter tretment nd t the third month (p < 0.01). VAS scores re summrized in Tble II. Goniometric rnge of motion In both groups, ROM during flexion, bduction, internl nd externl rottion improved significntly between bseline, fter tretment nd follow-up t the third month (p = 0.001). Ptients in group 2 hd significntly higher ctive nd pssive flexion fter tretment nd t the third month (p < 0.01), ctive nd pssive bduction fter tretment nd the third month (p < 0.05), ctive nd pssive internl rottion fter tretment nd the third month (p < 0.05). Ptients in both groups hd similr ctive nd pssive externl rottion fter tretment (p > 0.05), but ptients in group 2 hd higher externl rottion t the third month compred with group 1 (p < 0.05). Goniometric ROM mesurements re summrized in Tble III. Constnt score In both groups, Constnt scores improved significntly between bseline, fter tretment nd follow-up t third month (p = 0.001). Ptients in group 2 hd higher Constnt scores compred with group 1 fter tretment nd t the third month (p < 0.01) (Tble IV). Shoulder Disbility Questionnire In both groups the SDQ scores improved significntly between bseline, fter tretment nd follow-up t the third month (p = 0.001). Ptients in group 2 hd lower disbility scores fter tretment nd t the third month (Tble V). Ptient stisfction In both groups ptients reported better results t the third month compred with fter tretment (p < 0.05 nd p < 0.01, Tble II. Pin mesurements t bseline, fter tretment nd t the third month for both tretment groups Pin Group 1 p-vlue c Pin t rest Bseline 3.43 (1.74) 3.24 (2.19) After tretment 1.14 (1.22) 0.75 (1.18) Third month 0.44 (0.63) 0.20 (0.82) 0.018* Pin during ctivity Bseline 6.93 (1.39) 7.49 (1.57) After tretment 3.57 (1.18) 2.34 (2.15) 0.005** Third month 2.21 (1.45) 1.03 (1.84) 0.003** Group 1: hot pck, trnscutneous electricl nerve stimultion (TENS), stretching; b Group 2: hot pck, TENS, Mullign s technique; c Mnn Whitney U test; d Friedmn test. SD: stndrd devition. respectively). Ptients in group 2 reported significntly better results fter tretment nd t the third month compred with group 1 (p = 0.001) (Tble VI). Physiotherpist stisfction In both groups physiotherpists reported better results t the third month compred with fter tretment (p < 0.01). Ptients in group 2 reported significntly better results fter tretment Tble III. Rnge of motion (ROM) mesurements t bseline, fter tretment nd t the third month for both tretment groups ROM Group 1 p-vlue c Flexion Bseline (19.30) (17.90) After tretment (15.76) (13.30) 0.004** Third month (18.53) (8.41) 0.001** Pssive Bseline (19.06) (17.56) After tretment (16.35) (11.70) 0.008** Third month (17.13) (4.41) 0.013* Aduction Bseline (21.17) (26.71) After tretment (25.95) (30.65) 0.032* Third month (28.26) (21.73) 0.001** Pssive Bseline (22.17) (19.89) After tretment (24.90) (27.48) 0.024* Third month (26.97) (25.39) 0.024* Internl rottion Bseline (20.70) (11.75) After tretment (19.49) (15.85) 0.029* Third month (18.01) (7.45) 0.001** Pssive Bseline (19.06) (10.93) After tretment (16.95) (12.55) 0.032* Third month (14.46) (3.08) 0.002** Externl rottion Bseline (17.20) (12.55) After tretment (24.65) (23.76) Third month (24.89) (18.88) 0.041* Pssive Bseline (17.16) (12.98) After tretment (23.09) (21.37) Third month (22.70) (15.20) Group 1: hot pck, trnscutneous electricl nerve stimultion (TENS), stretching; b Group 2: hot pck, TENS, Mullign s technique; c Student s t-test; d repeted mesures nlysis of vrince. SD: stndrd devition. J Rehbil Med 45

4 90 G. Doner et l. Tble IV. Constnt scores t bseline, fter tretment nd t third month for both tretment groups Constnt scores Group 1 nd t the third month compred with group 1 (p = 0.001) (Tble VI). DISCUSSION This study compred the effects of two tretment strtegies; Mullign s technique nd stretching exercises. It ws demonstrted tht both strtegies re effective in reducing pin nd restoring ROM nd function in ptients with dhesive cpsulitis in the stiffness phse. Compred with stretching exercises, Mullign s technique led to better improvements in terms of pin, ROM, shoulder scores nd ptient nd physiotherpist stisfction. This is the first study to demonstrte tht the 3-month outcome of the Mullign s technique is fvourble compred with conventionl stretching exercises in ddition to the immedite effects of the tretment. Mullign s technique ws chosen for this study becuse it hs the dvntge of incresing ROM in ddition to providing nlgesi. Mullign s technique ws compred with stretching becuse stretching exercises re the minsty of exercises in joint limittions; however, in contrst to Mullign s technique they lck n nlgesic effect. Mnul therpy interventions, usully combined with physicl therpy, hve been shown previously to result fvourbly in terms of pin, ROM nd function in vrious studies (8, 16, 17). We imed to investigte the effects of specific intervention becuse it becomes difficult to drw conclusions due to multiple interventions. We chose stretching exercises for comprison becuse Griggs et l. (18) hve previously demonstrted tht the vst mjority of ptients who hve idiopthic Tble V. Shoulder disbility scores t bseline, fter tretment nd t third month for both tretment groups Group 1 p-vlue c Bseline (17.39) (17.39) After tretment (18.32) (11.70) 0.001** Third month (18.96) (3.56) 0.001** Group 1: hot pck, trnscutneous electricl nerve stimultion (TENS), stretching; b Group 2: hot pck, TENS, Mullign s technique; c Student s t-test; d repeted mesures nlysis of vrince (ANOVA). SD: stndrd devition. Bseline (12.22) (21.32) After tretment (29.84) (26.26) 0.001** Third month (28.33) 8.02 (22.07) 0.003** **p < Group 1: hot pck, trnscutneous electricl nerve stimultion (TENS), stretching; b Group 2: hot pck, TENS, Mullign s technique; c Mnn Whitney U test; d Friedmn test. SD: stndrd devition. p c Tble VI. Ptient nd physiotherpist stisfction t bseline, fter tretment nd t third month for both tretment groups Group 1 n (%) n (%) p-vlue c Ptient stisfction After tretment Sme 0 (0) 0 (0) Slightly better 12 (40.0) 1 (5.0) Better 8 (40.0) 17 (85.0) Full recovery 0 (0) 2 (10) Third month Sme 0 (0) 0 (0) Slightly better 8 (40.0) 0 (0) Better 9 (45.0) 7 (35.0) Full recovery 3 (15.0) 13 (65.0) Physiotherpist stisfction After tretment Sme 0 (0) 0 (0) Slightly better 13 (65.0) 2 (10.0) Better 7 (35.0) 15 (75.0) Full recovery 0 (0) 3 (15.0) Third month Sme 0 (0) 0 (0) Slightly better 6 (30.0) 0 (0) Better 12 (60.0) 7 (35.0) Full recovery 2 (10.0) 13 (65.0) *p < Group 1: hot pck, trnscutneous electricl nerve stimultion (TENS), stretching; b Group 2: hot pck, TENS, Mullign s technique; c χ 2 test. dhesive cpsulitis cn be treted successfully with specific 4-direction shoulder stretching progrmme. In our study, it ws not possible to include shm group since ptients would esily differentite. Scringe et l.(19) hve previously used the Mullign s technique in ddition to chiroprctic mnipultions of the spine for golfer with chronic shoulder, rm nd neck pin. The uthors hve followed the ptient for 29 weeks; however, they used multiple techniques, which mde it difficult to delinete the specific effects of certin tretment. In our study we included meticulously chosen subset of ptients with shoulder pin only, nd investigted the effect of the technique by comprison with stretching exercises. We combined both of the interventions, Mullign s technique nd stretching exercises, with HP nd TENS to eliminte pin. We did not include multiple techniques, which would hve mde it difficult to drw conclusion bout the effect of the prticulr tretment per se. Pungmli et l. hve previously demonstrted the hypolgesic effect of Mullign s technique for lterl epicondyllgi (7). In ddition, Teys et l. (20) stted tht cliniclly meningful improvements in both ROM nd pressure pin threshold occur immeditely fter the ppliction of Mullign s technique in the pin-limited shoulder. This study hs certin limittions. Since Mullign s technique is hnds-on tretment it is not possible to perform J Rehbil Med 45

5 Mullign s technique for dhesive cpsulitis 91 the study in blinded mnner. And, gin, since the study is bout mnul tretment, the therpy is pplied by the sme experienced therpist. It ws not ethicl to use shm group; thus the control group ws lso treted with conventionl stretching exercises. This study hs estblished the immedite nd 3-month effects of Mullign s technique in ptients with dhesive cpsulitis. The results show tht tht Mullign s technique offers dvntges over conventionl stretching exercises. In our study we were ble to nlyse the ptients with dhesive cpsulitis in the stiffness phse from vrious spects, including pin, ROM, disbility scores, nd ptient nd physiotherpist stisfction, fter completion of the therpy sessions nd in the subsequent 3-month period. The results show tht Mullign s technique offers dvntges tht re sustined fter completion of the tretment. The uthors declre no conflicts of interest. REFERENCES 1. Hrris JD, Griesser MJ, Copeln A, Jones GL. Tretment of dhesive cpsulitis with intr-rticulr hyluronte: systemtic review. Int J Shoulder Surg 2011; 5: Leung MS, Cheing GL. Effects of deep nd superficil heting in the mngement of frozen shoulder. J Rehbil Med 2008; 40: Mnske RC, Prohsk D. Dignosis nd mngement of dhesive cpsulitis. Curr Rev Musculoskelet Med 2008; 1: Brntinghm JW, Css TK, Bonnefin D, Jensen M, Globe G, Hicks M, et l. Mnipultive therpy for shoulder pin nd disorders: expnsion of systemtic review. J Mnipultive Physiol Ther 2011; 34: Nicholson GC. The effects of pssive joint mobiliztion on pin nd hypomobility ssocited with dhesive cpsulitis of the shoulder. J Orthop Sports Phys Ther 1985; 6: Yng JL, Chng CW, Chen SY, Wng SF, Lin JJ. Mobiliztion techniques in subjects with frozen shoulder syndrome: rndomized multiple-tretment tril. Phys Ther 2007; 87: Pungmli A, O Lery S, Souvlis T, Vicenzino B. Hypolgesic nd sympthoexcittory effects of mobiliztion with movement for lterl epicondyllgi. Phys Ther 2003; 83: Vermeulen HM, Rozing PM, Obermnn WR, le Cessie S, Vliet Vlielnd TP. Comprison of high-grde nd low-grde mobiliztion techniques in the mngement of dhesive cpsulitis of the shoulder: rndomized controlled tril. Phys Ther 2006; 86: Rinbow DM, Weston JP, Brntinghm JW, Globe G, Lee F. A prospective, clinicl tril compring chiroprctic mnipultion nd exercise therpy vs. chiroprctic mobiliztion nd exercise therpy for tretment of ptients suffering from dhesive cpsulitis/frozen shoulder. J Am Chiropr Assoc 2008; 45: Othmn A, Tylor G. Is the constnt score relible in ssessing ptients with frozen shoulder? 60 shoulders scored 3 yers fter mnipultion under nesthesi. Act Orthop Scnd 2004; 75: Dupeyron A, Gelis A, Sblyrolles P, Bousquet PJ, Juli M, Herisson C, et l. Heterogeneous ssessment of shoulder disorders: vlidtion of the Stndrdized Index of Shoulder Function. J Rehbil Med 2010; 42: Wright RW, Bumgrten KM. Shoulder outcomes mesures. J Am Acd Orthop Surg 2010; 18: Vn der Heijden GJ, Leffers P, Bouter LM. Shoulder Disbility Questionnire design nd responsiveness of functionl sttus mesure. J Clin Epidemiol 2000; 53: Ozshın M, Akgun K, Akts I, Kurtis Y. Adpttion of the shoulder disbility questionnire to the Turkish popultion, its relibility nd vlidity. Int J Rehbil Res 2008; 31: vn der Windt DA, vn der Heijden GJ, de Winter AF, Koes BW, Deville W, Bouter LM. The responsiveness of the Shoulder Disbility Questionnire. Ann Rheum Dis 1998; 57: Plczek JD, Roubl PJ, Freemn DC, Kulig K, Nsser S, Pgett BT. Long-term effectiveness of trnsltionl mnipultion for dhesive cpsulitis. Clin Orthop Relt Res 1998; 356: Roubl PJ, Dobritt D, Plczek JD. Glenohumerl gliding mnipultion following intersclene brchil plexus block in ptients with dhesive cpsulitis. J Orthop Sports Phys Ther 1996; 24; Griggs SM, Ahn A, Green A. Idiopthic dhesive cpsulitis. A prospective functionl outcome study of nonopertive tretment. J Bone Joint Surg Am 2000; 82-A: Scringe J, Kwok C, Studt T. Improved shoulder function fter using spinl mobiliztion with rm movement in 50 yer old golfer with shoulder, rm nd neck pin. Topics in Clinicl Chiroprctic 2002; 9: Teys P, Bisset L, Vicenzino B. The initil effects of Mullign s mobiliztion with movement technique on rnge of movement nd pressure pin threshold in pin-limited shoulders. Mn Ther 2008; 13: J Rehbil Med 45