Introduction Shoulder pain and stiffness has become one of

Introduction Shoulder pain and stiffness hasbecome one of the most common problems within the general community. It is thethird most frequent site of musculoskeletal pain after back and neck (Minerva,Alagini, Apparao & Chaturvedhi, 2016).

Over time, many approaches have beenemployed to provide a treatment for shoulder disorders ranging from surgicalprocedures to manual therapeutic techniques. Most often, physiotherapy tends tobe practioners first line of call with 53-79% of them referring to aphysiotherapist before other treatment modalities such as surgery or oral-drugtherapy (Chen, 2012). Shoulder pain has become more frequent over the yearswith 16-20% of the population being affected, however adhesive capsulitis (AC)(also known as frozen shoulder) has become the most common (Minerva et al.,2016).

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AC is characterised by insidiousand progressive pain with a loss of active and passive movements of theglenohumeral joint (Vermeulen, Rozing, Obermann, Cessie & Vlieland, 2006). Symptomsinclude pain, limited range of motion (ROM) and muscle weakness which is causedfrom the disuse of the shoulder region (Reeves, 1975 & Vermeulen et al.,2000). Physical therapy has become the foundation in preventing the developmentof shoulder capsule contracture and restoring shoulder motion. Many therapeuticapproaches have been used throughout time, however mobilisations of a jointhave become to most popular. The most accepted being Maitland and Mulligan,which have been acknowledged in literature to improve pain and restore functionand mobility in patients with frozen shoulder (Youssef, Ibrahim & Ayad,2015). Main body The Maitland and Mulliganmobilisation techniques present different but equally exclusive sets of widelyemployed manual therapy techniques for treating pain and stiffness in humanjoints. Whilst the literature reports considerably on the efficacy of theirrespective techniques (Minerva et al.

, 2016). The International Maitland TeachersAssociation (IMTA) defines the Maitland concept as a process of examinationassessment and treatment of musculoskeletal disorder in manipulative therapy(Mulligan, 1995). Maitlands mobilisations mainly consist of rhythmicoscillatory movements which stimulate mechanoreceptors and overall having aneffect on the circulatory perfusion.

Mobilisations have an effect on the fluidflow, as the blood flow in vessels supplies the nerve fibres and synovial fluidflow surrounding the avascular cartilage. This allows the mobilisation movementto cause a reversal of the ischemia, oedema, and inflammation cycle and reducesjoint effusion and relieves pain by decreasing the pressure over the nerveendings (Maitland, 1983). As a result of this, it shows the relevancemobilisations have on the early stages of rehabilitation. Mobilisations arerequired to reverse these effects therefore facilitating a speedier recovery.Mulligan incorporates the concave, convex rule in his mobilisations which aregiven in a painless way with an end pressure to restore reduced accessoryglides 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 lowerintensity. In essence, the limited painful physiological movement is performedactively and therapist applies a sustained posterolateral glide to therestricted joint aiming to increase the joint ROM (Mulligan, 1995).

 Throughout the literature, it hasbeen disputed whether or not the Mulligan technique is more superior comparedto the Maitland. Youssef, Ibrahim & Ayad (2015) conducted a study to associatethe effects of mulligan mobilisation versus the Maitland technique in treating diabeticfrozen shoulder. The study consisted of 30 subjectswith frozen shoulder and were split into two groups. Group A = Mulligan, groupB= Maitland, along with pendulum exercises at home to help with active dailyliving (ADL) and reducing the pain limit for the patient. Each subject receivedshoulder mobilisations 3 times a week for 6 weeks. The journal strongly statedthat the Mulligan technique is more effective in improving shoulder functionand motion. Within the Mulligan group, both shoulder function and motion had asignificant increase compared with the Maitland technique.

Regarding theshoulder function, this could have been a direct effect on the pain relief associatedwith this technique (stated above) which in time, could encourage the patientsto have the self-confidence to use the arm more in ADL. On the other hand, forshoulder motion, all movements showed a significant difference in the Mulligangroup except for internal rotation. Nevertheless, this could be down topatients feeling more comfortable and feeling as though the pain has decreasedmore through the application of the adjustment of moving articular surfaces(Yang, Chang, Chen, Wang & Lin, 2007).

This is expected to reduce tensionand trauma on all the aspects surrounding the shoulder, such as the ligamentcomplex.  Although the results of this studyare respectable, only active ROM was assessed, whereas other journals haveassessed 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 onboth active and passive ROM who was then able to give comparisons of bothpassive and active and why these have an effect on mobilisations.

This journalwas of a high quality with a good methodological procedure, however consistedof a short follow-up time therefore decreasing the effects of the results. Thiscreates a gap in the research for whether the superior effects of Mulligan willpersist over a longer period of time.  Vermeulen et al. (2000)demonstrated that with end-range mobilisation techniques (ERM) there is anincrease in joint capacity and glenohumeral mobility after 3 months oftreatment. He conducted a study which looked at the effect of ERM in treatingpatients with AC. The study recruited 7 subjects with a mean age of 50.2 yearsand a mean disease duration of 8.4 months.

This study focused on measuringpain, passive and active ROM of flexion abduction and lateral rotation whichthey measured on 3 occasions. For the ERM mobilisation techniques, grades IIIand IV were given twice a week for 30 minutes. The results obtained from thisstudy show that ERM increase the range of motion in shoulder abduction, flexionand lateral rotation. Nevertheless, this study did not use a control groupwhich 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 poordesign and a small sample size, however the study does show that there areimprovements 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 thedisadvantages of the article. Yang et al. (2007) conducted astudy comparing the use of ERM, mid-range mobilisation (MRM) and movement withmobilisation (MWM) in the treatment of AC. The research they conductedconsisted of 28 subjects, which were split into 2 groups. The results of thestudy showed a significant improvement in the FLEX-SF, humeral externalrotation, shoulder elevation and internal rotation in ERM and MRM groups ascompared to the MWM group.

Furthermore, there were no significant differencesbetween the MRM and ERM group. The results collected suggest an improvement infunction and mobility of the shoulder in all 3 interventions, however the improvementis more significant in the ERM than the MWM group. This journal followed a goodmethodological procedure however a control group was not used. This becomes adisadvantage as there is nothing to compare against. If this research was to bedone again, using a control group would enable the reliability and validity tobe improved.  Goyal et al. (2013) conducted astudy which combined the effects of end range mobilisations (ERM) and mobilisationwith movement (MWM) techniques on ROM and disability in frozen shouldertechniques.

A total of 30 subjects were split into 3 groups. Group A=ERM, groupB=MWM and group C=ERM+MWM. Along with the mobilisations, each subject was alsogiven conventional physiotherapy (Kumar, Kumar, Aggarwal, Kumar & Das, 2012)comprising of posterior capsular stretching in cross-body reach position usingthe opposite arm. All groups were given the mobilisation 2 days a week, for 3weeks. They received 3 sets of 10 repetitions, with 1 minute between sets. Thestretches were performed 5 times per day in a minute for total of approximately15 minutes per day and basic pendulum exercises.

The results of this studyconcluded that subjects in all three groups had shown significant improvementsin the flexion, abduction, external rotation and internal rotation ROM and adecrease in shoulder mobility. On the other hand, it was concluded that amongthe three groups, there was minimal improvement in end range mobilisation groupand combined intervention group. It was concluded that the effectiveness of bothERM+MWM was the more effective in increasing mobility and functional abilitynot ROM.  Vermeulen et al. (2006) went on tocompare the effects of high-grade mobilisation (HGMT) versus low-grade mobilisations(LGMT) in subjects with AC of the shoulder. This study consisted of 96 subjectswho were randomly allocated to either the HGMT or the LGMT group. The resultsindicate that there was a statistically significant improvement in the activeexternal rotation (p=0.051) and abduction (p=0.

059) ROM in the HGMT groupcompared to the LGMT. This was a well conducted study with a good design andfollowed a good procedure with the randomisation. It also provides evidencethat the application of grade III and IV (HGMT) is more beneficial in improvingthe active and passive ROM than grades I and II (LGMT). Johnson, Godges, Zimmerman &Ouanian (2007) found significant improvements in external rotation motion inpatients with frozen shoulder after performing posterior glide mobilisationssustained for 1 minute at end range abduction and external rotation bypromoting elongation of shortened fibrotic soft tissues.

They conducted a studycomparing the effects of anterior versus posterior glide joint mobilisations onexternal rotation in patients with AC. External rotation is known as the mostlimited motion in patients with AC and throughout literature anterior glidemobilisations have been the most known technique to improve this movement inpatients with frozen shoulder. This was accepted within literature due toprinciples agreeing with arthokinematics.

However, the research that Johnson etal. (2007) conducted, establish that posterior glide mobilisations, withtherapeutic ultrasound and upper extremity therapeutic exercises was the mosteffective for increasing external rotation. They found that the posteriormobilisation group had an average of 31.1 degrees of external rotation (after 3treatment sessions), compared to only 3 degrees’ average for the anteriormobilisation group.  From the researchconducted, we can also conclude that combining mobilisation techniquesalongside electrotherapy and therapeutic exercises has a more advantageouseffect than mobilisations alone. Johnson et al.(2007) including thermal ultrasound alongside mobilisations with the intentionto alter viscoelastic properties of the connective tissue which in turnmaximises the effectiveness of the stretch (Reed, Ashikaga, Fleming& Zimny, 2000). Therapeutic exercises were also included to elongate theglenohumeral capsular contracture providing an additional enhanced ROM.

 Vermeulen et al. (2000) showed asignificant difference with ERM in treating AC, however when Goyal et al.(2013) combined the use of ERM with MWM, there was also a significantdifference however the effectiveness was primarily for increasing mobility andfunctional ability whereas Vermeulen et al. (2000) showed a significantdifference in all movement planes, improving ROM .

This shows that to improveROM, ERM alone is more effective than combining techniques however to improvethe mobility of the shoulder joints and its functional ability, combined ERM+MWMis more effective overall.  Conclusion Following the research conducted inthis study, it can be concluded that a variety of different aspects have beenlooked at within the region of shoulder mobilisations in treating AC. Manydifferent authors have taken different approaches whereas some have highlightedconflicting points which give a different answer. This study has looked intodifferent areas and has been able to conclude a number of main points. ERM isuseful 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 ACwhen trying to increase shoulder function and mobility. HGMT and LGMT were alsocompared within the literature, Vermeulen et al. (2006) came to the conclusionthat HGMT were more effective than LGMT in improving active and passive ROM.Furthermore, Johnson et al. (2007) concluded that posterior glide mobilisationswere more beneficial than anterior glide mobilisations when used along sideultrasound and upper extremity exercises. This statement was accepted withinher research as the results showed a significant increase in external rotation.

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