The Initial Effects on Pain, Pain Sensitivity, Range of Motion and Muscle Strength of an Anteroposterior Mobilization of the Glenohumeral Joint in Overhead Athletes With Chronic Shoulder Pain
Phase: NA
Conditions: Shoulder Pain
Sponsor: University of Alcala

1 
The initial effects on pain, pain sensitivity, range of motion and muscle strength of 
an anteroposterior mobilization of the glenohumeral joint in overhead athletes 
with chronic shoulder pain 
INTRODUCTION 
Shoulder disorders are a common musculoskeletal condition, with an estimated 
lifetime prevalence of 42% in athletes performing highly repetitive overhead 
movements.34 Shoulder symptoms are often persistent and recurrent, with 40-50% of 
patients reporting persistent symptoms after 6-12 months,56 and 14% continuing care 
after 2 years.28 
Mobilization techniques are commonly used by physiotherapists for reducing 
pain and disability in patients with shoulder musculoskeletal disorders.5,9,17 One 
approach for mobilizing the shoulder joint is the Maitland’a approach, where passive 
rhythmic oscillatory mobilizations are applied anywhere within the shoulder joint range 
of movement (ROM) and graded according to force, amplitude, direction and duration.30 
When applied specifically over the glenohumeral joint, the Maitland’s approach 
includes both angular and translational mobilizations, with these latter being classified 
in terms of direction as anteroposterior (AP), posteroanterior and caudal 
mobilizations.29 
Humeral head AP mobilizations are often used with the intention to achieve 
mechanical effects on capsule extensibility, such as a stretching of posterior capsule 
tightness.16,27 Indeed, they can induce either a temporary or sustained elongation of the 
posterior capsule depending on the applied force36 and an increase in shoulder ROM 
(i.e. shoulder external rotation).20 Besides these mechanical effects, the application of an 
AP mobilization to the glenohumeral joint produced sympathoexcitatory effects (i.e. 

2 
increase in skin conductance, reduction in skin temperature) in healthy people47 and in 
subjects with posterior capsule tightness.59 However, the potential neurophysiological 
effects of this mobilization technique on other pain and function-related outcome 
measures have not yet been investigated. A greater understanding of the mechanisms 
underlying the beneficial effects reported after the application of shoulder AP 
mobilization techniques,10,20,31,40 would help clinicians for instance to identify those 
individuals more likely to respond to this manipulative intervention.1  
Previous studies have demonstrated positive effects in terms of improvement of 
shoulder ROM, pain sensitivity and muscle function (i.e. reduction on rotator cuff 
muscle activity) when applying an AP mobilization to the humeral head in the form of a 
mobilization with movement (MWM).43,51 Whether similar clinical effects might be 
obtained with an AP mobilization to the humeral head following Maitland’s approach is 
unknown. 
The aim of this study will be investigated the initial effects of a passive rhythmic AP 
mobilization applied to the glenohumeral joint on pain sensitivity and muscle function 
in overhead athletes with chronic shoulder pain. In addition, the effects of this technique 
on self-reported shoulder pain and disability and ROM will be also evaluated.  
      
METHODS 
A repeated-measures, double-blinded randomized, placebo-controlled study will 
be conducted to evaluate the initial effects of an AP mobilization of the glenohumeral 
joint on pressure pain threshold (PPT), muscle strength, self-reported shoulder pain and 
disability and ROM. 

3 
 
 
 
Participants 
The overhead athletes aged between 18-60 years of age will participated in this 
study. Besides presenting with a history of chronic shoulder pain (i.e. lasting ≥3 
months), athletes will required to play overhead sport regularly (at least once per week) 
in an organized way. Recruitment of potential volunteers will be conducted at the 
Student Sport Center BLINDED through poster advertisement. Volunteers who met the 
inclusion criteria will be then evaluated as they reached the laboratory. 
Subjects will be excluded if they had a non-musculoskeletal origin of shoulder 
pain, previous surgery to the shoulder complex, frozen shoulder, any co-existing 
inflammatory, infectious or neurological condition that would exclude the patient from 
physiotherapy treatment, or any evidence of pain referred from the cervical spine to the 
shoulder.55 In addition, they will be instructed to avoid any medication intake during the 
week prior to the study commencement and for the duration of the study.  
Data collection took place at the BLINDED from february to march 2018. All 
participants will received an information leaflet and will gave written informed consent 
prior to the study beginning. The study was approved by the local Institutional Ethics 
Committee and all the procedures will be conducted according to the Declaration of 
Helsinki. 
 

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Outcome measures (dependent variables) 
The outcome measures used in this study are: PPT, muscle strength, self-
reported shoulder pain and disability, and shoulder ROM.  
 
 
Pressure pain threshold (PPT)  
A standardized protocol for evaluating PPT will be used.44 One test site on the 
affected and non-affected shoulder (mid belly of the anterior deltoid, 5 cm caudal to the 
anterior border of the acromion) and one remote site on the ipsilateral tibialis anterior (5 
cm inferior and 2.5 cm lateral to the tibial tubercle) will be selected for PPT 
measurement. All these points will be marked with a permanent marker and 
photographed so that the same points could be used for pre-and post-condition 
measures. 
The PPT will be measured using an analogue Fisher algometer (Force Dial model 
FDK, Wagner Instruments) with a surface area at the round tip of 1cm2. The algometer 
probe tip will be applied perpendicular to the skin at a rate of 1kg/cm2/s until the first 
onset of pain.12 PPT will be measured three times on each site with a 30 s rest period 
between each repetition. The mean of the three measurements will be used in the 
statistical analysis. 
Pressure algometry is a valid and reliable method to measure PPT with studies 
showing good repeatability of measurements on the shoulder.21,41 
 
 
 

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Shoulder muscles strength 
Isometric strength of the shoulder internal and external rotator musculature will 
be measured using a portable hand-held dynamometer (Nicholas Manual Muscle Tester, 
Lafayette Instruments, USA). 
For external rotation testing, participants will be positioned in sitting with the 
shoulder in 0º of abduction and medially rotated 45º and the forearm in its mid-range of 
motion between supination and pronation.24 The dynamometer will be placed on the 
lateral surface of the distal forearm just proximal to the ulnar styloid process and 
anchored by a belt to the handlebar of a glass suction cup on the wall. This ensured 
reliability when quantifying external rotation strength.25 Subjects will be instructed to 
push in the direction of shoulder external rotation while maintaining the trunk in a 
stable position. 
Shoulder internal rotation testing will be performed in standing using the Gerber 
lift-off position.13 The dynamometer will be placed on the distal aspect of the ventral 
forearm, between the patient forearm and the wall, which provided in this case the 
stabilization counterforce. Subjects will be instructed to lift the dorsum of the hand off 
the mid-lumbar region against the wall.  
Participants will be instructed to exert as much force as possible against the 
dynamometer during six seconds (make test).49 This process will be repeated three times 
with a 30-s rest period between measurements and the mean will be used in the 
statistical analysis. 
Hand-held dynamometry by using fixed instrumentation is a reliable method for 
measuring strength of the internal and external rotator shoulder musculature.25  
 

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Self-reported shoulder pain  
Participants will be asked to indicate the intensity of their current shoulder pain 
using a numeric rating pain scale (NRPS). The NRPS has demonstrated good test-retest 
reliability and responsiveness to treatment in patients with shoulder pain.33  
 
Shoulder disability 
The Spanish version of the Disabilities of the Arm, Shoulder and Hand (DASH) 
questionnaire will be used to record shoulder disability.15 The DASH is comprised of 30 
items (disability/symptom section) and two optional sections related to the impact of 
pathology on work and sports.32 Each item is scored from 1 to 5 with increasing values 
representing more severity of symptoms. The total score for the disability/symptoms 
section ranges from 30 to 150, but it is then transformed to a scale from 0 (better score 
possible) to 100 (worse score possible).  
The Spanish version of the DASH has shown high internal consistency, 
excellent test-retest reliability, good construct and criteria validity and excellent 
responsiveness to treatment.15  
 
Shoulder range of movement  (ROM) 
Active elevation in the scapular plane and passive glenohumeral internal and 
external rotation will be measured using a Standard BASELINE ® 12-inch plastic 
goniometer following previous guidelines.26,39  
For measuring active elevation in the scapular plane, participants will be in a 
standing position. A flat stiff board will be positioned 30º anterior to the frontal plane 
(scaption plane) to control the plane of elevation of the affected arm.42 Participants will 
be instructed to move the affected arm into full elevation while maintaining contact with 

7 
the stiff board. The goniometer will be positioned with the fulcrum placed at the 
midpoint of the central aspect of the glenohumeral joint, the stable arm parallel to the 
trunk, and the moving arm parallel to the longitudinal axis of the humerus.26   
For assessment of passive glenohumeral internal rotation, participants laid 
supine with 90º of shoulder abduction in the frontal plane and the elbow flexed at 90°.11 
The examiner stabilized the scapula with one hand by applying mild pressure to its 
anterior aspect (coracoid process), while applying with the other hand a passive 
movement of shoulder internal rotation to its maximal point. An assistant read the 
measurement placing the goniometer with the stationary arm parallel to the floor and the 
mobile arm in alignment with the forearm starting at the olecranon.39 The same starting 
posture and goniometer positioning will be used for measuring passive glenohumeral 
external rotation. 
 
Experimental conditions (independent variables) 
There are two independent variables in the research design: treatment condition 
and time (pre-, post-application). Treatment condition has three levels, which include 
the AP shoulder mobilization, a manual contact and a no-contact condition.47 These 
experimental conditions will be administered in random order in three separated 
sessions to all participants, with each session separated by 48 h in order to control for 
carry-over effects.35 The treatment allocation sequence will be randomized using sealed 
envelopes and concealed from the investigator who took the outcome measurements. 
An experienced physiotherapist with a Master degree on manual therapy and more than 
10 years of working experience will apply all conditions. This physiotherapist will be 
blinded to the results of the measurements and questionnaires used as outcome 
measures.  

8 
All conditions will be applied for a total of 10 min, comprising three sets of 3 
min, alternating with 30-s rests. Verbal instructions and positioning will be strictly 
standardized during all the sessions. 
 
Treatment condition 
The treatment condition consist on the application of a passive rhythmic AP 
mobilization to the glenohumeral joint of the affected shoulder. In particular, a Grade III 
AP glide to the humeral head with the arm positioned in 90º of glenohumeral abduction 
and full internal rotation was used.47 The posterior gliding force to the humeral head 
was applied maintaining the glide at right angles to the plane of movement and at a 
frequency of 2 Hz which will be controlled by means of a metronome. The arm will be 
returned to its original position between each set. 
 
Manual contact condition 
During the manual contact condition the therapist positione the patient in a mid-
range position of glenohumeral abduction and internal rotation and apply the hands to 
the same contact point as in the treatment condition. However, a simulated posterior 
glide will be performed but with minimal pressure actually applied.47 The number of 
repetitions and sets were as per the treatment condition. 
 
No-contact condition 

9 
During the no-contact condition, the subject remain in the initial starting position 
thorough the entire session but there are no manual contact between the therapist and 
the participant.47 The total treatment time will be the same as per the other conditions. 
 
Procedure 
At the first session and after recording demographic data, the NRPS and DASH 
will be administered followed by PPT, ROM and muscle strength measurements in a 
standardized order. Subjects then will received the assigned intervention for that session 
and, immediately afterwards, all outcome measures will be reassessed following the 
same order as before. The only exception was the DASH, which will be assessed before 
and 24 hours after each experimental condition. This procedure will be repeated for all 
the three test sessions. 
An investigator, will blinded to the allocated intervention, performed all the 
outcome measures before and immediately after the application of the three 
experimental conditions. Discussion between researchers and subjects will be 
minimized during treatment in order to facilitate subject blinding and reduce potential 
interactions. No feedback will be given on performance until after the final session. The 
extent of subject blinding will be assessed through a short, self-administered, post-
experiment questionnaire, where participants will be asked to indicate whether they 
have experienced a physiotherapy treatment in any of the sessions and, if so, in which 
session.35 
 
 

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Statistical analysis 
Data will be analysed using SPSS 22 for Windows. Statistical significance will 
be set at p < 0.05. 
Two independent variables will be incorporated into the research design: 
treatment (AP mobilization, manual contact, no-contact) and time (pre- and post-
intervention). Five dependent variables will be considered including PPT, muscle 
strength, NRPS, DASH (disability/symptom section) and ROM.  
Descriptive statistics will be calculated to describe baseline data. A two-way 
analysis of variance (ANOVA) through a General Linear Model and appropriate post-
hoc tests of simple effects will be used to evaluate hypothesis that AP mobilization 
produced more changes than manual contact and no-contact conditions from pre- to 
post-intervention (P=0.05). The between subject factor will be treatment condition (AP 
mobilization, manual contact, no-contact) with time (pre and post-intervention) as 
within subject factors.   
Esphericity will be confirmed by means of Mauchly’s test. Bonferroni test will 
used for multiple comparisons and the effect size will be estimated using Eta square (η2) 
when significant. An effect size of 0.01 will be considered small, 0.06 medium and 0.14 
large.7 
 
REFERENCES 
1. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The 
mechanisms of manual therapy in the treatment of musculoskeletal pain: a 
comprehensive model. Man Ther. 2009;14(5):531-8. 

11 
2. Bialosky JE, Bishop MD, Cleland JA. Individual expectation: an overlooked, 
but pertinent, factor in the treatment of individuals experiencing musculoskeletal 
pain. Phys Ther. 2010;90(9):1345-55. 
3. Bialosky JE, Bishop MD, George SZ, Robinson ME. Placebo response to 
manual therapy: something out of nothing? J Man Manip Ther. 2011;19(1):11-9. 
4. Bishop MD, Torres-Cueco R, Gay CW, Lluch-Girbés E, Beneciuk JM, Bialosky 
JE. What effect can manual therapy have on a patient's pain experience? Pain 
Manag. 2015;5(6):455-64. 
5. Brantingham JW, Cassa TK, Bonnefin D, Jensen M, Globe G, Hicks M, 
Korporaal C. Manipulative therapy for shoulder pain and disorders: expansion of 
a systematic review. J Manipulative Physiol Ther. 2011;34(5):314-46.  
6. Chesterton LS, Sim J, Wright CC, Foster NE. Interrater reliability of algometry 
in measuring pressure pain thresholds in healthy humans, using multiple raters. 
Clin J Pain. 2007;23:760-766. 
7. Cohen J. Statistical Power Analysis for the Behavioral Sciences. New York, 
NY: Routledge Academic, 1988. 
8. Delgado-Gil JA, Prado-Robles E, Rodrigues-de-Souza DP, Cleland JA, 
Fernández-de-las-Peñas C, Alburquerque-Sendín F. Effects of mobilization with 
movement on pain and range of motion in patients with unilateral shoulder 
impingement syndrome: a randomized controlled trial. J Manipulative Physiol 
Ther. 2015;38(4):245-52. 
9. Desjardins-Charbonneau A, Roy JS, Dionne CE, Frémont P, MacDermid JC, 
Desmeules F. The efficacy of manual therapy for rotator cuff tendinopathy: a 
systematic 
review 
and 
meta-analysis. 
J 
Orthop 
Sports 
Phys 
Ther. 
2015;45(5):330-50. 

12 
10. Do Moon G, Lim JY, Kim da Y, Kim TH. Comparison of Maitland and 
Kaltenborn mobilization techniques for improving shoulder pain and range of 
motion in frozen shoulders. J Phys Ther Sci. 2015;27(5):1391-5. 
11. Ellenbecker TS, Roetert EP, Bailie DS, Davies GJ, Brown SW. Glenohumeral 
joint total rotation range of motion in elite tennis players and baseball pitchers. 
Med Sci Sports Exerc. 2002;34(12):2052-6. 
12. Fischer AA. Pressure algometry over normal muscles. Standard values, validity 
and reproducibility of pressure threshold. Pain. 1987;30(1):115-126. 
13. Greis PE, Kuhn JE, Schultheis J, Hintermeister R, Hawkins R. Validation of the 
lift-off test and analysis of subscapularis activity during maximal internal 
rotation. Am J Sports Med. 1996;24(5):589-93. 
14. Guimarães JF, Salvini TF, Siqueira AL Jr, Ribeiro IL, Camargo PR, 
Alburquerque-Sendín F. Immediate Effects of Mobilization With Movement vs 
Sham Technique on Range of Motion, Strength, and Function in Patients With 
Shoulder Impingement Syndrome: Randomized Clinical Trial. J Manipulative 
Physiol Ther. 2016;39(9):605-615. 
15. Hervás MT, Navarro Collado MJ, Peiró S, Rodrigo Pérez JL, López Matéu P, 
Martínez Tello I. [Spanish version of the DASH questionnaire. Cross-cultural 
adaptation, reliability, validity and responsiveness]. Med Clin (Barc). 
2006;127(12):441-7. 
16. Ho KY, Hsu AT. Displacement of the head of humerus while performing 
"mobilization with movements" in glenohumeral joint: a cadaver study. Man 
Ther. 2009;14(2):160-6. 

13 
17. Ho CY, Sole G, Munn J. The effectiveness of manual therapy in the 
management of musculoskeletal disorders of the shoulder: a systematic review. 
Man Ther. 2009;14(5):463-74. 
18. Jain NB, Wilcox RB 3rd, Katz JN, Higgins LD. Clinical examination of the 
rotator cuff. PM R. 2013;5(1):45-56.  
19. Jesus-Moraleida FR, Ferreira PH, Pereira LSM, Vasconcelos CM, Ferreira ML. 
Ultrasonographic analysis of the neck flexor muscles in patients with chronic 
neck pain and changes after cervical spine mobilization. Journal of Manipulative 
and Physiological Therapeutics 2011; 34: 514-524. 
20. Johnson AJ, Godges JJ, Zimmerman GJ, Ounanian LL. The effect of anterior 
versus posterior glide joint mobilization on external rotation range of motion in 
patients with shoulder adhesive capsulitis. J Orthop Sports Phys Ther. 
2007;37(3):88-99. 
21. Jones DH, Kilgour RD, Comtois AS. Test-retest reliability of pressure pain 
threshold measurements of the upper limb and torso in young healthy women. J 
Pain. 2007;8(8):650-6. 
22. Jull G, Trott P, Potter H, et al. A randomized controlled trial of exercise and 
manipulative therapy for cervicogenic headache. Spine 2002; 27: 1835-1843. 
23. Kaltenborn FM. Manual Mobilization of the Joints, Volume I, The Extremities, 
5 ed. Oslo: Norli, 2009. 
24. Kelly BT, Kadrmas WR, Speer KP. The manual muscle examination for rotator 
cuff strength. An electromyographic investigation. Am J Sports Med. 
1996;24(5):581-8. 
25. Kolber MJ, Beekhuizen K, Cheng MS, Fiebert IM. The reliability of hand-held 
dynamometry in measuring isometric strength of the shoulder internal and 

14 
external rotator musculature using a stabilization device. Physiother Theory 
Pract. 2007;23(2):119-24. 
26. Kolber MJ, Fuller C, Marshall J, Wright A, Hanney WJ. The reliability and 
concurrent validity of scapular plane shoulder elevation measurements using a 
digital inclinometer and goniometer. Physiother Theory Pract. 2012;28(2):161-8. 
27. Lin HT, Hsu AT, An KN, Chang Chien JR, Kuan TS, Chang GL. Reliability of 
stiffness measured in glenohumeral joint and its application to assess the effect 
of end-range mobilization in subjects with adhesive capsulitis. Man Ther. 
2008;13(4):307-16. 
28. Linsell L, Dawson J, Zondervan K, Rose P, Randall T, Fitzpatrick R, et al. 
Prevalence and incidence of adults consulting for shoulder conditions in UK 
primary care; patterns of diagnosis and referral. Rheumatology. 2006;45:215-21. 
29. Maitland GD. Treatment of the glenohumeral joint by passive movement. 
Physiotherapy. 1983;69(1):3-7. 
30. Maitland G, Banks K, English K, Hengeveld E (Eds): Maitland’s Vertebral 
Manipulation (7th edition). Oxford: Butterworth Heineman; 2005. 
31. Maricar N, Shacklady C, McLoughlin L. Effect of Maitland mobilization and 
exercises for the treatment of shoulder adhesive capsulitis: a single-case design. 
Physiother Theory Pract. 2009;25(3):203-17. 
32. McConnel S, Beaton DE, Bombardier C. Disabilities of the arm, shoulder and 
hand: the DASH outcome measure user’s manual. Toronto, Ontario: Institute for 
Work and Health; 1999. 
33. Mintken PE, Glynn P, Cleland JA. Psychometric properties of the shortened 
disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) and 

15 
Numeric Pain Rating Scale in patients with shoulder pain. J Shoulder Elbow 
Surg. 2009;18(6):920-6. 
34. Mohseni-Bandpei MA, Keshavarz R, Minoonejhad H, Mohsenifar H, Shakeri H. 
Shoulder pain in Iranian elite athletes: the prevalence and risk factors. J 
Manipulative Physiol Ther. 2012;35(7):541-8. 
35. Moss P, Sluka K, Wright A. The initial effects of knee joint mobilization on 
osteoarthritic hyperalgesia. Man Ther. 2007;12(2):109-18.  
36. Muraki T, Yamamoto N, Berglund LJ, Sperling JW, Steinmann SP, Cofield RH, 
An KN. The effect of cyclic loading simulating oscillatory joint mobilization on 
the posterior capsule of the glenohumeral joint: a cadaveric study. J Orthop 
Sports Phys Ther. 2011;41(5):311-8. 
37. Nijs J, Van Houdenhove B. From acute musculoskeletal pain to chronic 
widespread pain and fibromyalgia: Application of pain neurophysiology in 
manual therapy practice. Manual Therapy 2009; 14: 3-12. 
38. Nijs J, Van Houdenhove B, Oostendorp RAB. Recognition of central 
sensitization in patients with musculoskeletal pain: Application of pain 
neurophysiology in manual therapy practice. Manual Therapy 2010; 15: 135-
141. 
39. Norkin CC, White DJ 
Measurement 
of 
Joint 
Motion: 
A 
Guide 
to 
Goniometry.2nd ed. Philadelphia, PA: FA Davis Company; 1995. 
40. Noten S, Meeus M, Stassijns G, Van Glabbeek F, Verborgt O, Struyf F. The 
efficacy of different types of mobilization techniques in patients with primary 
adhesive capsulitis of the shoulder: a systematic review. Arch Phys Med 
Rehabil. 
2015 
Aug 
15. 
S0003-9993(15)01066-7. 
doi: 
10.1016/j.apmr.2015.07.025. [Epub ahead of print]. 

16 
41. Persson AL, Brogårdh C, Sjölund BH. Tender or not tender: test-retest 
repeatability of pressure pain thresholds in the trapezius and deltoid muscles of 
healthy women. J Rehabil Med. 2004;36(1):17-27. 
42. Prinold JA, Villette CC, Bull AM. The influence of extreme speeds on scapula 
kinematics and the importance of controlling the plane of elevation. Clin 
Biomech (Bristol, Avon). 2013;28(9-10):973-80. 
43. Ribeiro DC, Castro MP, Sole G, Vicenzino B. The initial effects of a sustained 
glenohumeral postero-lateral glide during elevation on shoulder muscle activity:  
A repeated measures study on asymptomatic shoulders. Man Ther. 2015 Nov 2. 
pii: S1356-689X(15)00204-0. doi: 10.1016/j.math.2015.10.014. [Epub ahead of 
print]. 
44. Rolke R, Baron R, Maier C, Tölle TR, Treede RD, Beyer A, Binder A, 
Birbaumer N, Birklein F, Bötefür IC, Braune S, Flor H, Huge V, Klug R, 
Landwehrmeyer GB, Magerl W, Maihöfner C, Rolko C, Schaub C, Scherens A, 
Sprenger T, Valet M, Wasserka B. Quantitative sensory testing in the German 
Research Network on Neuropathic Pain (DFNS): standardized protocol and 
reference values. Pain. 2006;123(3):231-43. 
45. Rowbotham MC. What is a 'clinical meaningful' reduction in pain? Pain 2001; 
94: 131-132. 
46. Schmid A, Brunner F, Wright A, Bachmann LM. Paradigm shift in manual 
therapy?  Evidence for a central nervous system component in the response to 
passive cervical joint mobilisation. Man Ther. 2008;13(5):387-96. 
47. Simon R, Vicenzino B, Wright A. The influence of an anteroposterior accessory 
glide of the glenohumeral joint on measures of peripheral sympathetic nervous 
system function in the upper limb. Man Ther. 1997;2(1):18-23.  

17 
48. Sterling M, Pedler A, Chan C, Puglisi M, Vuvan V, Vicenzino B. Cervical 
lateral glide increases nociceptive flexion reflex threshold but not pressure or 
thermal pain thresholds in chronic whiplash associated disorders: A pilot 
randomised controlled trial. Man Ther. 2010;15(2):149-53. 
49. Stratford PW, Balsor BE. A comparison of make and break tests using a hand-
held dynamometer and the Kin-Com. J Orthop Sports Phys Ther. 1994;19(1):28-
32. 
50. Swanson BT, Holst B, Infante J, Poenitzsch J, Ortiz A. EMG activity of selected 
rotator cuff musculature during grade III distraction and posterior glide 
glenohumeral mobilization: results of a pilot trial comparing painful and non-
painful shoulders. J Man Manip Ther. 2016;24(1):7-13. 
51. Teys P, Bisset L, Vicenzino B. The initial effects of a Mulligan's mobilization 
with movement technique on range of movement and pressure pain threshold in 
pain-limited shoulders. Man Ther. 2008;13(1):37-42.  
52. Teys P, Bisset L, Collins N, Coombes B, Vicenzino B. Oneweek time course of 
the effects of Mulligan's Mobilisation with Movement and taping in painful 
shoulders. Man Ther. 2013;18:372-7. 
53. Torres RR, Gomes JL. Measurement of glenohumeral internal rotation in 
asymptomatic 
tennis 
players 
and 
swimmers. 
Am 
J 
Sports 
Med. 
2009;37(5):1017-23. 
54. Voogt L, de Vries J, Meeus M, Struyf F, Meuffels D, Nijs J. Analgesic effects  
of manual therapy in patients with musculoskeletal pain: a systematic review. 
Man Ther. 2015;20(2):250-6. 
55. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. 
Reliability and diagnostic accuracy of the clinical examination and patient self-

18 
report measures for cervical radiculopathy. Spine (Phila Pa 1976). 
2003;28(1):52-62. 
56. Winters JC, Sobel JS, Groenier KH, Arendzen JH, Meyboom-de Jong B. The 
long-term course of shoulder complaints: a prospective study in general practice. 
Rheumatology. 1999; 38:160-63. 
57. Wright A. Hypoalgesia post-manipulative therapy: a review of a potential 
neurophysiological mechanism. Man Ther. 1995;1(1):11-6. 
58. Yang JL, Chang CW, Chen SY, Wang SF, Lin JJ. Mobilization techniques in 
subjects with frozen shoulder syndrome: randomized multiple-treatment trial. 
Phys Ther. 2007;87(10):1307-15. 
59. Yu IY, Jung IG, Kang MH, Lee DK, Oh JS. Immediate effects of an end-range 
mobilization technique on shoulder range of motion and skin temperature in 
individuals with posterior shoulder tightness. J Phys Ther Sci. 2015;27(6):1723-
5.