1. Joint Mobilizations on a Patient with Subacromial Impingement Syndrome
Kathleen Lautzenheiser
Clinical Problem Solving II
October 6, 2016
They’re gonna ask…what parameters would you use? I say go by Maitland’s mobs parameters (either an oscillation or prolonged stretch)
Capsular tissue stretching and repair process
I’m attributing her lack of IR due to pain and capsular tightness post surgery (secondary impingement)

2. Objectives Discuss patient case
To discuss the evidence on joint mobilizations in a patient with SAIS
To provide overall conclusion of the implementation of joint mobilizations with regard to the literature
To discuss the relation to patient case and provide overall thoughts for future treatment

3. Patient Background Demographics: 61 year old African American female
History of Left RC repair (2012), Right shoulder arthroscopy and RC repair (Dec 2015)
Works part-time in customer service
PMH:
Diabetes- diagnosed in 2011 (controlled with medication)
HTN
Arthritis
Other surgeries: L knee arthroscopy (1995), L thumb (2015)
The pt returned to the doctor in May (after a few months of PT) complaining of pain in the R shoulder, in particular. At least, that’s really what we ended up focusing on during treatment. She was complaining of pain that was aching and sharp, rates her pain anywhere from 5-8/10 consistently. Constant pain and pain at night.
The doctor diagnosed her with AC, yet based off my examination findings as I’ll explain in a minute, I decided to go with SAIS

4. Shoulder pain with ADLs Particularly concerned with IR ROM
Chief complaints:
Shoulder pain with ADLs
Particularly concerned with IR ROM
VAS: 5-8/10 consistently
Presenting diagnosis- Bilateral shoulder pain with possible adhesive capsulitis
All MRI imaging was clear
MRI can help identify abnormalities of the RC and capsule

5. Physical Therapy Examination
Objective: ROM
AROM in sitting
Flexion
Abduction
External Rotation
Internal Rotation
Right
100 90
Left
130
Patient had limitations reaching behind neck and back, ER/IR ROM not measured
I was not present from this- I got these measurements from my CI
The patient was limited in all planes of motion, active and passive, but was most limited in IR and ER on the R
As you can see here, the patient has more passive motion than active and does not have limitations with all ROM, which would be the case with adhesive capsulitis; therefore, I decided to go with SAIS as my diagnosis for this patient and researched based on the diagnosis
PROM in supine
Flexion
Abduction
External Rotation
Internal Rotation
Right
130 45 5
Left
160 80 50

6. Strength:
There was notable weakness in all planes of motion (4/5)
Medial border winging with repeated abduction and flexion in standing
Special Tests:
Pain at end range with all planes of motion
+ Impingement signs: Hawkins, painful arc
Outcome Measure: QuickDASH score of 20.5 (MDC=11)

7. Physical Therapy Assessment
The patient is a 61 year old female presenting with left shoulder pain, and primary impingement. The patient would benefit from physical therapy to address the following impairments and activity limitations:
Increased pain
Decreased ROM in all planes
Poor posture
Inability to perform ADLs such as bathing, dressing, and reaching
Hypothesis: If her symptoms are due to impingement and weakness of the scapular muscles, she may respond to a scapular and rotator cuff strengthening program

8. Plan of Care
Treatment included: posture re-education, AAROM and AROM exercises, rotator cuff and scapular muscle strengthening and stabilization exercises, joint mobilizations, posterior and anterior musculature stretching
Exercises were progressed appropriately given the patient’s tolerance
Frequency/Duration: Will see the patient 2x/week for 6-8 weeks
Prognosis- Good (age, motivation)
Prognosis- good, considering her age, motivation
Examples include: wand ROM ex; pulleys; IR/ER/SA punches/rows with band; ball on wall; PNF patterns with band; Ys,Ts,Is; S/L ER, HABD; GH stabilization in supine with shoulder flexion
Rationale for exercises:
Joint mobs- I decided to do mostly PA mobs over AP mobs because my patient was more comfortable in a supine position and I felt that I could get a good stretch of the anterior joint- the patient also enjoyed the treatment. There is evidence to suggest that PA mobs also increase IR ROM, so I played around with a few different positions and see the response of the patient
Three main mobs:
Posterior glide, elbow straight
Posterior glide with elbow flexed, adding ER as tolerated
Cross body ADD with posterior glide through the humerus
MET- used to try to get an increase in ROM- would use a contract relax of the external rotators to get an increase in IR
Stabilization exercises- used to add stability to the GH joint, to get control of the humeral head and prevent anterior/superior mvment, to prevent further impingement under the acromion

9. Goals
Within 2 weeks, the patient will increase R shoulder ROM in all planes in order to complete reaching, dressing and bathing tasks.
Within 2 weeks, the patient will decrease R shoulder pain from a 6/10 to at least 3/10 in order to perform HEP and sleep consistently throughout the night.
Within 8 weeks, the patient will be able to reach behind her back using her R hand to level T6-8 in order to dress and bathe independently.
Within 8 weeks, the patient will have full flexion and ER ROM on R as compared to the L side to allow for full participation in reaching overhead.
What ROM is necessary for the above ADLs?
You need a lot of IR ROM to reach behind the back; you need 56 degrees of ext

10. Clinical Question
For a 61 year old female with SAIS, are joint mobilizations combined with exercise more effective at increasing shoulder IR ROM than exercise alone?
This leads me to my clinical Q…my patient was especially concerned with IR ROM, which made me curious as to whether or not the treatment I provided (joint mobilizations and therapeutic exercises) were more beneficial in changing her ROM when performed 2-3x/week.
What is the most effective use of our time/treatment plan?

11. The Effect of Therapeutic Exercise and Mobilization on Patients With Shoulder Dysfunction: A Systematic Review With Meta-analysis
Brudvig et al. (2011)

12. Level of evidence- systematic review of RCTs, level 1a
The Effect of Therapeutic Exercise and Mobilization on Patients With Shoulder Dysfunction: A Systematic Review With Meta-analysis (Brudvig et al. 2011)
Purpose- to examine whether the combination of joint mobilizations and exercise is more effective than therapeutic exercise alone in decreasing pain and increasing ROM and function in patients with shoulder dysfunction
Level of evidence- systematic review of RCTs, level 1a

13. Clinically or radiographically confirmed shoulder dysfunction
The Effect of Therapeutic Exercise and Mobilization on Patients With Shoulder Dysfunction: A Systematic Review With Meta-analysis (Brudvig et al. 2011)
Inclusion criteria:
RCTs studying the effectiveness of therapeutic exercise and joint mobilization on adults
Clinically or radiographically confirmed shoulder dysfunction
Shoulder dysfunction includes: impingement, AC, tendinopathy, bursitis, GH arthritis, and RC tears; however, 4 studies excluded AC
Exclusion criteria:
Individuals with nonmusculoskeletal shoulder pain, systemic disease, complete RC tears, shoulder pain of cervical or neurological origin, and fractures less than a year old
Studies that used electrotherapeutic modalities and surgical interventions as primary independent variables
Confirmed shoulder dysfunction- resulting in pain, restricted range of motion, and/or limitations in function
Exclusion criteria- the studies excluded those with nonmusculoskeletal shoulder pain, systemic disease, complete RC tears, shoulder pain of cervical origin; also excluded studies that used therapeutic modalities (laser, US) as primary variables
They did use surgery as an exclusion criteria..however my patient was further out from surgery that I believe she should be treated more as an impingement case than a surgical patient

14. 7 RCTs fit the inclusion criteria (mod-high quality)
The Effect of Therapeutic Exercise and Mobilization on Patients With Shoulder Dysfunction: A Systematic Review With Meta-analysis (Brudvig et al. 2011)
Methods
Search of databases for RCTs that included mobilizations and/or therapeutic intervention for patients with shoulder dysfunction
7 RCTs fit the inclusion criteria (mod-high quality)
The quality of each study was determined using The Evaluation Guideline for Rating the Quality of an Intervention Study
Databases included Medline, Cochrane, etc.
The Evaluation Guideline for Rating the Quality of an Intervention Study includes 24 items in 7 domains; each item is scored 0-2; the domains include things such as study question, study design, subject selection, intervention outcomes, analysis, and recommendations; the max score by any study is 48; 36-48=high quality study, 25-35=moderate quality; <25=low quality study; is has been suggested that a methodological score of 70% is needed for a study to be of sound methodolological quality
4 high quality and 3 moderate quality studies
Two authors decided on the appropriate studies that met the inclusion criteria- discrepancies were resolved by a third author

15. Intervention group: therapeutic exercise + mobilizations
The Effect of Therapeutic Exercise and Mobilization on Patients With Shoulder Dysfunction: A Systematic Review With Meta-analysis (Brudvig et al. 2011)
Intervention group: therapeutic exercise + mobilizations
Control group: therapeutic exercise only
Outcome measures: pain, ROM, functional/disability outcome measures (variable per study)
Results:
Participants: convenience sampling (physician referred to PT)
290 participants, 146 in the experimental group and 144 in the control group
Convenience sampling was used- doctor referrals to physical therapy
Six studies compared the effect of therapeutic exercise vs. therapeutic exercise and mobilization
One study compared the effect of therapeutic exercise with mobilization alone
one subgroup of one study was eliminated and two subgroups of another study were eliminated because both met the exclusion criteria
Another study did not accurately document results of ROM, function, and disability, so these measures were not included in the analysis
Comparison of the effects of therapeutic exercise and the combination of therapeutic exercise and mobilization was performed on pain in 6 studies, on ROM in 4 studies, and on function or disability in 3 studies.

16. Statistical Analysis:
The Effect of Therapeutic Exercise and Mobilization on Patients With Shoulder Dysfunction: A Systematic Review With Meta-analysis (Brudvig et al. 2011)
Statistical Analysis:
Mean difference of the post-treatment scores (exper.-control group) were used to calculate the SMD with a 95% CI
SMD then used to calculate the WSMD (95% CI)
WSMD= a way for meta-analyses to compare studies that assess the same outcome in different ways; also gives more weight to studies that carry more information
For this study, the therapeutic exercise group was the control group and the mobilizations + exercise was the experimental group.
Mean difference of the post-treatment scores (experimental-comparison group) were used to calculate the SMD with a 95% C-interval
This data was then used to calculate the WSMD (95% CI)
Weighted standard mean difference= a way for meta-analyses to compare studies that assess the same outcome but so do in different ways (such as using different measurements or scales)
Meta analysis-- Rather than compute a simple mean of the effect sizes we compute a weighted mean, with more weight given to some studies and less weight given to others.

17. The Effect of Therapeutic Exercise and Mobilization on Patients With Shoulder Dysfunction: A Systematic Review With Meta-analysis (Brudvig et al. 2011)
Participant Characteristics by Study
Study
Sample Size
Average Age
Average Duration of Sx 1 17 43
19.2 mo
47.3
32.5 mo 2 90 64
9.3 mo
65.5
11.1 mo 3 52 42
5.6 mo 45
4.4 mo 4 67 46
2.5 mo
53.1
1 mo 5 14 55
1-6 mo
50.7 6 30 48 _
49.5 7 20 51
7 mo
7.5 mo
Variation across studies regarding average age, duration of symptoms, and diagnosis; however, most studies included patients on the dx of impingement syndrome or the report of pain and restricted ROM**
the inclusion/exclusion criteria differed as well- 4 studies excluded AC and calcific tendonitis
The average length of symptoms varied from 1-32 months
Overall, patients included were based on the actual diagnosis of impingement syndrome or on the report of pain and restricted ROM*
Experimental Group
Control Group

18. Joint Mobilization Treatment by Study
Mob Parameters
Frequency
Intensity
Position 1
Oscillations, 3x30 sec (30 sec rest)
1x/week for 6 weeks
Grades I-IV
Loose packed 2
---
At least 6x over up to 8 weeks
Grades II, III
End range 3
2-3x/week for 3-4 weeks
Grades I-V
N/S 4
3x/week for 6 weeks 5
Oscillations ,
3 or 4x30 sec
3x/week for 3 weeks
Mid-range 6
3x/week for 4 weeks 7
2-3x/week for 4 weeks
Maitland mobilizations grades I-IV were used in most studies, and 2 studies used grade V mobs; including anterior, posterior, and inferior glides and long axis distraction
Variations in parameters- frequency, repetition, and total treatment; a few of the studies did not specify parameters
Variations in position of the joint- one loose-packed, on mid-range, two at end range, and 3 unspecified
Joint Mobilization Treatment by Study

19. Post. stretching, RC strengthening, scap. stab. N/S
Study
Exercise
Repetition
Frequency 1
Post. stretching, RC strengthening, scap. stab.
N/S 2
NM control ex.
2x/day 3
A&P Stretching, RC strengthening (T band); press/push ups
Stretch- 3x30 sec
T-Band- 10 rep max
Press up/push up to fatigue
2x/week for 3 weeks 4
2x/week 5
AROM, stretching, AAROM, chair press-ups, IR/ER isometrics
3x/week for 3 weeks 6
AROM, stretching, RC strengthening
10-15 min
1x/day for 4 weeks 7
Active exercise in motion restrictions; strengthening weak muscles
The therapeutic exercises given included a variety of ROM, anterior and posterior stretching, strengthening, NM control and dynamic stability training ; all very similar to what my patient was doing in the clinic and for her HEP
In the chart I just summarized the information into categories of strengthening exercises to save space
Therapeutic Exercise by Study

20. The Effect of Therapeutic Exercise and Mobilization on Patients With Shoulder Dysfunction: A Systematic Review With Meta-analysis (Brudvig et al. 2011)
Rotation ROM
Here is a forest plot of rotation ROM used to demonstrate visually whether the studies favor the intervention or the control; I’ve highlighted the studies that were specifically looking at IR ROM
The chart indicates the measure of effect (odds ratio) for each study, incorporating confidence intervals represented by horizontal lines; in this study, the color of each square is representative of the weight that the study has in the meta-analysis
The measure of effect is commonly plotted as a diamond, the lateral points indicate the confidence interval
A vertical line of no effect is also plotted– if the confidence intervals of the individual studies and the measure of effect crosses this vertical line, there is no difference in the effect of intervention
Of importance, the Conry study 2 is IR, study 1 is ER; Nicholson 1 is ER, 2 is IR

21. The Effect of Therapeutic Exercise and Mobilization on Patients With Shoulder Dysfunction: A Systematic Review With Meta-analysis (Brudvig et al. 2011)
All 6 comparison groups had 95% CIs crossing 0, indicating that the combination of exercise and mobilizations is not superior to exercise alone in increasing IR ROM
When were these measurements assessed? 1 mo, 6 mo???
WSMD- what does this mean in terms of effectiveness/concluding a beneficial effect?
Internal Rotation ROM-- All 6 comparison groups had 95% CIs crossing 0, and the combined WSMD is .01, indicating that the combination of exercise and mobilizations is not superior to exercise alone
As you can see, this was the case for the other outcome measures
The change in pain, abduction, flexion, and function and disability were assessed by several studies; when finding the WSMD, all the scores landed within the confidence interval; therefore none of these measurements favored therapeutic exercise with mobs vs. exercise alone

22. Limitations and Future Research
There was variability in:
Study populations-age, cause of dysfunction, and duration of pathology
Sample size
Intervention
Outcome assessment tools
Follow-up
Future Research
Need more RCTs of higher evidence, with larger sample sizes and standardized methods of intervention
Examine the effects of intervention on specific diagnoses (such as SAIS)
The authors stated that the results were inconclusive
Sample size- the study with the largest sample size had patients at least a decade older than those in the other studies; the highest quality study had patients with more chronic symptoms
Intervention- the repetition, duration, and frequency of the exercises and mobilizations
Note: Hawkin-Kennedy and Neer tests are not specific enough to rule in a certain diagnosis
Treatment frequency ranged from 1 to 3 times per week, over a total treatment period ranging from 3 to 8 weeks.
Two of the studies, which found no significant difference in ROM between groups, had in fact given mobilization in the mid range, where the capsule might not have been adequately stretched to produce noticeable improvement in ROM. Therefore, the conclusion of insignificant effect size could be in fact due to such parameters.
Outcome assessment tools- including the Shoulder pain and disability questionnaire, the functional reach test, etc., all assessing different outcomes

23. “Passive mobilisation of shoulder region joints plus advice and exercise does not reduce pain and disability more than advice and exercise alone: a randomised trial”
Chen et al.(2009)

24. “Passive mobilisation of shoulder region joints plus advice and exercise does not reduce pain and disability more than advice and exercise alone: a randomised trial” (Chen et al. 2009)
Study Design: single-blinded RCT Purpose: To examine whether shoulder mobilizations with exercise and advice is more effective in reducing pain and disability for those with shoulder pain and stiffness than advice and exercise alone To see if gains are maintained at 1 mo. and 6 mo.
I like that this article examines the effect of the treatment at 6 months

25. Patients ≥18 years; average age was 65 yrs both groups
“Passive mobilisation of shoulder region joints plus advice and exercise does not reduce pain and disability more than advice and exercise alone: a randomised trial” (Chen et al. 2009)
Inclusion criteria:
Patients ≥18 years; average age was 65 yrs both groups
Shoulder pain and stiffness for >1 mo.
Unilateral shoulder pain
Must have <140 degrees flexion and ABD; >10 cm hand-behind-back deficit compared to other side
Exclusion criteria:
Trauma within 1 month
Inflammatory joint disease
Instability at the GH joint
Referred shoulder pain from vertebral column
Participants were randomly allocated into either the experimental or control group based on an assignment schedule provided in an envelope; the investigator in charge of the assignments was not associated with recruitment, intervention, or assessment
Inclusion criteria: pts presented at a large metropolitan hospital for PT intervention for shoulder pain and stiffness >1 mo. in duration

26. Control group: 45 individuals – advice and NM exercise only
“Passive mobilisation of shoulder region joints plus advice and exercise does not reduce pain and disability more than advice and exercise alone: a randomised trial” (Chen et al. 2009)
Methods:
Control group: 45 individuals – advice and NM exercise only
On average, 8 x 30 min. sessions within 8 weeks
Intervention Group: 45 individuals- advice+exercise+mobs
At least 6 sessions included passive mobs - GH or AC joint
Oscillatory movement or sustained stretch (low velocity), grades II or III used
Progression of techniques and NM exercises determined by the therapist
HEP: avoid provocative activities and do exercises 2x/day
Random allocation into either the control or intervention group
Could have up to 10 sessions but on avg received 8 sessions; the reason for the variability is that the authors wanted to treat the patients based on their clinical signs/sx as per routine clinical practice (individual treatment)
performed as either a passive oscillatory movement or sustained stretch with or without tiny amplitude oscillations at end range
participants attended up to twice weekly initially, and then once a week.
The movements above were aimed at restoring structures within the GH, AC joints to allow normal, pain-free ROM; use of Maitland mobs
Exercises were conducted in a pain-free manner to maximize normal muscle function and movement patterns
Exercises which involved a single shoulder muscle force couple were progressed to exercises which required multiple force couples

27. “Passive mobilisation of shoulder region joints plus advice and exercise does not reduce pain and disability more than advice and exercise alone: a randomised trial” (Chen et al. 2009)
Results:
Experimental group: 70% had mobilizations to the GH joint, 10% to the AC joint, and 20% a combination
AP glides at end range abduction- most common technique used for the GH joint; AP or PA glides were used at the AC joint
Note: we typically perform posteroanterior mobs in order to increase IR ROM (how we’ve been taught), because the idea is that in doing so we are stretching out the posterior joint capsule and hopefully increasing IR ROM; yet, this study looked primarily at AP mobs- it is still debatable which position to put the shoulder to increase shoulder IR/ER
(idea that by stretching the posterior capsule/cuff, it prevents the HH from sliding forward whereas when stretching the anterior capsule/cuff, it decreases holding the HH in an anterior position, so allowing the HH to slide backward in a proper position--- it is also generally increasing the mobility of the joint)
WHY AP MOBS AT END RANGE ABDUCTION?
The literature is mixed on the “proper” direction of such mobilizations (Brandt et al. 2007)
I did not perform joint mobs on the AC joint but did do PA and AP mobs on the GH joint

28. IR measured behind the back (distance from T1 to styloid process)
“Passive mobilisation of shoulder region joints plus advice and exercise does not reduce pain and disability more than advice and exercise alone: a randomised trial” (Chen et al. 2009)
Outcome measures:
IR measured behind the back (distance from T1 to styloid process)
Active shoulder ROM- flexion and abduction measured with still photography
Shoulder Pain and Disability Index (SPADI)
Global perceived effect (1 mo. and 6 mo.)
Groups compared at baseline, 1 mo. and 6 mo.
The SPADI is a self-administered questionnaire – primary outcome measure
it is overall a valid questionnaire, easy to complete, and responsive to change;
is also has no floor or ceiling effects
13 items- 5 relating to pain, 8 relating to disability….all items are rated on a VAS of “no pain” to “worst pain imaginable” or “no difficulty” to “requires help”; all rate from 0-10
Global perceived effect and active shoulder ROM- 6 point Likert scale, ranging from significantly deteriorated, slightly deteriorated, no change, slightly improved, significantly improved, and completely recovered
Active shoulder ROM- photography was used because it was less likely to exacerbate symptoms due to the shorter time required to complete measurements
“Behind the back” IR measurement- pts were instructed to “take the arm as far as they could go” and the distance b/t T1 and the styloid process was measured…they did this instead of the thumb in order to account for those with decreased thumb flexibility; the larger the negative value, the worse the ROM; HOWEVER, note that the level achieved is also dependent on shoulder ext, retraction and downward rotation of the scapula, and elbow flexion ROM; so…why did the authors look at this for IR ROM? They should have examined IR at 45 or 90 degrees of ABD with the pt supine. Keep in mind, the behind-the-back method is functional given my patient case, so although this may not be an accurate measurement of IR ROM, this may be considered a functional measurement of ROM, and one that my patient cared most about regaining

29. Same conclusion for all outcome measures
“Passive mobilisation of shoulder region joints plus advice and exercise does not reduce pain and disability more than advice and exercise alone: a randomised trial” (Chen et al. 2009)
For IR ROM, the difference in measurement (R vs. L) was 13 cm at 0 mo., 9 cm at 1 mo., and 6 cm at 6 mo. (HBB method)
These values were statistically non-significant; therefore the authors concluded that the addition of passive mobilization with exercise conferred no added benefit to advice and exercise alone, at follow up of 1 mo. and 6 mo.
Same conclusion for all outcome measures
The authors concluded that there was no benefit, however…
Referring to the experimental group
.13 meters= 5.12” or 13 cm
.09 meters= 3.54” or 9
.06 meters= 2.36”
Improvement in all outcome measures at 1 and 6 mos.; the experimental group had 3% less pain and disability than the control group at 1 month and 1% less at 6 months.

30. Limitations Included a wide range of diagnoses
Details of the HEP provided
Patient compliance?
Skill of therapist
IR measurement validity (Ginn et al. 2006)
We are not given the specifics of the diagnosis of the patients, just that they had “shoulder pain and stiffness”
Not told the details of the HEP-it seems like exercise, if you stop treatment, there will be a loss of what was gained in the clinic
My patient saw improvement in her ROM but was also very compliant with her home program– compliance was not mentioned in the RCT which to me is a pretty significant limitation
Mobilization technique- they chose to do (mostly) AP mobs versus PA mobs– may affect the outcome (although Hsu et al. (2002) indicated that both techniques could be effective)
One problem that I had was that the authors chose to measure IR by the behind the back method. I’m not sure why they just didn’t measure IR with a goniometer (or take a picture as they did for flexion and abduction). This is a functional position, and a position that my patient was concerned with, but it would have been easier to assess the effects of GH joint IR ROM with a goniometric measurement.
The authors concluded that the changes were not statistically significant—YET what about clinical significance? In my opinion, a change of about 3” may be a significant enough change for a given patient when reaching behind the back

31. Case Outcome R shoulder PROM: Flex-170 Abduction- 160 ER-60, IR-65
QuickDASH (MDC=11)
However, this patient was very compliant with her HEP
These are her measurements- as assessed at a later time by my CI
She did not meet the MDC of 11 points on her QuickDASH outcome measure
Unlike what the authors suggested, I did see a change in her IR clinically; however, don’t know if these effects are due to exercise compliance

32. Considerations for Future Treatment
Duration of mobilizations
Emphasis on a home program and compliance that may benefit the patient long-term (stretching, self-mobs)
Consider the effects of other techniques (ex. prolonged positioning) to lengthen the capsule
Effect of compliance
Duration of mobs- I spent between min. with my pt performing mobs, none of the studies looked at long duration tx
Cannot rule out joint mobs
Consider focusing more on a home program (AROM, MET, scapular and GH strengthening exercises) but emphasize patient compliance– we don’t know the long term effects from these studies
Ensure patient compliance- what are the long term effects? One of the issues with the RCT was that there wasn’t clear
Duration of mobilizations may also play a big role– I spent min. doing these
There is value to touch- the patient liked the mobilizations and felt they were beneficial– effect of patient expectations
Focus on postural exercises in order to decrease the anterior, superior translation of the humeral head and thus prevent further impingement of the subacromial structures
Continue to focus on scapular and GH exercises, posture correction
Treatment
My patient performed many of the therapeutic exercises as described in the systematic review and I also did both PA and AP joint mobilizations (unspecified in the syst review regarding type of mob)
I did posterior mobilizations (low initially and high grade with arm across the body), distraction, posterior cuff/capsule stretches, as well as typical GH and scap stab and strengthening exercises
Examples of exercises that I did with my patient AND were included in the study were- anterior stretches, posterior stretches, band exercises (rows, punches, IR/ER), neuromuscular stabilization exercises, press ups on wall
Overall thoughts on the studies
Limitations given my case scenario

33. Clinical Question
For a 61 year old female with SAIS, are joint mobilizations combined with exercise more effective at increasing shoulder IR ROM than exercise alone?
We may see a patient post-op 2-3x/week, is this enough to increase ROM? Are manual techniques actually effective or are we wasting our time?

34. Conclusion Answer: MAYBE
More high quality RCTs are needed related to my case (age, diagnosis, condition)
Need more evidence regarding specific parameters, frequency, HEP etc.
Need more studies that look at the long term effects of joint mobilizations
We may work on joint mobs with a patient a few times a week for min…is this enough to increase ROM?
I would like to see additional studies that examined long term effects on ROM– often we may see a clinically significant change in ROM, yet is this really functional? My patient was going home and not seeing that much carry-over to her normal routine activities.
What can I take away from these articles? My overall thoughts? I think that we likely need to emphasize the importance of the patient to perform the HEP (possibly) stretches and exercises consistently in order to see gains in ROM that are long-term.
Many studies have found that there is an increase in IR ROM after shoulder stretches and posterior mobilizations in the clinic but these treatments are more short-term effects. So, maybe consider as a therapist directing more of our time with the patient in teaching HEP exercises and/or self mobilizations that can benefit the patient in the long-term as well as GH and scapular exercises for overall strength and stability.

35. References
Brandt, C., Sole, G., Krause, M. W., & Nel, M. (2007). An evidence-based review on the validity of the Kaltenborn rule as applied to the glenohumeral joint. Manual therapy, 12(1), 3-11.
Brudvig, T. J., Kulkarni, H., & Shah, S. (2011). The effect of therapeutic exercise and mobilization on patients with shoulder dysfunction: a systematic review with meta-analysis. journal of orthopaedic & sports physical therapy, 41(10),
Hsu, A. T., Hedman, T., Chang, J. H., Vo, C., Ho, L., Ho, S., & Chang, G. L. (2002). Changes in abduction and rotation range of motion in response to simulated dorsal and ventral translational mobilization of the glenohumeral joint. Physical therapy, 82(6),
Chen, J. F., Ginn, K. A., & Herbert, R. D. (2009). Passive mobilisation of shoulder region joints plus advice and exercise does not reduce pain and disability more than advice and exercise alone: a randomised trial. Australian journal of physiotherapy, 55(1),
Ginn, K. A., Cohen, M. L., & Herbert, R. D. (2006). Does hand-behind-back range of motion accurately reflect shoulder internal rotation?. Journal of shoulder and elbow surgery, 15(3),
Mallon, W. J., Herring, C. L., Sallay, P. I., Moorman, C. T., & Crim, J. R. (1996). Use of vertebral levels to measure presumed internal rotation at the shoulder: a radiographic analysis. Journal of Shoulder and Elbow Surgery, 5(4), (for the IR ROM behind-the-back accuracy)

36. Questions? So what would you do differently?
Based off of these articles, I cannot say whether joint mobs would be more beneficial in gaining IR ROM in MY SPECIFIC CASE; HOWEVER I do know that my patient was compliant with her HEP (which consists of RC strengthening, GH joint stabilization, and post cuff/capsule stretching) and has seen an increase in IR ROM…and I’m not convinced that increase in ROM is because of the joint mobs that I’ve been doing with her
Educate the patient in the importance of compliance with a HEP and the importance of continuing to move the arm– staying active (decreased use can lead to capsular shortening and abnormal collagen fiber cross-linking
Focus on a home program with good strengthening exercises and ROM– something that she can progress once discharged
I do not know what her behind-the-back ROM looks like…that would be something that I would want examine
Consider prolonged stretching/positioning (one article looked at this to lengthen the capsule)
May consider MET if more muscular in origin
Parameters for mobs? 3-5x 60 sec prolonged holds at end range (to inhibit guarding and decrease stiffness) OR 3-5x 60 sec. oscillations at mid-range to decrease pain