EFFICACY OF MAITLAND MOBILIZATION IN FROZEN SHOULDER

Abstract

ABSTRACT
Objectives: Efficacy of Maitland Mobilization in Frozen shoulder. Design: Randomized Control Trial. Methodology: A total of 40 patients were included as per pre defined inclusion and exclusion criteria and randomly assigned into two groups each having 20 patients. Group A was given Maitland mobilization along with Exercises (stretching, strengthening and ROM exercises) while Group B was given Ultrasound therapy along with Exercises (stretching, strengthening and ROM exercises) for thrice a week for four weeks (12 sessions). The patient’s outcome measures were assessed by visual analog scale, Shoulder pain and disability index (SPADI) and Goniometry for Shoulder Range of Motion. Pre and post treatment values were recorded for comparison of results. Results: Results revealed that means and S.D of both groups were clinically significant but statically the Group of patients treated with Maitland mobilization along with Exercises managed pain (pre=5.27±1.5, post=1.72±0.9), SPADI (pre= 80.27±3.45, post= 35.24±7.27) and range of motion(flexion pre=104.4±36.02, post=151.31±15.83, Abduction pre=92±33.96 ,post=161.5±8.45, lateral rotation =22.31±12.88, post=72.06±6.84 and Medial rotation pre=41.56±9.34, post=66.56±9.25, is better than group of patients treated with Ultrasound therapy along with Exercises in terms of pain (pre=5.35±1.6, post=2.30±0.5), SPADI (pre=81.25±3.21,post=9.12±5.53) and range of motion (flexion pre=99.25±47.13, post=118.38±35.61, Abduction pre=84.56±48.16, post=112.63±37, lateral rotation pre=28±18.83 post=40.94±17.15, Medial rotation pre=41.37±13.80, post=50.81±11.61. Conclusion: The result of study suggests that both Maitland Mobilization and Ultrasound improves the symptoms of frozen shoulder. Better improvement was shown by Maitland’s group than Ultrasound group. Based on these results Maitland mobilization with Exercise’s should be the treatment of choice for frozen shoulder rather than Ultrasound with Exercises.
KEYWORDS: Ultrasound, Shoulder Pain, Maitland’s, Exercise.

Full text

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22
EFFICACY OF MAITLAND MOBILIZATION IN FROZEN SHOULDER
Dr. Abdullah Al Shehri1, Sami S. Almureef2, Shabana Khan3 and Dr. Sharick Shamsi*4
1PhD in Physiotherapy, Director of Physiotherapy department at PSMMC- Riyadh -Saudi Arabia.
2Mater in Physiotherapy Senior Physiotherapist in male ortho in patient at PSMMC -Riyadh -Saudi Arabia.
3Mater in Physiotherapy (Sports Medicine) Physiotherapist in female ortho OPD at PSMMC -Riyadh -Saudi Arabia.
4PhD in Physiotherapy, Senior Physiotherapist in male ortho OPD at PSMMC -Riyadh -Saudi Arabia.
Article Received on 25/09/2018 Article Revised on 15/10/2018 Article Accepted on 06/11/2018
INTRODUCTION
The name “frozen shoulder” firstly given by Codman in
1934. He described frozen shoulder as a painful shoulder
condition of insidious onset that was associated with
stiffness in forward elevation, external rotation and
difficulty in sleeping on affected side. Naviesar coined
term “adhesive capsulitis” in 1945.[1] Adhesive capsulitis,
periarthritis, and frozen shoulder are all terms used to
describe a painful and stiff glenohumeral joint.[2]
Adhesive capsulitis can be defined as a common
condition characterized by insidious and gradual
inflammation of the glenohumeral joint capsule leading
to its contracture and thus resulting in stiffness and loss
of shoulder mobility.[3] The prevalence rate has been
reported to be 2–5.3%, with individuals commonly
affected in the age group between40 to 70 years.[4-8]
Usually this condition is self-limiting which may resolve
within 2–3 years but it can extend beyond 3 years in up
to 40% of patients.[9,10] According to Smita Bhimrao
2014, Frozen Shoulder or Adhesive Capsulitis is reported
to affect 3% to 5% of the general population and up to
20% in people with diabetes. The occurrence of Frozen
Shoulder in unilateral shoulder increases the risk of
contra lateral shoulder involvement by 5% to 34%.[11] It
is generally divided in to 3 stages of symptoms lasting
for 30 months.
1. Stage I/ freezing stage / painful stage
 As described by Smita Bhimrao.[11] typically lasts for
10 to 36 weeks.
 Patient presents with spontaneous onset of shoulder
pain which is more severe at night and with activities,
associated with a sense of discomfort that radiates down
the arm.
SJIF Impact Factor 4.918
Research Article
ejbps, 2018, Volume 5, Issue 12, 22-27.
European Journal of Biomedical
AND Pharmaceutical sciences
http://www.ejbps.com
ISSN 2349-8870
Volume: 5
Issue: 12
22-27
Year: 2018
*Corresponding Author: Dr. Sharick Shamsi
PhD in Physiotherapy, Senior Physiotherapist in male ortho OPD at PSMMC -Riyadh -Saudi Arabia.
ABSTRACT
Objectives: Efficacy of Maitland Mobilization in Frozen shoulder. Design: Randomized Control Trial.
Methodology: A total of 40 patients were included as per pre defined inclusion and exclusion criteria and
randomly assigned into two groups each having 20 patients. Group A was given Maitland mobilization along with
Exercises (stretching, strengthening and ROM exercises) while Group B was given Ultrasound therapy along with
Exercises (stretching, strengthening and ROM exercises) for thrice a week for four weeks (12 sessions). The
patient’s outcome measures were assessed by visual analog scale, Shoulder pain and disability index (SPADI) and
Goniometry for Shoulder Range of Motion. Pre and post treatment values were recorded for comparison of results.
Results: Results revealed that means and S.D of both groups were clinically significant but statically the Group of
patients treated with Maitland mobilization along with Exercises managed pain (pre=5.27±1.5, post=1.72±0.9),
SPADI (pre= 80.27±3.45, post= 35.24±7.27) and range of motion(flexion pre=104.4±36.02, post=151.31±15.83,
Abduction pre=92±33.96 ,post=161.5±8.45, lateral rotation =22.31±12.88, post=72.06±6.84 and Medial rotation
pre=41.56±9.34, post=66.56±9.25, is better than group of patients treated with Ultrasound therapy along with
Exercises in terms of pain (pre=5.35±1.6, post=2.30±0.5), SPADI (pre=81.25±3.21,post=9.12±5.53) and range of
motion (flexion pre=99.25±47.13, post=118.38±35.61, Abduction pre=84.56±48.16, post=112.63±37, lateral
rotation pre=28±18.83 post=40.94±17.15, Medial rotation pre=41.37±13.80, post=50.81±11.61. Conclusion: The
result of study suggests that both Maitland Mobilization and Ultrasound improves the symptoms of frozen
shoulder. Better improvement was shown by Maitland’s group than Ultrasound group. Based on these results
Maitland mobilization with Exercise’s should be the treatment of choice for frozen shoulder rather than
Ultrasound with Exercises.
KEYWORDS: Ultrasound, Shoulder Pain, Maitland’s, Exercise.

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2. Stage II/ Frozen stage /stiffening stage
 It lasts for 4 to 12 months.
 Pain at rest usually diminishes during this stage,
leaving the shoulder with restricted motion in all planes.
 Activities of daily living become severely restricted.
 When performing the activities, a sharp, acute
discomfort, can occur as the patient reaches the restraint
of the tight capsule. Pain at night is a common
complaint.
3. Stage III/ thawing stage / resolution stage
 This phase lasts for 5 to 26 months.
 This stage is characterized by gradual recovery of
range of motion.
There are two main types of frozen shoulder idiopathic
primary frozen shoulder and secondary frozen shoulder
corresponds to traumatic capsulitis or if some other
medical condition is present alongside.[12]
Goals of treatment for frozen shoulder are pain relief,
maintenance of range, and restoring function.
Physiotherapy treatment consists of stretching and
strengthening exercises, electrotherapy modalities or
mobilization which may be applied side by side.[13]
Joint mobilization is a form of passive movement in a
broad spectrum of exercise used to treat painful and stiff
synovial joints. Several forms of mobilization exist and
terminology varies among the authorities. The oscillatory
movements will be in the direction of the joint's
accessory motions which are small spinning, gliding,
rolling, or distractive motions that occur between joint
surfaces and are essential for normal mobility. An
example of an accessory motion at the shoulder would be
movement of the humeral head inferiorly as it moves on
the glenoid fossa during normal abduction. This gliding
motion is necessary for the greater tuberosity of the
humerus to pass under the coracoacromial arch and
thereby allow full elevation of the arm. Accessory
motions can be demonstrated in normal, synovial joints
when an examiner passively moves one articular surface
while the other is stabilized.[2] Ultrasound therapy (UST)
is used to treat frozen shoulder, increases tissue
temperature upto 5 cm deep, causing increased collagen
tissue flexibility, pain threshold, and enzymatic activity.
UST also affect nerve conduction velocity and
contractile activity of the skeletal muscle.[14] Therefore,
effective treatment that shortens the duration of
symptoms and disability has the potential to be of
significant value in terms of reduced morbidity and
costs.[15]
MATERIAL AND METHODS
The study was designed as Randomized Control Trial
and has two groups. Group A was given Maitland
mobilization along with Exercise’s (stretching,
strengthening and ROM exercises) while Group B was
given Ultrasound along with Exercise’s (stretching,
strengthening and ROM exercises). It was conducted at
Physical Therapy Department of Prince Sultan Military
Medical City- Riyadh Saudi Arabia.
Inclusion criteria[14,17,18]
 Age 40- 60 yrs.
 Shoulder ROM restriction (external rotation ≥ 600,
abduction ≥300, internal rotation≥50)
 Shoulder pain more than 3 months.
 Patients with adhesive capsulitis abduction test and
external rotation test positive.
Exclusion criteria[19,20,21]
 Diabetes mellitus.
 History of trauma or accidental injuries.
 Neurological involvement (stroke, Parkinsonism,
radiating pain to arm).
 History of surgery on particular shoulder.
A total of 40 patients were included as per inclusion
criteria. They were randomly assignment into two groups
A and B with 20 patients in each group. Baseline
assessment using Visual analog Scale (VAS), Shoulder
pain and disability index (SPADI) and Goniometry was
done respectively for Pain, Function and shoulder range
of motion (flexion, abduction, lateral rotation, and
medial rotation) for both groups. Treatment was given
thrice a week for four weeks (12 sessions).[14,22]
Maitland’s Mobilization procedure
Patient was in supine lying with arm abducted to 30
degrees and therapist was in walk standing position
holding proximal end of the humerus and maintaining a
lateral humeral distraction in its midrange position.
Glenohumeral caudal glide mobilization was given at the
rate of 2-3 glides per second for 30 seconds for each
glide,given for 5 sets (Fig.1) .The technique was applied
thrice a week for four weeks (12 sessions).[14, 22]
Fig. 1: Caudal glide position.
Ultrasound Procedure
Patient received pulsed ultrasound for 5 minutes with a
device that was operated at a frequency of 1 MHz, and
an intensity of 1 W/cm2. The treating physical therapist
applied the transducer head in circular motion over the
superior and anterior periarticular regions of the
participant's glenohumeral joint and on the shoulder
trigger points.[23]

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Exercise therapy
Stretching exercises
External rotators and flexors were stretched by stretching
in hand-behind the-back. Patients were asked to maintain
each stretch for 30 seconds, with 10 sec rest in between
and repeat these stretches for 4 times. They were
informed to perform stretching exercises at home daily.
Self-stretching exercises is give for improving abduction,
flexion, external rotation, internal rotation, and
horizontal adduction.[24]
Self-Stretching to Increase External (Lateral)
Rotation
Patient sitting on the side of a table with the forearm
resting on the table and elbow flexed to 90°. Have the
patient bend from the waist, bringing the head and
shoulder level with the table.[25] (Fig.2).
Fig. 2. Self Stretching.
Strengthening exercises
Strengthening exercises were started with weights,
therabands, springs and pushups. The exercise protocol
and manual therapy were given to improve coordination,
muscle strength and mobility of rotator cuff muscles to
unload the subacromial space during active
movements.[26]
Range of Motion Exercises Program[14,22,25]
Pulley Exercises
Patient sitting on a chair holding a skipping rope, passing
over an iron beam. Patient swing the rope alternatively
up and down; this helps improve flexion and extension
movements of shoulder. Patients were asked to perform
this for 5 to 10 minutes every day(Fig. 3).
Fig. 3. Pulley Exercise.
Finger ladder Exercises: Patient standing facing a
ladder which is hanging over a wall. Patients were asking
to place the affected hands over the ladder at a low level.
Then slowly start an upward climb on the finger ladder
until it reached the top and then slowly down back to the
starting position (Fig. 4).
Fig. 4. Finger ladder Exercise.
Circumduction Exercises: Patients were asked to lie on
prone position on the edge of the bed, hang the affected
shoulder out of the bed then slowly rotate the affected
shoulder in all the directions in a circular manner.
Patients were asked to perform this for 5 to 10 times
daily (Fig. 5).
Fig. 5. Circumduction Exercises.

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Pendulum Exercises: Patients were asked to bend
forward with sound forearm supported on a table or
bench, shoulder relaxed, and then gently swings affected
side arm forwards and backwards until feel a mild to
moderate stretch. Patients were asked to perform this for
5 to 10 times provided the exercise is pain free (Fig. 6).
Fig. 6- Pendulum Exercise.
DATA ANALYSIS
Data was analyzed with SPSS 20. Outcome measures
were calculated as mean and standard deviation and
compared by using paired and independent sample t-test.
P-value of less than 0.05 was taken as significant.
Informed consent was taken from all patients before
enrollment in the study to assure willingness,
confidentiality of information and to aware the patients
about all procedure and interventions.
RESULTS
In this study 40 patients participated with a mean age of
47.25±15.30 in group A and 47.10±14.90 in Group B
ranging from 40 to 60 years.
Table. 1: Mean and SD of age between group A
and B.
1
Group A
(N=30)
Mean±SD
Group B
(N=30)
Mean±SD
2
Age (Yrs)
47.25±15.30
47.10±14.90
Mean reduction in VAS: Both groups had clinically
significant difference in pre Rx to Post RX values as p
values for group A and B were p=0.005 and p=0.06
respectively.
Table. 2: Mean reduction in VAS values between group A and B. Mean and standard deviation at pre RX, Post
RX with p values.
1
Groups
Pre RX
Post RX
Pre Rx to Post RX
Mean±SD
P value
2
Group A (N=20)
Mean±SD
5.27±1.5
1.72±0.9
4.21±1.25
0.005
3
Group B (N=20)
Mean±SD
5.35±1.6
2.30±0.5
2.51±0.75
0.06
Shoulder pain and disability index (SPADI)
Table 3: Shoulder pain and disability index.
1
Group
Pre RX
Post RX
P value
2
Group A (N=20)
Mean±SD
80.27±3.45
35.24±7.27
0.0005
3
Group B (N=20)
Mean±SD
81.25±3.21
9.12±5.53
0.10
Mean reduction in ROM
Both groups had significant difference in pre Rx to Post RX p=0.000 respectively.
Table. 4: Mean reduction in ROM values between group A and B. Mean and standard deviation at pre RX, Post
RX with p values.
1
ROM
Group A (N=20) (Mean±S.D)
Group B (N=20) (Mean±S.D)
p-value
(<0.05)
Pre RX
Post RX
Pre RX
Post RX
2
Flexion
104.4±36.02
151.31±15.83
99.25±47.13
118.38±35.61
0.001
3
Abduction
92±33.96
161.5±8.45
84.56±48.16
112.63±37
0.000
4
lateral rotation
22.31±12.88
72.06±6.84
28±18.83
40.94±17.15
0.000
5
Medial rotation
41.56±9.34
66.56±9.25
41.37±13.80
50.81±11.61
0.002
DISSCUSION
The aim of the study to find out effectiveness of
Maitland techniques in frozen shoulder. This study
compared the effectiveness of Maitland’s mobilization
technique against Ultrasound in frozen shoulder along
with stretching, strengthening and ROM exercises on
numeric pain rating scale, ROM and Shoulder pain and
disability index. In a general results shows that subjects

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26
in both the groups improved well. A significant
difference was found in both groups clinically. VAS and
SPADI scores reduced in both groups, but comparison
between groups showed that Group A was better than
group B statistically.
Group A receiving Maitland Mobilization showed better
improvement on VAS score (4.21) than group B received
Ultrasound (2.51) after four weeks of treatment.
Farah shaheen 2017, study shows that use of therapeutic
ultrasound decreased pain in frozen shoulder.[26]
Hasan Kerem Alptekin 2016, who found on his study
that evaluation of function at visits on the 7th and 12th
weeks showed the presence of significant improvement.
In all patients not presenting a contraindication to deep
or superficial heat application, the treatment protocol
included interferential current and hot pack application
for 20 min each, ultrasound therapy during 3 min, regular
ROM exercises, stretching exercises, strengthening with
Theraband in all directions, and the application of post-
exercise PNF techniques. Twenty manual stretching
exercises were performed, five in each direction.[27]
Do Moon et al. compared the Maitland and Kaltenborn
mobilization techniques and found significant differences
in pain and the ROM of both internal and external
shoulder rotation pre- and post-intervention in the
Maitland and Kaltenborn groups; however, there were no
significant differences when the groups were compared
for outcome measures.[28]
Robertson VJ et. al 2001, reported the usage of
ultrasound therapy (UST) clinically in rehabilitation of
patients with frozen shoulder. According to them both
thermal and non-thermal effects of UST are effective in
reducing inflammation and improving tissue flexibility
and decreasing pain. Increased tissue extensibility with
reduction of inflammation due to thermal effects of UST
helps in aggressive mobilization of shoulder with low
pain. The non-thermal effects of UST have shown to
reduce the recurrence of the symptoms also reducing the
in-house rehabilitation duration.[29]
Shahbaz Nawaz Ansari 2012 also found on his study that
use of therapeutic ultrasound decreased pain in the
treatment of frozen shoulder.[14]
Smita Bhimrao 2014 found on his study that patients
receiving Maitland mobilization with conventional
therapy have improvement in the functional outcome in
frozen shoulder.[11]
Range of motion exercises also contribute in improving
joint and soft tissue mobility and decreases risk of
adhesions and contracture formation. Stretching
exercises given as home Programme were also helpful in
breaking the collagen bonds and realignment of the
fibres for permanent elongation or increased flexibility
and mobility of the soft tissues that have adaptively
shortened and become hypo mobile over time in Frozen
Shoulder.[12,30,31]
Ketan Bhatikar 2018 in his study also gave Maitland
mobilization along with conventionl physiotherapy
treatment had a positive effect on pain and joint range of
motion.[32]
Abhay 2012 have conducted a clinical study to find the
effectiveness of Maitland mobilization technique in the
treatment of idiopathic shoulder adhesive capsulitis. The
study confirmed that combination of shoulder exercises
and Maitland mobilization technique results in relieving
pain and improving ROM and shoulder function.[13]
Sengpya Phukon 2017 conducted a study and the results
of the study, shows that both Maitland mobilization and
METS are effective in improving the ROM and decrease
in pain in patient with adhesive capsulitis.[33]
All about study results strongly support our study that
Maitland mobilization and Ultrasound along with
stretching, strengthening and ROM exercise improve
frozen shoulder condition.
CONCLUSION
The results showed that both the interventions resulted in
positive outcomes, but comparing the highest level of
positive outcome within the interventions the Maitland
technique imposed remarkable rate of recovery in
regaining pain free range of motion when compared to
the Ultrasound and is effective in the treatment of frozen
shoulder.
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