(with inferior glides) and after two weeks an increased emphasis on stretches for external rotation. At year’s end, the patient was discharged due to lapse of insurance coverage. Although she had remnant external rotation deficits as cited in prior discussion, she wa s pleased with her functional capacity and minimal pain. As the bottom-line numbers indicate in Figure 7, each plane of motion improved by an average of 5° or more per week. The 5° degree rule has served as a reliable clinical measure of optimal patient progress. This is notable in several successful treatment outcomes of patients who received 3-4 months of conservative therapy regimens. Healthcare Consideration: 5° Rule - In the settled or frozen phase of stiffness, compliant patients receiving comprehensive multi-modal care can improve ROM in each treated plane by 5° per week. There is a need for more published outcome studies regarding weekly progress as this type of data constitutes an important parameter of clinical success. The study by Levine (2007) offers a rare comparative report for weekly range of motion changes. Resulting from the average 3.8-month long treatment program, the shoulder flexion mobility improved from 118-164 degrees, showing a 46° improvement. For shoulder external rotation, mo- bility improved from 26- 59 degrees, a 33° change overall. The approximate weekly change of flexion demonstrates 3° and 2° for external rotation. This study was effective in producing the minimal mobility needed for reported normal activities of daily living. However, these improvement rates may have fallen short of optimal, full mobility return.
Figure 7 Flexion Abduction External Rotation
October 15th
54°
46°
14°
November 1st
101°
74°
24°
November 15th
104°
76°
35°
December 1st
110°
78°
48°
December 15th
121°
84°
52°
December 30th
124°
88°
54°
Average Change/ Week
8.75°
5.25°
5°
A 66-year-old, right-handed dominant patient presents with left frozen shoulder syndrome. The patient reported insidious onset of left shoulder pain, increased stiffness and loss of functional mobility for several months. The patient denied prior injury or no relevant medical history. She did not receive any injections or pharmacological treatment to the shoulder. This patient was treated with combined joint mobilization using proximal control and in-clinic manual stretches. She was also provided a home exercise program that emphasized daily external rotation static self- stretches. The patient adhered to the home exercise pro- gram and clinic attendance. The patient’s progress indicates an optimal, steady improvement in active ROM (Figure 7). The listed mobility changes correlate with the early emphasis on elevation
THE HYBRID MOBILIZATION TECHNIQUE: “PROXIMAL CONTROL
forces is delivered distally, in direct alignment with the humerus. The pressure from the therapist’s hand should remain light. Figure 8: Proximal Control
There are many mobilization techniques and variation of ap- proaches to address shoulder stiffness. A clinical technique to mobilize frozen shoulder, adhesive capsulitis and primary im- pingement was developed in the mid-1980s. This hybrid method consolidated primary studies that define glide duration, quality, amplitude, and direction. The term proximal control refers to ap- plying manual contact directly on the shoulder joint. The finger- tips of both hands surround the joint. This proximal placement is confirmed by a soft feel with a light squeeze of the hands. A hard feel indicates that the hands are on the humeral head and should be avoided. The goal is to apply translation to the joint and avoid applying forces on the humeral head. This contact point also pre- vents the risk of applying a torque moment to the shaft of the humerus through a long lever arm. The greatest bony strain on the humerus arises from rotational torque and clinicians should be cautious of such. The proximal control method was created by the late Gordon Cummings, who wrote Soft Tissue Contracture (1983). Performed by the therapist standing at the patient’s side outside the humer- us, the hands are placed around the joint line. The distal humerus of the patient is clamped to the therapist’s iliac crest with thera- pist’s inner most arm (Figure 8). This control isolates motion to be only at the proximal segment of the shoulder. This provides a measure of trust and relaxation with the patient as the humeral head is not being gripped. The patient’s shoulder is placed in the plane of the scapula (equiv- alent to 40° abduction) and slight elevation. Light grade 2-3 oscil- lations are performed first, with therapist progressing to grade 4 when tolerated (Figure 8). With some mobilization or stretching methods, patients often need frequent verbal cuing to relax. With the proximal control method, the therapist’s fingers will be able to detect increased muscular tension or guarding. Many patients will be apprehensive with initial mobilization efforts. During the proximal control technique, patient guarding is frequently caused by excessive tension in the therapist’s grip. When appropriate, the therapist will add increased abduction or external rotation on the shoulder while continuing the inferior glides. The direction of the
The most effective quality of glides for shoulder mobilization is a rhythmic, repeated oscillation delivered at approximately 30 pounds of pull. The capsular restriction is “bumped” and released with each inferior glide. This concept is confirmed by the findings of Bang (2000) and Vermeulen (2006). These studies determined the most effective duration for glides range from 30 seconds to two minutes. While this degree of time can be challenging for a therapist to maintain, the proximal stabilization is designed to allow minimal hand fatigue and maximal leverage from support from the hips. Mobilizing the joint at the end-range of capsular restraints provides greater TERT effects. The primary differences between this technique and other mobili- zation recommendations are: 1. The repetitive application of inferior glide “bumps.” 2. No distraction is applied to the joint, only inferior glide. 3. No stabilization of the scapula is required.
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