passive mobs and shoulder joint

Does Passive Mobilization of ShoulderRegion Joints Provide Additional BenefitOver Advice and Exercise Alone forPeople Who Have Shoulder Pain andMinimal Movement Restriction?A Randomized Controlled TrialRoss Yiasemides, Mark Halaki, Ian Cathers, Karen A. Ginn

Background. Passive mobilization of shoulder region joints, often in conjunctionwith other treatment modalities, is used for the treatment of people with shoulderpain and minimal movement restriction. However, there is only limited evidencesupporting the efficacy of this treatment modality.

Objective. The purpose of this study was to determine whether passive mobili-zation of shoulder region joints adds treatment benefit over exercise and advice alonefor people with shoulder pain and minimal movement restriction.

Design. This was a randomized controlled clinical trial with short-, medium- andlonger-term follow-up.

Setting. The study was conducted in a metropolitan teaching hospital.

Patients. Ninety-eight patients with shoulder pain of local mechanical origin andminimal shoulder movement restriction were randomly allocated to either a controlgroup (n51) or an experimental group (n47).

Intervention. Participants in both groups received advice and exercisesdesigned to restore neuromuscular control at the shoulder. In addition, participantsin the experimental group received passive mobilization specifically applied toshoulder region joints.

Measurements. Outcome measurements of shoulder pain and functionalimpairment, self-rated change in symptoms, and painful shoulder range of motionwere obtained at 1, 3, and 6 months after entry into the trial. All data were analyzedusing the intention-to-treat principle by repeated-measures analyses of covariance.

Results. No statistically significant differences were detected in any of the out-come measurements between the control and experimental groups at short-,medium-, or longer-term follow-up.

Limitations. Therapists and participants were not blinded to the treatmentallocation.

Conclusion. This randomized controlled clinical trial does not provide evidencethat the addition of passive mobilization, applied to shoulder region joints, toexercise and advice is more effective than exercise and advice alone in the treatmentof people with shoulder pain and minimal movement restriction.

R. Yiasemides, Discipline of Phys-iotherapy, Faculty of Health Sci-ences, Sydney Medical School,The University of Sydney, Sydney,New South Wales, Australia.

M. Halaki, PhD, is Lecturer, Disci-pline of Exercise and Sport Sci-ence, Faculty of Health Sciences,The University of Sydney.

I. Cathers, PhD, is Senior Lecturer,Discipline of Exercise and SportScience, Faculty of Health Sci-ences, The University of Sydney.

K.A. Ginn, PhD, is Associate Pro-fessor, Discipline of BiomedicalScience, Sydney Medical School,The University of Sydney, Sydney,New South Wales, Australia.Address all correspondence toAssociate Professor Ginn at: [email protected].

[Yiasemides R, Halaki M, Cathers I,Ginn KA. Does passive mobiliza-tion of shoulder region joints pro-vide additional benefit over adviceand exercise alone for people whohave shoulder pain and minimalmovement restriction? A random-ized controlled trial. Phys Ther.2011;91:178189.]

2011 American Physical TherapyAssociation

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178 f Physical Therapy Volume 91 Number 2 February 2011

Shoulder pain is a common com-plaint, with the prevalenceranging from 20% to 33% in theadult population.14 It has beenreported that shoulder pain is thethird most frequent musculoskeletalcomplaint, after back and knee pain,in the general community.4 In 2007,the US Bureau of Labor Statisticsreported that injuries to the shoulderin the workforce required the mostnumber of days off work, with amedian of 18 days to recuperate.With the exception of the knee andwrist, the shoulder took at leasttwice the median time to recovercompared with all other body parts.5

Nocturnal disturbance, the inabilityto sleep on the affected side, func-tional disability, and a reduction inthe overall quality of life are com-mon complaints resulting fromshoulder pain.68

Manual therapy in the form of pas-sive joint mobilization is used byphysical therapists for the manage-ment of pain, including shoulderpain, and often is used in conjunc-tion with other treatment modalities,including exercise therapy.911 Forthe management of shoulder pain,mobilization techniques are com-monly applied to the joints of theshoulder region (glenohumeral,acromioclavicular, and sternoclavic-ular joints), to the scapula, to thejoints of the cervicothoracic verte-bral column, and to the ribs. Passivejoint mobilization aims to manageshoulder pain by physiologicalmechanisms (eg, inducing hypoanal-gesia)12,13 or by mechanical mecha-nisms (eg, restoring normal biome-chanical relationships by addressingrelated joint stiffness).14

Clinical trials that have investigatedthe effectiveness of passive jointmobilization therapy, whichincluded mobilization of the cervico-thoracic vertebral column and ribs,for the management of painful shoul-der dysfunction indicate that this

form of mobilization therapy ismore effective than other therapymodalities. Winters et al15 demon-strated greater, more rapid de-crease in pain in patients withacute and chronic shoulder painwho received manipulation andmobilization of vertebral column,ribs, or shoulder region joints thanthose who received massage, exer-cises, and electrotherapy. Inaddition, patients with chronicshoulder pain demonstrated addedtreatment benefit (greater decreasein pain intensity and functional lim-itation) when passive mobilizationof vertebral column or shoulder re-gion joints were added to exercis-es.16 In the only clinical trial thathas investigated mobilization andmanipulation therapy specificallyapplied to the vertebral columnand ribs for the management ofshoulder pain, patients who re-ceived the manual therapy in addi-tion to usual care reported signifi-cantly greater overall improvementand decrease in pain.17

Despite their common use, littleevidence is available to support thecontribution of passive mobilizationapplied specifically to shoulder regionjoints in the management of painfulshoulder conditions. Indeed, the re-sults of a recent well-powered ran-domized controlled trial (RCT)indicate that this form of manual ther-apy is not more effective than exer-cises and advice from a physical ther-apist in the management of thepainfully restricted shoulder.18 Theseresults support the findings of anotherstudy of a small sample of participantsin which passive mobilizations ofshoulder region joints were found tobe ineffective in the management ofadhesive capsulitis.19 Only one RCTthat examined the effects of passivemobilization of shoulder region jointsin patients diagnosed with impinge-ment syndrome showed limited evi-dence in support of the benefit of thistreatment modality.20

Although the evidence indicating noadditional benefit of passive mobili-zations of shoulder region jointsabove exercise and advice in painful,restricted shoulder conditions18,19 ismounting, little information is avail-able regarding the effectiveness ofthis modality for the treatment ofpeople with shoulder pain and min-imal movement restriction. There-fore, a clear clinical rationale for theuse of mobilization therapy appliedto shoulder region joints for the man-agement of nonrestricted painfulshoulder conditions has not beenestablished. As passive joint mobili-zation therapy is most commonlyused in conjunction with other treat-ment modalities and with increasingevidence to support the efficacy ofexercise therapy in the managementof painful shoulder conditions,2126

the specific aim of the study was todetermine whether low-velocity pas-sive joint mobilization therapy spe-cifically applied to shoulder regionjoints (glenohumeral, acromioclavic-ular, and sternoclavicular joints) andpassive mobilization of the scapulaadd benefit over exercise and advicealone in the treatment of peoplewith shoulder pain and minimalmovement restriction.

MethodDesign OverviewThis RCT compared passive mobili-zation of shoulder region joints,exercise, and advice with exerciseand advice alone for the treatment ofpeople with shoulder pain and min-imal movement restriction. Prior to

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Passive Mobilization of Shoulder Joints

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group allocation, baseline outcomemeasurements were obtained. Fol-lowing measurements of pain, func-tional ability, and painful activerange of motion (AROM), partici-pants were randomly allocated to anexperimental or control group basedon a concealed assignment schedulethat had been generated by an inves-tigator who was not involved withrecruitment, treatment, or outcomemeasure assessment in the study.Primary outcome measurements ofpain, functional impairment, andself-rated improvement wereobtained from participants whowere not blinded to treatment groupallocation at 1, 3, and 6 months afterrandomization. Secondary outcomemeasurements of painful AROMwere obtained by a researcher (R.Y.)blinded to group allocation at thesame time points.

Setting and ParticipantsAll patients referred to the outpa-tient physical therapy department ata large metropolitan governmenthospital with painful active flexion

or abduction shoulder movements ofgreater than 1 months duration andminimal shoulder movement restric-tion were eligible to participate inthis study. In addition, pain, tender-ness, or restriction during passiveaccessory movements at the gleno-humeral, acromioclavicular, or ster-noclavicular joint or during passivescapular movements was required tobe present. Diagnostic classificationssystems were not used to select par-ticipants for inclusion in this studybecause they lack reliability and uni-formity, thus causing confusion andmiscommunication among healthcare professionals.2735 Participantswere excluded if: they were lessthan 18 years of age; they wereunable to understand spokenEnglish; their shoulder symptomswere reproduced during active cer-vical spine movements or during pal-pation of cervical or thoracic regionjoints; they reported paresthesia inthe affected upper limb; passiveshoulder region joint mobilizationwas contraindicated; shoulder flex-ion or abduction range of motion

(ROM) was less than 140 degrees, asdetermined from digital photo-graphs; shoulder pain was due to aninflammatory or neoplastic disorder;they had had surgery or trauma tothe shoulder in the previous 4weeks; or they reported a feeling ofshoulder instability.

Ninety-eight volunteers (47 men and51 women) were recruited for thisstudy after providing writteninformed consent. The sample sizefor this study was calculated usingdata from the Shoulder Pain and Dis-ability Index (SPADI) questionnaire,one of the primary outcome mea-sures in this trial. Statistical powercalculations indicated that a samplesize of 98 participants would providean 80% chance of detecting a mini-mum change of 15 points in totalSPADI score, assuming a standarddeviation of 25 points and a maxi-mum 10% loss to follow-up.36

Randomization andInterventionsAll patients seen at the participatinghospital who were potentially eligibleto participate in this study were con-tacted by telephone. The aims of thestudy and its procedures were ex-plained, and an appointment was ar-ranged to conduct an interview andphysical assessment. At thisappointment, the patients were ques-tioned and examined to confirm thatthey fulfilled all inclusion criteria. Suit-able participants then signed a con-sent form, and baseline outcome mea-surements of pain, functionalimpairment, and painful AROM wereobtained. Additional demographic in-formation such as participants age,sex, affected and dominant upperlimb, and duration of symptoms wererecorded during the interview.

Following initial assessment, partici-pants were randomly allocated toeither the control group or theexperimental group. Randomallocation of participants was per-

The Bottom Line

What do we already know about this topic?

Passive mobilization of shoulder joints has been a common component ofphysical therapy for people who have shoulder pain. For patients withpainful, restricted shoulder function, recent evidence indicates that theaddition of this form of manual therapy to exercise and advice from aphysical therapist may not improve outcome.

What new information does this study offer?

For patients with shoulder pain without movement restriction, the resultsof this unblinded clinical trial indicate that the addition of passive mobi-lization of shoulder joints to exercise and advice from a physical therapistmay not improve treatment outcome.

If youre a patient, what might these findings meanfor you?

In terms of physical therapy, passive mobilization of the shoulder jointsprovides no additional benefit over advice and exercise alone.



formed using a previously deter-mined treatment assignment sched-ule with random numbers generatedfrom the data analysis function inMicrosoft Excel.* To ensure conceal-ment, the randomization procedurewas carried out by a researcher(K.A.G.) not involved in participantrecruitment, treatment, or assess-ment, and the treatment assignmentschedule was stored in consecu-tively numbered, sealed opaqueenvelopes.

All participants received treatmentin the form of advice and exercises.Physical therapists provided adviceon how to avoid or minimize painfulshoulder movements during activi-ties of daily living. This adviceincluded: limiting movement to thepain-free ROM; maintaining normalscapulohumeral rhythm within pain-free ROM; using the affected upperlimb in a slow, careful manner; usingtechniques to minimize shoulderpain (eg, during dressing and reach-ing); and preferentially using thenonaffected upper limb. Exerciseswere directed toward restoring neu-romuscular control mechanisms atthe shoulder. This exercise approachhas been shown to be effective inprevious clinical trials,22,23 and allparticipating therapists were giveninstructions in the implementationof this treatment approach.

The primary aim of the exercises wasto restore normal muscle function inorder to regain normal dynamic sta-bility and muscle force couple coor-dination at the shoulder region, thusleading to restoration of function.37

Stretching exercises to lengthenshortened muscles, exercises tostrengthen weakened muscles and toimprove muscle coordination, andexercises aimed at restoring normalscapulohumeral rhythm could beincluded. Motor retraining exercises

were devised and upgraded based onmotor learning principles designedto improve motor skills by incremen-tally increasing the complexity of theexercise tasks. Full range of shouldermovement requires the coordinationof a number of muscle force couples.Therefore, less-difficult exercises prin-cipally involved muscles within oneforce couple (eg, isolated rotationexercises for the rotator cuff musclesor scapular depression exerciseswith the arm by the side). The mostdifficult exercises involved all shoul-der muscle force couples (eg, full-range flexion and abduction exer-cises requiring coordination ofaxiohumeral, rotator cuff, andaxioscapular muscles).37 The exer-cises were performed in a pain-freemanner to optimize normal musclefunction and movement patterns.22

Exercises and advice were tailoredby the treating physical therapist tomeet the requirements of each par-ticipant. The exercise treatment wasadministered as a daily home-basedprogram and reviewed by the treat-ing therapist 1 or 2 times per week.The purposes of this review were tocorrect the performance of the exer-cises if necessary and to increase theintensity and complexity of theexercises as muscle functionimproved. As motor skill acquisitionis a lengthy process that requires reg-ular practice to establish new habit-uated motor patterns, participantswere strongly encouraged to do theirexercises on a daily basis at homeand to continue them after formaltreatment had ceased.37

In addition to this advice and exer-cise therapy, participants allocatedto the experimental group receivedlow-velocity passive joint mobiliza-tions applied to any of the shoulderregion joints (ie, glenohumeral, ster-noclavicular, and acromioclavicularjoints) and passive mobilization ofthe scapula. Mobilization therapywas aimed at relieving pain andrestoring pain-free functional move-

ments.14 Passive mobilizations couldbe applied in a sustained or oscilla-tory manner. As per routine clinicalpractice, the regions mobilized, aswell as the force, direction, andamplitude of the mobilization tech-niques, were individually deter-mined and progressed by the treat-ing therapist based on eachparticipants clinical signs and symp-toms. The study design required thata minimum of 60% of all treatmentsprovided to participants in theexperimental group involved passiveshoulder region mobilization inorder to ensure an adequate dosageof the mobilization therapy underevaluation.

Participants in both groups received1 or 2 treatment sessions per weekfor the first month of the trial, fol-lowed by additional treatment overthe next 4 weeks to a maximum of12 treatment sessions if deemed nec-essary by the treating therapist. Thephysical therapists involved in thetrial recorded the number of treat-ment sessions and the type of mobi-lization techniques applied for eachparticipant in a logbook. All partici-pants were requested to receivephysical therapy treatment onlyfrom the involved physical therapydepartment and to refrain from seek-ing any other form of therapy whileparticipating in this clinical trial.

Seventeen physical therapists wereinvolved in providing treatment toparticipants in this clinical trial. Fourof these physical therapists had post-graduate qualifications in physicaltherapy: 1 with a masters degree inphysical therapy, 1 with a mastersdegree in manipulative physiother-apy, and 2 with graduate diplomas inmanipulative therapy. The numberof years of clinical experience fortherapists involved in this studyranged from 2 to 28 (X8.4,SD7.5). All therapists receivedinstructions regarding all treatmentoptions and clinical trial adherence,

* Microsoft Corporation, One Microsoft Way,Redmond, WA 98052-6399.



and all therapists were involved intreating participants in both the con-trol and experimental treatmentgroups.

Outcomes and Follow-upTwo primary outcome measureswere used in this study. The firstprimary outcome measure, shoulderpain intensity and functional impair-ment during the previous week, wasassessed using the SPADI question-naire.36 This self-administered ques-tionnaire consists of 2 sections: thefirst section of 5 questions relates topain, and the second section of 8questions relates to function.36 Thisquestionnaire was chosen becauseit has been shown to be reliable,valid,38,39 and responsive tochange3942 and has no floor or ceil-ing effects.40 The second primaryoutcome measure, self-rated changein symptoms, was measured with a6-point Likert scale. This scale con-sisted of a horizontal line with 6points, each with verbal anchorsrelating to participants perceivedchange in symptoms (ie, feelingmuch worse, slightly worse, thesame, slightly improved, greatlyimproved, and fully recovered).43

Participants were asked to use thisscale to indicate their perceived levelof change in symptoms since theirlast assessment. A Likert scale waschosen because it is easy to adminis-ter and interpret and it consists ofcategories labeled with words,which assists individuals to specifi-cally relate to how they feel, thusassisting in defining the change intheir symptoms.44

Secondary outcome measurementsof AROM during shoulder flexion inthe sagittal plane and abduction inthe coronal plane were assessedusing a photographic method shownto be reliable in previous studies ofpatients with shoulder pain.18,22,23

Participants were instructed to per-form these movements, and photo-graphs were taken when pain was

initiated and when pain eitherresolved or when the maximalachievable ROM was reached. Usingmarkers placed on bony land-marks,22,23 shoulder joint angleswere measured on the photographs.The painful ROM was recorded asthe difference between the shoulderangles in the 2 photographs. Thismethod of measuring painful AROMwas used because it is quicker toperform than standard goniometryand thus less likely to exacerbatesymptoms and influence measure-ment.18,22,23 The intrarater reliabilityof these AROM measurements wasestablished for the blinded assessor(R.Y.) in this study prior to the com-mencement of the trial. Intraclasscorrelation coefficients (2,1) dem-onstrated excellent intrarater reli-ability of .92 and .98 for flexion andabduction, respectively.45

Participants received between 4 and8 treatment sessions over a 1-monthperiod. Primary outcome measure-ments of pain and functional impair-ment were reassessed, and self-ratedchange in symptoms was obtainedfrom participants who were notblinded to treatment allocation. Sec-ondary outcome measurements ofpainful AROM were reassessed by aresearcher (R.Y.) who was blindedto treatment allocation. To ensureblinding, participants wereinstructed to refrain from discussingtheir treatment with this assessor.Following assessment at 1 month,treatment could continue for a max-imum of 12 treatment sessions over amaximum of 8 weeks. Reassessmentof all outcome measurements wasrepeated at 3 and 6 months afterbaseline measurements.

Data AnalysisAll analyses were conducted usingan intention-to-treat approach. Miss-ing data (lost to follow-up) werereplaced with values obtained byimputation using regression modelswithin each variable and group at all

available time points. For the 2 con-trol group participants who werelost prior to reassessment at 1 monthafter recruitment and, therefore, didnot have a self-rated change in symp-toms score, the average of the groupwas used for their missing scores. Arepeated-measures analysis of covari-ance was used to analyze between-group differences in both primary(SPADI and self-rated improvement)and secondary (painful AROM) out-come measurements at 1, 3, and 6months following randomization.There was a statistically significantdifference in the mean duration ofcurrent shoulder symptoms betweenthe experimental and control groupsat baseline, and this factor was usedas the covariate in the analysis.

Role of the Funding SourceThis study was partially funded by aMusculoskeletal Physiotherapy Aus-tralia Research Grant from the Phys-iotherapy Research Foundationawarded in 2005. The PhysiotherapyResearch Foundation played no rolein the design, conduct, or reportingof this study, although regularreports of the progress of this clini-cal trial were provided.

ResultsA total of 230 patients referred to theoutpatient physical therapy depart-ment for the management of shoul-der dysfunction between May 2005and July 2008 were contacted viatelephone regarding potential inclu-sion in this clinical trial. The flow ofparticipants through the trial is illus-trated in Figure 1. Of the 230patients screened via telephone, 64were not considered eligible forinclusion in the clinical trial, primar-ily because they indicated that theyhad severely restricted shoulder flex-ion or abduction ROM or becausetheir pain was exacerbated by neckmovements suggesting referral fromthe vertebral column. The remaining166 patients were invited to attend aphysical assessment. Of these



Patients with shoulder problemsscreened by telephone (n=230)

Excluded (n=64) Shoulder restriction (n=30) Referred pain (n=19) Other reasons (n=15)

Patients who attended for physicalassessment (n=166)

Excluded (n=68) Shoulder restriction (n=43) Referred pain (n=25)

Baseline Baseline outcome measurements taken and randomization to treatment group (n=98)

Lost to 1-monthfollow-up (n=0)

1 month

Experimental Group(n=47) Passive joint mobilization Exercise Advice

Control Group(n=51) Exercise Advice

(n=47) (n=49)

Measured shoulder pain and functional impairment, range of motion, and self-perceived change in symptoms


Lost to 1-monthfollow-up (n=2) Surgery (n=1) Without reason (n=1)

3 months

Lost to 3-monthfollow-up Without reason (n=3)

6 months


Measured shoulder pain and functional impairment, range of motion, and self-perceivedchange in symptoms

(n=44) (n=49)

Measured shoulder pain and functional impairment, range of motion, and self-perceivedchange in symptoms

(n=44) (n=47)

Lost to 6-monthfollow-up (n=2) Without reason (n=1) Secondary illness (n=1)

Figure 1.Design and flow of clinical trial participants.



patients, 68 failed to meet the inclu-sion criteria. The reasons for exclu-sion were shoulder flexion or abduc-tion of less than 140 degrees ofAROM and shoulder symptomsreproduced during active cervicalspine movements or during palpa-tion of cervical or thoracic joints.The remaining 98 patients who metthe inclusion criteria accepted theinvitation and were recruited for thestudy.

Baseline characteristics for the totalcohort at the commencement of thistrial are presented in Table 1. Groupswere well matched at baseline, withthe only significant difference beinga longer duration of symptoms in thecontrol group (P.03). The studypopulation consisted of a young-elderly cohort, with approximatelyequal numbers of men and womenwith chronic shoulder pain. At base-line, both groups reported a moder-ate level of shoulder pain and func-tional impairment (mean total SPADIscore50% for both groups) andapproximately 30 degrees and 50degrees of painful shoulder flexionand abduction AROM, respectively.

Four participants were unable tophysically attend the outpatientphysical therapy department for

reassessment: 1 at both 1- and3-month follow-ups, 1 at the 3-monthfollow-up, and 2 at 3- and 6-monthfollow-ups. For these participants,data relating to their shoulder painand functional impairment and self-rated change in symptoms wereobtained via telephone. The SPADIhas been found to be suitable foradministration via telephone.46

Therefore, primary outcome mea-surement data were obtained for98% (control group96%, experi-mental group100%), 95% (controlgroup96%, experimental group94%), and 93% (control group92%,experimental group94%) of all par-ticipants at the 1-, 3-, and 6-monthfollow-ups, respectively. Reasons forparticipant withdrawal are detailed inFigure 1.

Participants in both experimentaland control groups received a meanof 9 (SD5) treatment sessions,ranging from 0 to 24 and 1 to 24sessions, respectively. Participants inthe experimental group received amean of 7 (range216) treatmentsessions involving passive mobiliza-tion of shoulder region joints. Onaverage, 67% of the total number oftreatment sessions for the experi-mental group included passive mobi-lization of shoulder region joints,

thus meeting the minimum dosagerequirement (60%) for this study. Allbut 1 participant in the experimentalgroup received some mobilizationtherapy. However, 11 experimentalgroup participants had mobilizationtherapy in less than 60% of theirtreatment sessions, even thoughthey had up to 9 mobilization treat-ments. Of the participants whoreceived passive mobilization ther-apy, 59% received mobilizationsolely to the glenohumeral joint, 2%solely to the acromioclavicular joint,2% solely to the scapula, and 35% toa combination of shoulder regionjoints, including the glenohumeral,acromioclavicular, and sternoclavic-ular joints.

Group data for all outcome measuresat 1, 3, and 6 months following ran-domization for the experimental andcontrol groups are presented inTable 2 and Figures 2, 3, and 4.Improvement was seen in all out-come measurements in both groupsat 1, 3, and 6 months (P.001). Dif-ferences in mean total shoulder painand functional impairment scores(total SPADI scores) between thecontrol and experimental groups atall follow-up periods were small andstatistically nonsignificant. At the1-month follow-up, the experimental

Table 1.Baseline Characteristics of Participants at Commencement of the Triala

VariableExperimental Group

(n47)Control Group

(n51)

Age (y), X (range) 62 (3585) 58 (2781)

Sex, n (male:female) 20:27 27:24

Shoulder affected, n (right:left) 31:16 34:17

Dominant shoulder affected, n (right:left) 41:6 45:6

Duration of symptoms (mo), X (SD) [95% CI]b 9.7 (12) [6.3 to 13.1] 22 (38) [12.1 to 32.8]

Total SPADI score (%), X (SD) [95% CI] 50 (21) [43 to 55] 50 (19) [45 to 55]

SPADI pain score (%), X (SD) [95% CI] 56 (21) [50 to 62] 56 (18) [51 to 61]

SPADI disability score (%), X (SD) [95% CI] 45 (23) [39 to 52] 46 (22) [40 to 52]

Flexion painful arc (), X (SD) [95% CI] 28 (17) [23 to 33] 31 (20) [25 to 36]

Abduction painful arc (), X (SD) [95% CI] 46 (22) [39 to 52] 50 (23) [43 to 56]

a 95% CI95% confidence interval, SPADIShoulder Pain and Disability Index questionnaire.b Significant differences between the experimental and control groups (P.05).



group had 1% (95% CI [confidenceinterval]7% to 9%) less shoulderpain and functional impairment thanthe control group. The controlgroup had 5% (95% CI3% to 12%)and 0% (95% CI7% to 7%) lessshoulder pain and functional impair-ment than the experimental group at3 and 6 months, respectively. Simi-larly, small and statistically nonsignif-icant differences in scores for self-rated change in symptoms betweenthe control and experimental groupswere demonstrated at all follow-upperiods. The control group was 0.2out of 5 (95% CI0.1 to 0.6) betterthan the experimental group at the1-month follow-up, and the experi-mental group was 0.2 out of 5 (95%CI0.3 to 0.6) and 0.1 out of 5(95% CI0.2 to 0.5) better thanthe control group at 3- and 6-monthfollow-ups, respectively. No adverseeffects of any treatment interventionwere reported.

DiscussionThis is the first adequately poweredRCT that has specifically evaluatedthe effectiveness of passive jointmobilization specifically applied toshoulder region joints for the treat-ment of people with shoulder painand minimal movement restriction.Our results demonstrate that theaddition of passive mobilization ofshoulder region joints to exerciseand advice is not more effective thanexercise and advice alone in decreas-ing pain and painful ROM andimproving function and self-ratedchange in symptoms in this cohort,with no significant differences in anyof the outcome measurementsbetween the 2 groups at short-,medium-, or longer-term follow-up.

The findings of small, nonsignificantdifferences in functional impairmentand AROM between the groupsreceiving and not receiving passivemobilizations to shoulder regionjoints in this study support thefindings of the only other clinical Ta

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trial that specifically evaluated theeffectiveness of this modality for thetreatment of people with shoulderimpingement syndrome.20 However,although Conroy and Hayes 20 foundpassive mobilization of shoulderregion joints to be effective indecreasing the maximum pain levelreported over a 24-hour period andduring an impingement test in thiscohort in the short term, the currentstudy found no differences in painlevels measured on the SPADI ques-tionnaire in the short, medium, orlonger term. The current well-

powered, longer-term study con-firms and extends the majority offindings of this smaller short-termstudy (ie, that passive mobilizationsapplied to shoulder region joints donot add clinical benefit in the man-agement of painful shoulderdysfunction).

The results of the current study alsostrongly support the findings of pre-vious RCTs investigating the effec-tiveness of passive mobilizations spe-cifically applied to shoulder regionjoints for the management of painful,

restricted shoulder dysfunction.18,19

Similar to the current study, thesestudies found no significant differ-ences in pain,18,19 functional impair-ment,18 self-rated change in symp-toms,18 or AROM18,19 between agroup that received passive mobili-zations and a group that did notreceive passive mobilizations atshort-term follow-up18,19 or longer-term follow-up.18 The results of thecurrent and other relevant RCTs,therefore, indicate that passive jointmobilizations specifically applied toshoulder region joints for the man-agement of shoulder pain of localmechanical origin without instabilitydo not provide additional clinicalbenefit above exercise and advicealone.

Systematic reviews of clinical trialsinvestigating mobilization therapyhave concluded that there is limitedevidence to support the effective-ness of passive joint mobilizationtherapy for the management ofshoulder pain.11,47,48 Of the 3 avail-able clinical trials included in thesereviews,15,16,20 the majority investi-gated mobilizations directed at verte-bral column or rib joints, as well asshoulder region joints.15,16 With theaddition of more-recent evidencefrom clinical trials conducted sincethese reviews were performed, this

Figure 2.Mean (95% confidence interval) Shoulder Pain and Disability Index (SPADI) question-naire scores (%) for shoulder pain and functional impairment for the control andexperimental groups at entry into the trial (baseline) and at 1-, 3-, and 6-monthfollow-ups.

Figure 3.Scores for self-rated change in symptoms for the control (shaded) and experimental (unshaded) groups at 1-, 3-, and 6-monthfollow-ups.



conclusion can be further refined.The results of the current study andof the study by Chen et al18 consid-ering the effectiveness of passivemobilization specifically applied toshoulder region joints provide strongevidence that passive mobilization ofshoulder region joints does not addclinical benefit in the treatment ofpeople who have shoulder pain withand without movement restriction.In addition, Bergman et al17 providedevidence that mobilization or manip-ulation therapy specifically appliedto the vertebral column and ribs ismore effective than usual care in themanagement of shoulder pain. Itwould appear, therefore, that theconclusion that patients with painfulshoulder dysfunction gain clinicalbenefit from the application ofmobilization therapy only applies topassive joint mobilization of the ver-tebral column or rib joints.

The design of the current studyincluded several features to mini-mize bias, thus enhancing the inter-nal validity of results obtained andstrengthening the conclusions thatcan be drawn from this study. Partic-ipants were allocated to 1 of 2 treat-ment groups using a predeterminedrandom and concealed allocationprocess. An exercise approach ofproven efficacy was implemented asthe control treatment.22,23 Passivemobilization therapy was isolated tothe shoulder region joints in order toevaluate the contribution of this spe-cific component of the commongroup of treatment modalities usedby physical therapists to treat peoplewith shoulder pain. Participants inboth groups were provided with thesame mean number of treatmentsand thus the same amount ofparticipant-therapist contact time.Short-, medium-, and longer-termreassessments were conducted. Thenumber of participants unavailablefor reassessment was low at allfollow-up periods, thus preservingthe successful randomization

achieved at the commencement ofthe clinical trial. The sample size waslarge enough to provide adequatepower to detect significant differ-ences, and responsive, reliable out-come measures were used. With theexception of duration of symptoms,which was taken into account in theanalysis, baseline demographicswere similar at the commencementof the trial, and baseline outcomemeasurements were well matched.Finally, an intention-to-treat analysiswas implemented.

In addition, this RCT included fea-tures to enhance the external validityof the study and thus enhance thegeneralizability of the resultsobtained. All treatments were specif-ically tailored to the individual par-ticipant rather than following a pre-scribed pattern and, therefore, weremore reflective of a typical clinicalsetting. Seventeen physical thera-pists with varying clinical experi-ence ranging from 2 to 28 years wereinvolved in providing treatment inthis study, and all of these physicaltherapists provided treatment forparticipants in both the experimen-tal and control groups.

The conclusion from this clinicaltrial, that the addition of passive jointmobilizations of shoulder regionjoints to exercise and advice is notmore effective than exercise andadvice alone for the treatment ofpeople with shoulder pain and min-imal movement restriction, how-ever, does need to be viewed in lightof some limitations. The lack of areliable diagnostic classification sys-tem for shoulder pain resulted in aheterogeneous study population inthe current study consisting ofpatients with a mix of mechanicalshoulder symptoms, only excludingthose with restricted shoulder ROM.It is possible that specific subgroupswithin this heterogeneous group, ifthey can be reliably identified, maybenefit from mobilization therapydirected at the shoulder regionjoints. In addition, the lack of evi-dence to guide therapists in thechoice of passive mobilization tech-nique may have resulted in thechoice of less-than-optimal mobiliza-tion therapy for some participants.Finally, although the loss tofollow-up was smaller than thatassumed in the calculation of thesample size for the current study,there is the chance that significant

Figure 4.Mean (95% confidence interval) painful flexion and abduction active range of motionfor the control and experimental groups at entry into the trial (baseline) and at 1-, 3-,and 6-month follow-ups.



differences between the treatmentgroups were missed due to type 2statistical error, and the possibility ofbias due to the lack of blinding of thetreating therapists and participantscannot be discounted.

Mr Yiasemides and Associate Professor Ginnprovided concept/idea/research design andproject management. All authors providedwriting, data analysis, and consultation(including review of manuscript before sub-mission). Mr Yiasemides provided data col-lection. Associate Professor Ginn providedfund procurement, facilities/equipment, andinstitutional liaisons. The authors are gratefulto the outpatient physical therapy staff at theRoyal Prince Alfred Hospital, Sydney, Austra-lia, for their involvement in this clinical trial.

This study was approved by the HumanResearch Ethics Committees of the Universityof Sydney and Central Sydney Area HealthServices (Royal Prince Alfred Hospital).

This research was presented at the 15thInternational Congress of the World Confed-eration for Physical Therapy; June 26, 2007;Vancouver, British Columbia, Canada, and atthe 13th Biennial Musculoskeletal Physio-therapy Australia Conference; October 15,2009; Sydney Convention Centre, Sydney,Australia.

This study was partially funded by a Muscu-loskeletal Physiotherapy Australia ResearchGrant from the Physiotherapy ResearchFoundation awarded in 2005.

Trial registration: ACTRN: 12605000151639.

This article was submitted March 29, 2010,and was accepted October 20, 2010.

DOI: 10.2522/ptj.20100111

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