Introduction Shoulder pain and stiffness has become one of



Shoulder pain and stiffness has
become one of the most common problems within the general community. It is the
third most frequent site of musculoskeletal pain after back and neck (Minerva,
Alagini, Apparao & Chaturvedhi, 2016). Over time, many approaches have been
employed to provide a treatment for shoulder disorders ranging from surgical
procedures to manual therapeutic techniques. Most often, physiotherapy tends to
be practioners first line of call with 53-79% of them referring to a
physiotherapist before other treatment modalities such as surgery or oral-drug
therapy (Chen, 2012). Shoulder pain has become more frequent over the years
with 16-20% of the population being affected, however adhesive capsulitis (AC)
(also known as frozen shoulder) has become the most common (Minerva et al.,

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AC is characterised by insidious
and progressive pain with a loss of active and passive movements of the
glenohumeral joint (Vermeulen, Rozing, Obermann, Cessie & Vlieland, 2006). Symptoms
include pain, limited range of motion (ROM) and muscle weakness which is caused
from the disuse of the shoulder region (Reeves, 1975 & Vermeulen et al.,
2000). Physical therapy has become the foundation in preventing the development
of shoulder capsule contracture and restoring shoulder motion. Many therapeutic
approaches have been used throughout time, however mobilisations of a joint
have become to most popular. The most accepted being Maitland and Mulligan,
which have been acknowledged in literature to improve pain and restore function
and mobility in patients with frozen shoulder (Youssef, Ibrahim & Ayad,


Main body


The Maitland and Mulligan
mobilisation techniques present different but equally exclusive sets of widely
employed manual therapy techniques for treating pain and stiffness in human
joints. Whilst the literature reports considerably on the efficacy of their
respective techniques (Minerva et al., 2016).


The International Maitland Teachers
Association (IMTA) defines the Maitland concept as a process of examination
assessment and treatment of musculoskeletal disorder in manipulative therapy
(Mulligan, 1995). Maitlands mobilisations mainly consist of rhythmic
oscillatory movements which stimulate mechanoreceptors and overall having an
effect on the circulatory perfusion. Mobilisations have an effect on the fluid
flow, as the blood flow in vessels supplies the nerve fibres and synovial fluid
flow surrounding the avascular cartilage. This allows the mobilisation movement
to cause a reversal of the ischemia, oedema, and inflammation cycle and reduces
joint effusion and relieves pain by decreasing the pressure over the nerve
endings (Maitland, 1983). As a result of this, it shows the relevance
mobilisations have on the early stages of rehabilitation. Mobilisations are
required to reverse these effects therefore facilitating a speedier recovery.

Mulligan incorporates the concave, convex rule in his mobilisations which are
given in a painless way with an end pressure to restore reduced accessory
glides of the joints (Mulligan, 1995). If a patient feels pain at any point,
the mobilisation should be stopped and tried in a different way, or at a lower
intensity. In essence, the limited painful physiological movement is performed
actively and therapist applies a sustained posterolateral glide to the
restricted joint aiming to increase the joint ROM (Mulligan, 1995).


Throughout the literature, it has
been disputed whether or not the Mulligan technique is more superior compared
to the Maitland. Youssef, Ibrahim & Ayad (2015) conducted a study to associate
the effects of mulligan mobilisation versus the Maitland technique in treating diabetic
frozen shoulder. The study consisted of 30 subjects
with frozen shoulder and were split into two groups. Group A = Mulligan, group
B= Maitland, along with pendulum exercises at home to help with active daily
living (ADL) and reducing the pain limit for the patient. Each subject received
shoulder mobilisations 3 times a week for 6 weeks. The journal strongly stated
that the Mulligan technique is more effective in improving shoulder function
and motion. Within the Mulligan group, both shoulder function and motion had a
significant increase compared with the Maitland technique. Regarding the
shoulder function, this could have been a direct effect on the pain relief associated
with this technique (stated above) which in time, could encourage the patients
to have the self-confidence to use the arm more in ADL. On the other hand, for
shoulder motion, all movements showed a significant difference in the Mulligan
group except for internal rotation. Nevertheless, this could be down to
patients feeling more comfortable and feeling as though the pain has decreased
more through the application of the adjustment of moving articular surfaces
(Yang, Chang, Chen, Wang & Lin, 2007). This is expected to reduce tension
and trauma on all the aspects surrounding the shoulder, such as the ligament


Although the results of this study
are respectable, only active ROM was assessed, whereas other journals have
assessed the effects of both passive and active ROM. Such as, Vermeulen et al.

(2006) who compared the effects of high grade and low grade mobilisations on
both active and passive ROM who was then able to give comparisons of both
passive and active and why these have an effect on mobilisations. This journal
was of a high quality with a good methodological procedure, however consisted
of a short follow-up time therefore decreasing the effects of the results. This
creates a gap in the research for whether the superior effects of Mulligan will
persist over a longer period of time.


Vermeulen et al. (2000)
demonstrated that with end-range mobilisation techniques (ERM) there is an
increase in joint capacity and glenohumeral mobility after 3 months of
treatment. He conducted a study which looked at the effect of ERM in treating
patients with AC. The study recruited 7 subjects with a mean age of 50.2 years
and a mean disease duration of 8.4 months. This study focused on measuring
pain, passive and active ROM of flexion abduction and lateral rotation which
they measured on 3 occasions. For the ERM mobilisation techniques, grades III
and IV were given twice a week for 30 minutes. The results obtained from this
study show that ERM increase the range of motion in shoulder abduction, flexion
and lateral rotation. Nevertheless, this study did not use a control group
which does not allow the comparison of the results against a control group,
limiting the external validity. The study by Vermeulen et al. (2000) had a poor
design and a small sample size, however the study does show that there are
improvements in the shoulder ROM in patients with AC when treated with ERM. Therefore,
the study is of suitable relevance but should be used with caution due to the
disadvantages of the article.


Yang et al. (2007) conducted a
study comparing the use of ERM, mid-range mobilisation (MRM) and movement with
mobilisation (MWM) in the treatment of AC. The research they conducted
consisted of 28 subjects, which were split into 2 groups. The results of the
study showed a significant improvement in the FLEX-SF, humeral external
rotation, shoulder elevation and internal rotation in ERM and MRM groups as
compared to the MWM group. Furthermore, there were no significant differences
between the MRM and ERM group. The results collected suggest an improvement in
function and mobility of the shoulder in all 3 interventions, however the improvement
is more significant in the ERM than the MWM group. This journal followed a good
methodological procedure however a control group was not used. This becomes a
disadvantage as there is nothing to compare against. If this research was to be
done again, using a control group would enable the reliability and validity to
be improved.


Goyal et al. (2013) conducted a
study which combined the effects of end range mobilisations (ERM) and mobilisation
with movement (MWM) techniques on ROM and disability in frozen shoulder
techniques. A total of 30 subjects were split into 3 groups. Group A=ERM, group
B=MWM and group C=ERM+MWM. Along with the mobilisations, each subject was also
given conventional physiotherapy (Kumar, Kumar, Aggarwal, Kumar & Das, 2012)
comprising of posterior capsular stretching in cross-body reach position using
the opposite arm. All groups were given the mobilisation 2 days a week, for 3
weeks. They received 3 sets of 10 repetitions, with 1 minute between sets. The
stretches were performed 5 times per day in a minute for total of approximately
15 minutes per day and basic pendulum exercises. The results of this study
concluded that subjects in all three groups had shown significant improvements
in the flexion, abduction, external rotation and internal rotation ROM and a
decrease in shoulder mobility. On the other hand, it was concluded that among
the three groups, there was minimal improvement in end range mobilisation group
and combined intervention group. It was concluded that the effectiveness of both
ERM+MWM was the more effective in increasing mobility and functional ability
not ROM.


Vermeulen et al. (2006) went on to
compare the effects of high-grade mobilisation (HGMT) versus low-grade mobilisations
(LGMT) in subjects with AC of the shoulder. This study consisted of 96 subjects
who were randomly allocated to either the HGMT or the LGMT group. The results
indicate that there was a statistically significant improvement in the active
external rotation (p=0.051) and abduction (p=0.059) ROM in the HGMT group
compared to the LGMT. This was a well conducted study with a good design and
followed a good procedure with the randomisation. It also provides evidence
that the application of grade III and IV (HGMT) is more beneficial in improving
the active and passive ROM than grades I and II (LGMT).


Johnson, Godges, Zimmerman &
Ouanian (2007) found significant improvements in external rotation motion in
patients with frozen shoulder after performing posterior glide mobilisations
sustained for 1 minute at end range abduction and external rotation by
promoting elongation of shortened fibrotic soft tissues. They conducted a study
comparing the effects of anterior versus posterior glide joint mobilisations on
external rotation in patients with AC. External rotation is known as the most
limited motion in patients with AC and throughout literature anterior glide
mobilisations have been the most known technique to improve this movement in
patients with frozen shoulder. This was accepted within literature due to
principles agreeing with arthokinematics. However, the research that Johnson et
al. (2007) conducted, establish that posterior glide mobilisations, with
therapeutic ultrasound and upper extremity therapeutic exercises was the most
effective for increasing external rotation. They found that the posterior
mobilisation group had an average of 31.1 degrees of external rotation (after 3
treatment sessions), compared to only 3 degrees’ average for the anterior
mobilisation group.  From the research
conducted, we can also conclude that combining mobilisation techniques
alongside electrotherapy and therapeutic exercises has a more advantageous
effect than mobilisations alone. Johnson et al.

(2007) including thermal ultrasound alongside mobilisations with the intention
to alter viscoelastic properties of the connective tissue which in turn
maximises the effectiveness of the stretch (Reed, Ashikaga, Fleming
& Zimny, 2000). Therapeutic exercises were also included to elongate the
glenohumeral capsular contracture providing an additional enhanced ROM.


Vermeulen et al. (2000) showed a
significant difference with ERM in treating AC, however when Goyal et al.

(2013) combined the use of ERM with MWM, there was also a significant
difference however the effectiveness was primarily for increasing mobility and
functional ability whereas Vermeulen et al. (2000) showed a significant
difference in all movement planes, improving ROM .This shows that to improve
ROM, ERM alone is more effective than combining techniques however to improve
the mobility of the shoulder joints and its functional ability, combined ERM+MWM
is more effective overall.




Following the research conducted in
this study, it can be concluded that a variety of different aspects have been
looked at within the region of shoulder mobilisations in treating AC. Many
different authors have taken different approaches whereas some have highlighted
conflicting points which give a different answer. This study has looked into
different areas and has been able to conclude a number of main points. ERM is
useful at increasing ROM in patients suffering AC (Vermeulen et al., 2000),
whereas Goyal et al. (2013) suggests that ERM+MWM is useful in patients with AC
when trying to increase shoulder function and mobility. HGMT and LGMT were also
compared within the literature, Vermeulen et al. (2006) came to the conclusion
that HGMT were more effective than LGMT in improving active and passive ROM.

Furthermore, Johnson et al. (2007) concluded that posterior glide mobilisations
were more beneficial than anterior glide mobilisations when used along side
ultrasound and upper extremity exercises. This statement was accepted within
her research as the results showed a significant increase in external rotation.

Overall, the research on the effect of shoulder mobilisations in treating AC is
effective and a lot is available. However, many of these studies have
limitations which include low sample size, short follow-ups and poor study
designs. For future research to be improved, these should all be considered,
considering a large sample size with a longer follow procedure, and a better
quality study design will improve the outcome of results and increase the knowledge
being provided. Future research could also focus on comparing the effects of
mulligan versus Maitland but including both passive and active ROM instead of
just comparing one. 


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