MANUAL THERAPY
The sequence of a MUA procedure follows the same progression that a series of mobilizations will follow in a therapy setting. However, the MUA adds higher end-range capsular stretch forces. The anesthesia allows for inhibition of the patient’s neuro-muscular protection. MUA is typically completed in a single short session. Research mentions manual therapy can be moderately effective in combination with other interventions, such as exercise and cortico-steroid injections. Additionally, it is mentioned that manual therapy is effective in the short-term combined with NSAIDs. It is crucial to note that several studies state manual therapy is not effective in one treatment session alone, highlighting the importance of consistent implementation during in- clinic visits (Favejee, 2017; Kelley, 2012; Page, 2014; and Steuri, 2017). Both manual therapy and exercise are the main interventions used for patients with frozen shoulder, adhesive capsulitis and shoulder stiffness. Various studies will provide specific support for manual therapy techniques and joint mobilizations.
Manual therapy encompasses a broad family of techniques such as cross-friction massage, stroking type of massage, trigger point release, hold-relax methods, joint mobilization, movement with simultaneous mobilization and manipulation. When discussing manipulation in physical therapy practice, the term is defined as a high-speed, short arc mobilization. Manipulation carries risk of injury to the shoulder joint. While it is within the scope of practice for physical therapists according to the APTA, it is not part of the legal practice act for many states. Clinicians must be aware of their state’s specific guidelines on mobilization. Additionally, clinicians should have proper training and education before initiating manipulation techniques with their patients. Manipulation differs from the medical procedure of forceful translation manipulation under anesthesia (MUA), performed by physicians, typically orthopedic surgeons.
JOINT MOBILIZATION
valuable for clinicians to review the different components of joint mobilization treatment, such as hand positioning, amplitude and quality of glides, and other preparatory aspects. The goal is to introduce a hybrid treatment approach that incorporates different manual therapy techniques. Studies support the specific efficacy of joint mobilization, both as an adjunct to other shoulder stiffness treatments or as a singular intervention (Conroy, 1998; Dierks, 2004; Favejee, 2011; Green, 2003; Hanchard, 2010; Jewell, 2009; Kelley, 2009; Kumar, 2016; Levine, 2007; Nicholson, 1985; Page, 2016; Steuri, 2017; Tanaka, 2010; Yang, 2012). Several other studies have provided specific guidelines on position, quality and amplitude of joint mobilization techniques. These provide clinicians with a reference point to maximize success within the clinic. These studies identify the importance of placing the contracted capsule in a loose pack position with initial joint mobilizations. When we consider the anatomy of a shoulder joint capsule, the goal of mobilization is to deliver stretch loads to all areas of the capsule. Hsu (2000) determined the efficacy of applied mobilization at the end-range, regardless of direction. However, it is suggested that early mobilization glides should concentrate on the anterior-inferior segment (Conroy, 1998; Hsu, 2000; Hurschler, 2001; Johnson, 2007; Lin, 2007; Nicholson, 1985). Lin (2007) found that the loose pack position was at 40° of abduction and slight external rotation, closely related to the plane of the scapula. This is the optimal position to initiate light stretches to the anterior-inferior shoulder joint capsule, as translation movements are maximized. Additionally, it was found the optimal position for rotational freedom was from 40-60° of abduction (Lin 2007). This concept was expanded on, with evidence that freest position for external rotation occurs at 60° of abduction (Hurschler, 2001). The combination of these positions creates the composite measure for joint mobilization: 40° of abduction (Ludewig, 2004). The next component of effective mobilization involves the amplitude of glides. Initial mobilizations are applied in the Grade 2-3 range (within the freest motion on the joint) and graduate to Grade 4 (with a light force to the capsular end- feel and quick release). These grades are dependent on patient tolerance. The quality of the glide is also something to consider; i.e., short and forceful or smooth and repetitive.
The goal of joint mobilization is range of motion acquisition. Joint mobilizations allow for gradual improvements in inferior capsular length. This promotes range of motion gains in elevation, abduction and external rotation mobility. There are several things to consider when performing joint mobilizations such as the time it takes to regain functional range of motion. As mentioned, insurance can influence a patient’s recovery process and it is important to maximize a patient’s time spent in the clinic. Joint mobilizations should not monopolize the treatment session, especially when a patient experiences plateaus with range of motion acquisition. Joint mobilization is defined as a localized, isolated manual joint stretch with control of plane, position, direction, and force amplitude. Clinicians should consider starting joint mobilizations at around 3 weeks post-injury with inflammatory signs or after 3 weeks of immobilization to the shoulder joint. When choosing the appropriate mobilization technique, consideration of patient symptoms and clinical presentation is essential. The best type of joint mobilization will vary if patients experience more stiffness versus pain. If pain is present before end-range resistance, gentle joint mobilization forces are indicated. If pain is present at end-range restriction, moderate mobilization forces are appropriate. If pain is resolved but joint stiffness is still present, increased forces are required and most beneficial. Joint mobilization, combined with prolonged static stretch, are two main treatment strategies frequently used to address shoulder joint stiffness. Physical therapy is described as the foundation of frozen shoulder treatment. Research recognizes the medical communities’ reliance on physical therapy as the initial treatment for conservative care of shoulder stiffness (Pandey, 2021, 2022). Joint mobilization is one of the most frequently used interventions in most physical therapy treatment sessions. Joint mobilization techniques will monopolize a majority of the available in-clinic time for the early stages of frozen shoulder and adhesive capsulitis. With joint mobilization methods, there is overall lack of standardization. Clinicians currently demonstrate a variation of joint mobilizations techniques. There are significant inconsistencies with timing and duration of joint mobilization treatments. Most notably, manual therapy training differs greatly, leading to irregularity in individual therapist skill. This section will investigate the research of the many determinants of effective joint mobilization to develop an evidence-based clinical session format and define optimal ROM acquisition progress. It is
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