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

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