Saturday, August 29, 2009

More about frozen shoulder (2): About End range mobilizations (High-Grade mobilization technique) & Early range mobilization (Low-Grade Mobilization

In year 2000 Henricus MV et al found End-range mobilization techniques with adhesive capsulitis of the shoulder increases glenohumeral mobility, but in the absence of a control group, they could not be sure what led to reduced impair as it is debated that natural course of the disease (FS) is self limiting.

In 2006 Henricus MV et al found HGMT proved to be more effective than LGMT in the management of adhesive capsulitis of the shoulder; however, subjects improved significantly with both treatment strategies, and the differences were small.


Each session must start with assessment of the ROM. All 3 affected physiologic movements of the glenohumeral joint are assessed passively. At each position of the shoulder, the end-feel of the movement are assessed in order to apply the mobilization techniques into the stiffness zone (HGMT group) or within the pain-free zone (LGMT group).

1. The treatment started with inferior glides aimed at improvement of the extensibility of the axillary recess.
2. Both hands were held close to the humeral head to work with a short-lever arm. Oscillatory movements in the caudal, lateral, and anterior directions were used.
3. To influence the posterior part of the joint capsule, the hand was placed on the anterior part of the shoulder, and the applied force was in the posterior and lateral directions. To treat the anterior part of the capsule, an anterior and medial glide was applied with one hand pushing on the posterior part of the humeral head.
4. Distraction of the humeral head with respect to the glenoid was performed by pulling the humeral head in the superior, lateral, and anterior directions with a firm grip of both hands close to the humeral head and pushing the scapula on the table.
5. If the fixation of the scapula proved to be difficult, a reversed distraction technique was applied, with the subject lying on the unaffected side. The therapist supported the affected arm and moved the shoulder into the end-range of elevation. The heel of the other hand pushed against the lateral border of the scapula in medial rotation to produce distraction within the glenohumeral joint.

What is expected & proceeding further.

1. If the glenohumeral joint ROM increased during treatment, then mobilization techniques were performed at greater elevation and abduction angles.
2. In these new positions, the changed position of the humeral head and glenoid required an individual adjustment of the direction of the accessory movements in accordance with the concave-convex rules stated by Kaltenborn.
3. Modification of the mobilization techniques consisted of more abduction or adduction, more flexion or extension, more internal or external rotation, more distraction, or a combination of adjustments.

Application of HGMT (High Grade Mobilization Technique) intervention:

1. For the HGMT group mobilization techniques were applied with intensities of Maitland grades III and IV.
2. The duration of prolonged stress on the shoulder capsule in the end-range position varied according to the subject’s tolerance ("treating the stiffness").
3. Subjects were instructed to inform the therapist about the degree and nature of pain during and after treatment. If pain influenced the execution of the mobilization techniques in a negative way (by increasing the reflex muscle activity), then the therapist altered the direction or degree of mobilization as described earlier.
4. If subjects experienced a dull ache, without increased reflex muscle activity, then the mobilization techniques were continued. Subjects were informed that this ache could last for a few hours after the treatment session.
5. If the pain worsened or continued for more than 4 hours after treatment ("treatment soreness"), then the intensity of the mobilization techniques was decreased in the next session.

LGMT (Low Grade Mobilization Technique) intervention.

1. Therapist explicitly informs the subjects that all techniques should be performed without causing pain in the shoulder.
2. Mobilization techniques commenced in the basic starting positions with translation and distraction techniques performed with the joint near its neutral position (grade I).
3. Reflex muscle activity was carefully monitored because it can be a first indication of joint pain.
4. If joint mobility increased, then mobilization techniques were adjusted, and the amplitude of movements was increased without reaching the limits of ROM (grade II).
5. In the last 3 minutes of each treatment session, passive PNF patterns within the pain-free zone in the supine position were applied. In addition, Codman pendular exercises were performed for 2 minutes in a prone position to move the shoulder joint in more than one direction at a time and to obtain maximal relaxation of the shoulder muscles.
6. All techniques used in connection with the LGMT intervention were aimed at the gleno-humeral joint and did not specifically intend to move the scapulothoracic joint.


1. PHYS THER, Vol. 80, No. 12, December 2000, pp. 1204-1213
2. PHYS THER,Vol. 86, No. 3, March 2006, pp. 355-368

Friday, August 28, 2009

Frozen shoulder as a algo-neuro-dystrophic process!

Waldburger et al (1992) of Switzerland subjected 50 cases of frozen shoulder across 3 Swiss medical centres to a radioisotope bone scan (99 mTc diphosphonate) study. They included 3 separate aetiological groups: post-traumatic (40%), neurological (14%) and idiopathic (46%). The findings are interesting:

a. The so-called idiopathic frozen shoulder showed a scapulo-humeral increase in radioisotope uptake in several areas (in 82% of cases) without involvement of the ipsilateral carpus.
b. Clinically, the neurological type was associated with a shoulder-hand syndrome with positive bone scan of the shoulder and the wrist in all cases.
c. The post-traumatic type showed a diffuse (in 50% of the cases) or at several circumscribed areas (also in 50%) increase in radioisotope uptake in the shoulder. In 45% of the post-traumatic type, there was also a shoulder-hand syndrome with uptake in the wrist also.

These findings made the resesrchers to intervene the FS subjects with calcitonin administration along with Physical treatment. Calcitonin (100 U Calcitonin Sandoz) was administered for 21 days subcutaneously.

The researchers claim that this form of treatment (Calcitonin + physical activity) had a statistically significant increased effect on pain compared to treatment with physiotherapy alone by patients with post-traumatic frozen shoulders (p < 0.02). However they also found no significant difference in the speed of recovery of function. These observations made the researchers claim that adhesive capsulitis behave like an algoneurodystrophic process.

More on frozen shoulder & techniques of frozen shoulder mobilization (1)

Types of FS:

Idiopathic FS- When no secondary causes are attributed or no cause can be assigned to the onset.
Secondary FS: FS as a result of diabetes, cardiac problems, stroke, rheumatoid arthritis, or trauma.

Phases of FS:

Reeves documented 3 phases with which to address the progression of FSS: the pain phase, the stiffness phase, and the recovery phase.

To regain the normal extensibility of the shoulder capsule and tight soft tissues, passive stretching contrast to active stretching of the shoulder capsule and soft tissues by means of mobilization techniques has been recommended.

The in-vogue techniques encompasses
1. Midrange mobilization (MRM)- recommended by Maitland
2. End-range mobilization (ERM)- recommended by Kaltenborn
3. Mobilization with movement techniques (MWMs)- recommended by Mulligan

However these above recommended techniques for FS base are not based on research they are rather suggestions. Yang et al investigated the effect of mobilization treatment and to determine whether a difference of treatment efficacy exists among 3 mobilization techniques (MRM, ERM, and MWM) in patients with idiopathic 2nd phase FS. They found:
1. Co-intervention of MWM and ERM treatment techniques may be more beneficial.
2. Cumulative effects of mobilizations may be expected
3. Total 2 visits per week to the physiotherapist for total mobilization for 12 visits are more reasonable for application to normal clinical practice.

Wednesday, August 5, 2009

Lumbo-coxa contribution to forward bending in symptomatic & asymptomatic LBA cases.

I. Asymmetry 3-dimensional motion patterns in Chr. LBA

Chronic LBP patients exhibited motion patterns altered from those of the normal population. 3D motion analyses reveal 3 distinct patterns of motion observed in each principal direction of movement in LBA cases. They are reflected as:

1. Differences in the extension-flexion ratio (asymmetry between flexion and extension).
2. Lateral bending asymmetry and
3. Differences in coupled axial rotation-lateral bending ratio.

II. Lumbar-hip flexion motion in LBA

A. Hip movements in normal healthy patients without LBA during forward bending of the lumbar spine:

1. Earlier reported values for lumbar spine motion during forward bending vary from 23.9 degrees to 60 degrees and hip motion during forward bending ranges from 26 degrees to 66 degrees.

2. Esola & colleagues found mean total forward bending to be 111 degrees: 41.6 degrees from the lumbar spine and 69.4 degrees from the hips.

B. The lumbo-coxa contribution to forward bending:

1. To describe the movement forward bending is divided into early (0-30 degrees), middle (30-60 degrees), and late (60-90 degrees). Esola & colleagues found, Lumbar-to-hip ratios for early, middle, and late forward bending were 1.9, 0.9, and 0.4, respectively.

2. Therefore, the lumbar spine had a greater contribution to early forward bending, the lumbar spine and hips contributed almost equally to middle forward bending, and the hips had a greater contribution to late forward bending.

3. Hamstring flexibility is strongly correlated to motion in subjects with a history of low back pain, but not in healthy subjects.

III. Chr. LBA cases with reduced hip movements:

The hips and lumbar spine both contribute to the forward bending motion, and an aberrant pattern of contribution in one or both regions could be related to the presence of chronic low back pain (2).

Porter & colleagues carried out a study 32 white men aged 18-36 years; 15 with chronic low back pain and 17 asymptomatic. The method used to study was a 3-dimensional motion analysis that allowed uninterrupted forward bending. The results of this study are as follows:

1. The men with chronic low back pain demonstrate a significant reduction in the mean total range and mean maximum lumbar flexion relative to the asymptomatic group.

2. Mean hip flexion was not significantly different.

3. Data analysis for 120 degrees of gross flexion revealed a subgroup of men with chronic low back pain with a significant decrease in hip flexion.

This study reveals 2 distinct subgroups of individuals with chr. LBA. One moved relatively similarly to the asymptomatic group, whereas the other sub-group demonstrated reduced hip mobility. Hence it is important to assess not only the lumbar spine motions but also hip flexion motion in chronic low back pain patients.

Esola & colleagues (3) reported that although people with a history of low back pain have amounts of lumbar spine and hip motion during forward bending similar to those of healthy subjects, the pattern of motion is different. It may be desirable to teach patients with a history of low back pain to use more hip motion during early forward bending, and hamstring stretching may be helpful for encouraging earlier hip motion.


1. Lund T et al; Spine (Phila Pa 1976). 2002 Sep 1;27(17):1865-74.
2. Porter JL et al; Spine (Phila Pa 1976). 1997 Jul 1;22(13):1508-13; discussion 1513-4.
3. Esola MA et al; Spine (Phila Pa 1976). 1996 Jan 1;21(1):71-8.

Tuesday, August 4, 2009

Spine Asymmetry & LBA (specific focus on lumbo-pelvic spine)


Subtle pelvic asymmetry (exhibited as either lateral pelvic tilt or iliac rotational asymmetry), which is common among normal individuals, has not been convincingly linked to abnormalities in back. Given the difficulty in diagnosing most LBA, a classification using pelvic asymmetry and patterns of movement are helpful in establishing a rational treatment plan (2).

I. Impact of pelvic asymmetry in work-stations:
Structural and functional asymmetries are factors that may be considered in the seating design and work environment (1). A study consisting of 59 subjects revealed that significant:
(1) Correlations between pelvic asymmetry and asymmetric trunk motion performed in sitting.
(2) Differences between the LBP and control groups in patterns of trunk motion performed in a sitting posture.
(3) Differences between kinematics of motions performed in sitting versus standing postures.

This study concluded that in LBA cases pelvic asymmetry and altered trunk motion in sitting position exists specifically of lateral flexion and axial rotation. Movement asymmetry, rather than range of motion, becomes a better indicator of disturbed spine function. People with LBA have a distinct compensatory mechanism, secondary to pelvic asymmetry, which puts the lumbar spine under higher stress (1).

II. Differences in FB (forward bending) in LBA cases & girdle pain patients:
BP and PGP patients show specific, consistent, and distinct motion patterns. One study (3) tried to identify differences in forward bending in 2 subcategories of back pain patients in females. Patients either with low back pain (LBP) or pelvic girdle pain (PGP) ware compared with motion characteristics of healthy subjects. Chronic LBP can be distinguished from PGP using specific evidence-based diagnostic tests.

Forward bending was studied with specific reference of trunk motion, pelvic tilt, and lumbar lordosis. This study has following findings:
1. During erect stance in the PGP group, the pelvis is significantly tilted backwards.
2. At maximally forward bending, the ROM of the trunk is limited in all patient groups, but only the PGP group has significantly limited hip motion.
3. During the initial part of forward bending, lumbar motion is increased in PGP patients and decreased in LBP patients.
4. In the final part of forward bending contribution of the lumbar spine is increased in both patient groups.

The authors of this study concluded that these motion patterns are functional compensation strategies, following altered neuromuscular coordination.

III. Pelvic asymmetry & Lumbar spine:
There are differences in patterns of lumbar movement between asymptomatic subjects and patients with LBA. Subtle anatomic abnormality in the pelvis is associated with altered mechanics in the lumbar spine. Further, asymmetry of lumbar movement is suggested to be a better indicator of functional deficit than the absolute range of movement in LBA (1).
LBA patients exhibit different pattern of coupled rotation during lateral flexion. Asymmetry in lumbar lateral flexion was highly related to two types of pelvic asymmetry: lateral pelvic tilt (LPT) and iliac rotation asymmetry (IRA). Asymmetry in lumbar axial rotation is highly related to IRA but weakly related to LPT (2).

IV. Lumbar spine asymmetry & LBA
Leach & colleagues reported thoracolumbar asymmetry, contralateral responsivity (increased myoelectric activity opposite the side of leg pain), loss of flexion/relaxation (F/R) at L3 and right/left asymmetry (R-L/A) at L3. They conducted the study on 10 LBA patients via a Paraspinal surface electromyographic (SEMG) scanning technique (4).

1. Al-Eisa E et al Spine (Phila Pa 1976). 2006 Mar 1;31(5):E135-43.
2. Al-Eisa E et al; Spine (Phila Pa 1976). 2006 Feb 1;31(3):E71-9.

3. van Wingerden JP et al; Spine (Phila Pa 1976). 2008 May 15;33(11):E334-41.
4 Leach RA et al; J Manipulative Physiol Ther. 1993 Mar-Apr;16(3):140-9.