TITLE: Comparison of Maitland and Kaltenborn mobilization techniques for improving
shoulder pain and range of motion in frozen shoulders

  ABSTRACT:
[Purpose] This study compared the use of the Maitland mobilization and Kaltenborn
mobilization techniques for improving pain and range of motion in patients with frozen
shoulders. [Subjects and Methods] The subjects were 20 patients with frozen shoulder who
visited Hospital H, Ulsan, Korea. The subjects were divided randomly into two groups to
receive Maitland or Kaltenborn mobilization to the affected shoulder. Grade III
anteroposterior oscillation and posterior translation were used for the Maitland and
Kaltenborn mobilization groups, respectively. Pain and range of motion of external and
internal rotation were evaluated pre- and post-intervention in both groups. Paired t-tests
were used to compare the pre- and post-intervention results in both groups, and
independent t-tests were used to compare groups. [Results] Both groups exhibited
significant decreases in pain post-intervention. Moreover, the range of motion of internal
and external rotation increased significantly post-intervention in both groups. However,
there was no significant difference between groups with respect to pain improvement or
range of motion. [Conclusion] The posterior Maitland and Kaltenborn mobilization
techniques are effective for improving pain and range of motion in frozen shoulder
patients. Therefore, we recommend both techniques for such patients.

BODY.INTRODUCTION:
Frozen shoulder (FS), more formally termed adhesive capsulitis, is a disease that causes
tissue degeneration, joint capsule thickening, and diminished glenoid cavity volume1). It is one of the most frequently observed
shoulder diseases in clinical settings. FS has various etiologies such as periarticular
tissue degenerative changes, synovial joint thickening, articular surface adhesion, etc2). FS is usually divided into the following
three stages: (1) severe pain, (2) gradual restrictions in range of motion (ROM) accompanied
by pain, and (3) pain resolution and ROM recovery3). The disease causes slowly increasing pain and gradually decreasing
ROM, creating difficulty performing daily activities. Its incidence is higher among office
workers than laborers and higher among females than males; the non-dominant shoulder is more
likely to develop FS4). FS was previously
thought to heal naturally one to two years after occurrence. However, as it became obvious
that the disability persists without adequate treatment, various treatment methods have been
proposed5, 6).  The most effective surgical or medical treatment strategy for ROM recovery in FS patients
remains controversial7). However,
physiotherapy is frequently performed for FS treatment; treatment programs comprising
exercise, massage, and modality are reported to improve all aspects of shoulder ROM with the
exception of external and internal rotation8).  Clinically, FS causes losses of passive and active ROM of the shoulder; external rotation
usually shows the most severe loss. There are the previous studies for the application of
joint mobilization related to the rotation defect of shoulder joint among FS patients. Joint
mobilization, which is often used to treat FS patients, can be divided into the oscillatory
technique suggested by Maitland9) and the
sustained stretch technique suggested by Kaltenborn3). The Maitland mobilization (MM) and Kaltenborn mobilization (KM)
techniques are both passive treatments, but they differ in that MM uses oscillation while KM
uses sustained stretching.  MM applies a passive oscillatory technique, classified from Grade I–IV with respect to
intensity, to the shoulder in order to treat pain and stiffness. Grade I refers to an
intensity of small amplitude that is applied at the beginning of the joint ROM, where there
is no loading on connective tissue; it is often used in cases of severe pain. Meanwhile,
Grade II refers to an intensity of slightly larger amplitude applied from the beginning of
the joint ROM to the middle. Grade I and II oscillation stimuli provoke the mechanical
receptor of the joint, restricting the nocuous stimulus that generates the pain stimulus,
which is transmitted to the central nervous system; therefore, it is appropriate for
relieving pain. Grade III is applied at a large amplitude from the middle of the joint ROM
to the beginning of the restriction. Finally, Grade IV is applied against the tissue
resistance at a small amplitude to the restricted part of the joint. Grade III and IV
oscillation stimuli are used for provoking a stretching to relieve joint stiffness by
applying in a shorter tissue.  On the other hand, KM evaluates the motions on the articular surface and applies them to
treatment according to MacConaill's classification, which posits most articular surfaces
have convex interiors and concave exteriors10). KM involves the application of a passive sustained stretch
technique to enhance joint mobility without articular surface suppression. The forces
applied to increase joint mobility are graded from I–III. Grade I applies a distraction of
minor intensity that hardly causes stress within the joint capsule; it is often used to
decrease pain. Grade II refers to a force that stretches the periarticular tissue; such
stimulus is colloquially referred to as "taking up the slack." Finally, Grade III force
causes enough distraction or gliding so that joint capsule can sufficiently stretch; it is
often used for enhancing ROM11, 12).  Several studies have investigated the treatment effects of joint mobilization to the
shoulders of FS patients. Maricar and Chok13) report no significant difference in the treatment effects between
MM and another exercise program in a study of FS patients. Vermeulen et al.14) argue that the application of MM from
diverse directions rather than a single direction to FS patients' shoulders improves
abduction, flexion, and external rotation ROM. Moreover, the application of KM to FS
patients usually improves shoulder ROM15).
Despite the several studies on passive joint mobilization in FS patients, few studies have
compared MM using oscillation and KM using sustained stretching.  Therefore, this study compared the effects of MM and KM for improving the pain and ROM of
FS patients.

BODY.SUBJECTS AND METHODS:
The study subjects were 20 FS patients who visited Hospital H located in Ulsan, Korea.
Patients' diagnosis, age, gender, affected area, duration, etc. were collected from medical
records and by interviews. The inclusion criteria were a diagnosis of FS or adhesive
capsulitis, more than two passive ROMs (i.e., anterior flexion, frontal abduction, and
external rotation at 0° abduction) of a damaged shoulder showing a loss of over 50% compared
to the non-damaged side16), increasing
restriction of the shoulder's external rotation ROM following an increase in shoulder
abduction, no history of surgery to the damaged shoulder, no manipulation of the damaged
shoulder under anesthesia, and pain lasting at three months. Patients with shoulder mobility
defects accompanying neurological damage, such as in stroke or Parkinson's disease, as well
as those with diabetes, rheumatism, osteoporosis, surgical fixation, malignant tumors, or
radiating pain from a cervical lesion were excluded.  We clarified whether the patients' shoulder ROM restrictions were due to muscle contraction
or the joint capsule. According to clinical experience and cadaveric experiments17), we defined joint capsule tightness as a
shoulder external rotation defect that becomes more severe following shoulder abduction. If
the shoulder external rotation ROM defect is unaffected by the shoulder's abduction, it
might be due to muscle flexibility. Therefore, patients showing no change in external
rotation ROM following abduction were excluded from the study.  After providing a sufficient explanation of the experimental process, patients who
volunteered to participate in the study provided written informed consent. In accordance
with the Declaration of Helsinki, this study was approved by the Ethics Committee of Daegu
University. The general characteristics of the subjects are summarized in Table 1Table 1.General characteristics of the patients (N = 20)KaltenbornMaitlandAge (years)48.3 ± 2.9849.1 ± 3.07Height (cm)169.8 ± 4.1170.9 ± 2.23Weight (kg)67.9 ± 7.3769.6 ± 4.58BMI (cm/kg)23.58 ± 2.6623.86 ± 1.92Pain (VAS, 0–10)5.58 ± 0.806.05 ± 1.12Symptom duration (months)7.85 ± 1.278.15 ± 1.25Internal rotation (°)31.98 ± 6.1731.74 ± 6.77External rotation (°)38.8 ± 5.7540.85 ± 7.51Mean ± SD. BMI: body mass index, VAS: visual analog scale.  A visual analogue scale (VAS) was used to measure pain intensity pre- and
post-intervention. Bulgen et al.18) report
that it is difficult to recognize patient pain, because FS patients tend to complain about
pain during motion, even though they possess chronic pain. Therefore, to measure pain
intensity, each patient was instructed to execute shoulder flexion, internal rotation, and
external rotation three times and then directly note the pain intensity. Regarding
quantification, the patient marked the pain intensity he/she felt on a 10-cm line; the left
end indicated no pain (0 points), and the right end indicated the maximum pain intensity (10
points). The VAS is a reliable (intraclass correlation coefficient = 0.99) and valid pain
evaluation tool19) that is widely used in
clinical practice.  A digital goniometer was used to measure the passive ROM of the shoulder's internal and
external rotation pre- and post-intervention. With the patient in the supine position,
passive joint ROM was measured with the elbow joint at 90° flexion, external rotation at 90°
abduction, and internal rotation at 90° abduction. The angle between the forearm and a line
vertical to the therapeutic table was measured. However, as the majority of FS patients
presented with broad shoulder ROM defects with shoulder abduction limited to less than 90°,
the rotation was performed at the maximum degree possible when 90° was not possible. The
tester recorded the baseline abduction degree of the shoulder of each subject, which was
always passively located at the baseline abduction degree before measurement. This method
was chosen because of the variability in the ROM defect in FS patients. Any abnormal
movement in the scapula was prevented in order to maintain a stable shoulder abduction
degree. The humerus moved passively while maintaining a neutral position. Next, in order to
measure the external and internal rotations, the coracoid and clavicle were pressed by one
hand to stabilize the scapula, while the forearm was rotated toward the foot and head in
cases of internal and external rotation, respectively, by the other hand to measure the
passive joint ROM. The point where forearm rotation stopped differed in each patient
according to the point where the tester detected an end feel or the patient felt too much
pain to move further20). An assistant
tester placed the digital inclinometer on the dorsal side of the forearm such that it was
parallel to the major axis of the backbone. In order to exclude the effects of joint
mobilization during measurement, a one-minute rest period was allowed after each
measurement. The average value of three measurements was used for the analysis.  The patients were randomly assigned to one of two therapists. A sealed box containing cards
with numbered 1 or 2 was prepared, and the patients chose one card; patients with cards
numbered 1 and 2 were allocated to the Kaltenborn group (n = 10) and
Maitland group (n = 10), respectively. Each patient underwent testing
before the experiment in order to evaluate pain intensity and shoulder joint ROM. When the
treatment began, a hot pack was applied to the affected shoulder for 20 minutes, followed by
interferential current treatment for 15 minutes21). Each joint mobilization exercise was subsequently performed. The
treatment was performed by a clinical physiotherapist with more than 10 years' experience
with joint mobilization therapy. Patients received a total of 12 therapy sessions three
times per week for four weeks.  Each patient's pain and ROM were evaluated four weeks after therapy. The patients were
recommended to use their arms and shoulders within the possible ROM in daily activities,
although they did not receive a home-based exercise program.  For joint mobilization, one of the manual therapies of KM Grade III posterior translation
was used. As mentioned above, KM Grade III refers to sustained stretching at an intensity at
which the joint capsule is stretched. With the patient in the supine position, the damaged
scapula was fixated by placing a wedge underneath. The therapist executed maximum abduction
of the humerus using one hand while standing beside the patient. After executing 90° flexion
of the elbow joint, the forearm was rotated toward the head so that it was located at the
end range of the glenohumeral joint. Next, posterior translation was applied to the humeral
head using the other hand. The translation was applied a set for 30 seconds for 15 sets over
10 minutes; after each set, the patient rested in a neutral position for approximately 10
seconds.  For additional joint mobilization, one of the manual therapies of MM Grade III
anteroposterior oscillation was used9). MM
Grade III is applied at an intensity that slightly exceeds the restriction point of the ROM
to provoke tissue resistance, involving an oscillation movement with slow and large
amplitude; it improves joint mobilization by inducing joint capsule and connective tissue
stretching22). With the patient in the
supine position, the damaged scapula was fixated by placing a wedge underneath. The
therapist executed maximum abduction of the humerus using one hand while standing beside the
patient. After executing 90° flexion of the elbow joint, the forearm was rotated toward the
head so that it was located at the end range of the shoulder joint. Afterwards,
anteroposterior oscillation was applied to the humeral head using the other hand. The
oscillation was one per second applied for a total of fifteen 30-second sets for 10
minutes23); after each set, the patient
was allowed to rest in the neutral position for approximately 10 seconds.  SPSS version 18.0 was used for all statistical analyses. Prior to analysis, data normality
was tested by the Shapiro-Wilk test. A paired t-test was used to compare pre- and
post-intervention data in each group, and an independent t-test was used to compare the MM
and KM groups. The level of significance in all analyses was set at α <
0.05.

BODY.RESULTS:
There were significant differences in pain and the ROM of both internal and external
shoulder rotation pre- and post-intervention in the MM and KM groups (p < 0.05) (Table 2Table 2.Changes in pain and rotation ROM pre- and post-interventionKaltenborn (n = 10)Maitland (n = 10)PrePostPrePostPain (VAS) 5.58 ± 0.8 2.65 ± 0.67* 6.05 ± 1.123.12 ± 0.98*Internal rotation (°) 31.98 ± 6.17 37.32 ± 7.76* 31.74 ± 6.77 36.84 ± 6.90*External rotation (°) 38.8 ± 5.7549.64 ± 5.17* 40.85 ± 7.5149.76 ± 8.64*Mean ± SD. VAS: visual analog scale. *p < 0.05, pre- vs. post-intervention.). However, there were no significant differences between the MM and KM groups
with respect to pain or ROM improvement in FS patients (p > 0.05) (Table 2).

BODY.DISCUSSION:
The results indicate the oscillatory technique in MM and sustained stretch technique in KM
combined with therapeutic modalities were both effective for treating external and internal
rotation ROM deficits frequently observed among FS patients as well as reducing pain.  In clinical practice, physical therapists have traditionally used anterior translation of
the humeral head following the convex-concave rule in order to recover the shoulder's
external rotation ROM. However, several studies demonstrate posterior translation is more
effective than anterior translation for external rotation ROM recovery15, 24). Roubal et
al.24) applied posterior translation to
improve shoulder rotation based on the "capsular constraint mechanism," while Johnson et
al.15) argue that posterior gliding is
more efficient than anterior gliding for improving external rotation ROM among FS patients.
However, Vermeulen et al.15) compared the
effects of high- and low-grade mobilization techniques on FS patients and report that the
former are more effective for shoulder ROM improvement and malfunction reduction. Therefore,
posterior joint mobilization was selected for the present study with an intensity of Grade
III.  Both the MM and KM groups showed decreases in pain post-intervention, and joint
mobilization exhibited a hypoalgesic effect25). Various mechanisms explaining the pain reduction after joint
mobilization have been proposed. Mangus et al.26) argue that joint mobilization controls pain through
neurophysiological effects by stimulating type II mechanoreceptors while inhibiting type IV
nociceptors. Passive joint mobilization provokes Golgi tendon organ activity at the end of
the joint mobilization and causes reflex inhibition of the muscle27). Decreased muscle activity after joint mobilization
decreases joint concentric activation, alleviating pain and muscle tension in periarticular
tissue28). However, the mechanisms
underlying the reduction in pain observed in the present study remain unclear.  In the case of KM Grade III posterior translation, both the external and internal rotation
ROMs increased after the intervention. Harryman et al.29) conducted a cadaveric experiment to determine if a tightened
rotator cuff interval affected the translation of the humeral head during the movement of
the humerus. Joint capsule contracture is frequently observed in rotator cuff intervals
among FS patients30). Their results
indicate that a tight rotator cuff interval causes undesirable anterosuperior translation
and eventually limits the ROM by restricting the posterior translation during external
rotation. Hence, the result of the present study are consistent with those of Roubal et
al.24) and Johnson et al.15) in that external rotation was enhanced by
increasing posterior translation through rotator cuff interval stretching. Moreover,
contracture of the shoulder posterior capsule is known to cause internal rotation reduction
in abduction at 90°31). Gong et al.32) observed that posterior translation is
effective for increasing shoulder internal rotation in normal individuals. Thus, the
posterior translation applied in the present study likely contributed to the increased
internal rotation by stretching the posterior capsule.  In the case of the Grade III anteroposterior oscillation in MM, both the external and
internal rotation ROMs increased significantly post-intervention, similar to that after KM.
This can be interpreted to mean that MM provokes tissue stretching even though it uses
oscillation and produces results similar to those of KM.  The limitations of this study are as follows. First, the sample size was not large enough
to generalize the study results to other populations. Second, even though patients were
selected according to strict inclusion criteria, the strength of the third stage of
mobilization differed according to each patient's recovery. Third, the study allowed all
movements during daily activities and was therefore unable to control for the diverse
motions of each patient. Finally, the direction of mobilization applied for treatment was
not diverse enough. Future studies involving FS patients should investigate mobilization in
various directions in addition to posterior mobilization.  In summary, anteroposterior MM and KM reduced pain and improved ROM in FS patients.
Therefore, these techniques are effective for improving FS-associated joint contracture and
pain. However, there was no significant difference between the MM and KM techniques with
respect to pain reduction or ROM improvement. Therefore, we recommend both anteroposterior
MM and KM be considered for ROM improvement and pain reduction among FS patients.

Question: Compared to Kaltenborn mobilization what was the result of Maitland mobilization on pain or range of motion (ROM) improvement?
Evidence: However, there were no significant differences between the MM and KM groups
with respect to pain or ROM improvement in FS patients (p > 0.05) (Table 2).
Answer: no significant difference