Manipulation following regional interscalene anesthetic block for shoulder adhesive capsulitis: A case series

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Manual Therapy 10 (2005) 164–171
Case report
Manipulation following regional interscalene anesthetic block for
shoulder adhesive capsulitis: a case series
$
Robert E. Boyles
a,
, Timothy W. Flynn
b
, Julie M. Whitman
c
a
US Army-Baylor University Doctoral Program in Physical Therapy, AMEDDC & S, Fort Sam Houston, TX 78234, USA
b
Regis University, Denver, CO 80221, USA
c
Kirtland Air Force Base, Albuquerque, NM 87117, USA
1. Background and purpose
Adhesive capsulitis (AC) of the glenohumeral (GH)
joint, commonly known as ‘‘frozen shoulder’’, is a
prevalent condition that is frequently treated by physical
therapists (Dockrell and Wiseman, 1995;Holmes et al.,
1997;van der Heijden et al., 1997;Winters et al., 1997;
Connolly, 1998;Pearsall and Speer, 1998;Schwitalle et
al., 1998;van der Windt et al., 1998;Siegel et al., 1999;
Sandor, 2000;Vermeulen et al., 2000;Bentley and
Tasto, 2001;Green et al., 2001). AC is more prevalent in
women and in middle-aged individuals (Nevaiser, 1983,
1987;Siegel et al., 1999), in the diabetic patient
population, with a rate of 2–5% in the non-diabetic
population and 10–20% patients with non-insulin-
dependent diabetes mellitus (Siegel et al., 1999;Carette,
2000;Bentley and Tasto, 2001). Patients with GH AC
typically suffer from significant pain and progressively
diminishing shoulder function (Nevaiser, 1983, 1987;
Roubal et al., 1996;Placzek et al., 1998;Sandor, 2000).
In a recent review on interventions for shoulder pain by
the Cochrane Collaboration, Green et al. (2001), define
AC as the presence of shoulder pain with restriction of
passive and active GH motion. However, in their review
of the literature, these same researchers found no
standardized definitions for AC and reported conflicting
criteria defining AC in the clinical trials reviewed.
The recommended course of treatment for patients
with AC is highly variable (Schwitalle et al., 1998;
Thomas et al., 1981;Nevaiser, 1983, 1987;Parker et al.,
1989;Grubbs, 1993;Dockrell and Wiseman, 1995;
Holmes et al., 1997;van der Heijden et al., 1997;
Winters et al., 1997;Connolly, 1998;Harwood, 1998;
Tukmachi, 1999;Griggs et al., 2000;Hannafin and
Chiaia, 2000;Sandor, 2000;Bentley and Tasto, 2001;
Green et al., 2001;Jerosch, 2001;Kivimaki and
Pohjolainen, 2001;Omari and Bunker, 2001). In 1995,
Dockrell and Wiseman (1995) randomly surveyed 100
patient records from ten out-patient physical therapy
(PT) clinics in an effort to determine the ‘‘typical’’ PT
treatment for patients with a primary diagnosis of
shoulder AC. The majority of patients received eight to
18 treatments over a 2-month period of time. The most
frequently utilized treatments included exercise (98%),
manual GH mobilization (93%), and thermal modalities
(60%). In a retrospective descriptive study evaluating
the 10-year outcomes of a cohort of 50 patients, Miller
et al. (1996) reported that many patients with AC will
regain motion with minimal pain following a treatment
program of home-based therapy, moist heat, NSAIDs,
and physician-directed rehabilitation. Griggs et al.
(2000) conducted a trial of clinic and home-based
stretching exercises as a treatment for a cohort of 75
consecutive patients with AC. Although 85% of the
patients reported satisfactory outcomes, significant
differences still existed in pain and range of motion
(ROM) when compared to the unaffected shoulder.
Variables associated with unfavorable outcomes were a
previous unsuccessful trial of PT and the presence of
severe pain and functional limitations prior to the
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The views expressed in this case report are those of the authors
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
Corresponding author. Tel.: +1-210-221-7387; fax: +1-210-221-
7585.
E-mail address: robert.boyles@amedd.army.mil (R.E. Boyles).

initiation of treatment. Two recent, large randomized
clinical trials have compared PT treatments to steroid
injection (Winters et al., 1997;van der Windt et al.,
1998). Van der Windt et al. (1998) in a study of painful,
stiff shoulders noted greater short-term improvements in
pain and disability with injections versus a combined
program of mobilization, exercise, and physical agents
but no long-term differences (26th and 52nd weeks).
In a similar study, Winters et al. (1997) compared
treatments of physiotherapy (without mobilization/
manipulation), injection, and manipulation to the entire
upper quarter for 198 patients with shoulder complaints.
Of those patients thought to have symptoms primarily
of GH etiology, patients receiving corticosteroid injec-
tions showed quicker recovery and higher patient-
perceived ‘‘cure’’ rates compared to patients receiving
the other treatments. However, recurrence of pain by 11
weeks was highest in the injection group (18%),
followed by physiotherapy (13%) and manipulation
(8%). These trials appear to indicate that steroid
injections are more helpful than conventional PT for
short-term pain relief and improved disability scores,
but this difference in benefit diminishes in the long-term.
Manipulation under anesthesia (MUA) using long-
lever arm techniques in physiologic planes of motion,
i.e. flexion, abduction, and rotations, has been described
in the treatment for AC and is considered a last resort
procedure for these patients (Neviaser, 1983, 1987;
Grubbs, 1993;Connolly, 1998;Pearsall and Speer,
1998;Siegel et al., 1999). In this procedure, the clinician
moves the patient’s shoulder through physiologic mo-
tions while the patient is under general anesthesia.
Although positive post-manipulative clinical outcomes
have been reported, potential complications associated
with this long-lever arm technique include rotator cuff
tears, humeral fractures, and brachial plexus injuries
(Neviaser, 1983, 1987;Parker et al., 1989;Roubal et al.,
1996;Connolly, 1998;Placzek et al., 1998;Sandor,
2000). In contrast to this technique, Roubal et al. (1996)
and Placzek et al. (1998) have reported on a total of 39
patients treated with translational manipulations im-
mediately following a regional interscalene brachial
plexus anesthetic block. The technique utilized is
purported to be safe and effective because small-
amplitude, high-velocity, short-lever arm manipulations
are employed rather than long-lever arm techniques
(Roubal et al., 1996;Placzek et al., 1998). In both of
these studies, marked improvements in shoulder ROM
without complication were reported. Although Roubal
et al. (1996) did not report long-term outcomes,
favorable outcomes were reported at the 1-year follow-
up for the 31 patients in the Placzek et al. (1998) study.
Researchers in both studies concluded that manipula-
tion can be an effective intervention for patients with
AC and that this intervention should be considered by
those practitioners skilled in joint manipulation.
On the whole, it seems that some patients improve
after a program of PT, steroid injections, and/or
physician- or therapist-directed home care. However,
some patients fail to respond to these approaches
and continue to demonstrate residual passive range
of motion (PROM) and functional losses in the long
term (Shaffer et al., 1992). Therefore, some patients may
elect for a manipulative approach in an attempt to
improve the mobility and function of the affected
shoulder. In this case series, the use of manipulation
to the GH joint after an interscalene anesthetic block for
patients with AC is described. In addition, the use of
video fluoroscopy to assess GH joint arthrokinematics is
presented.
2. Case description
2.1. Patient presentation
The following four patients were referred to PT at
Brooke Army Medical Center and Wilford Hall Air
Force Medical Center, San Antonio, TX for manage-
ment of shoulder disorders:
Patient #1: A 47-year-old female nurse practitioner
with a 7-month history of right shoulder pain, stiffness
and inability to perform her normal activities of daily
living. Referral diagnosis: AC.
Patient #2: A 45-year-old female homemaker with an
insidious onset, 6-month history of left shoulder pain
and stiffness, sleep cycle disturbances, and inability to
perform daily activities such as bathing, cleaning the
house, and cooking. She particularly reported difficulty
with overhead tasks such as washing her hair. This
patient had already been treated with steroid injections
with no reported improvements in mobility, function, or
pain. Referral diagnosis: rotator cuff tear.
Patient #3: A 56-year-old male computer program-
mer with a 7-month history of right shoulder pain, sleep
cycle disturbance, and inability to put on his jacket or
shirt without pain, reach across his desk, or use a
computer mouse. Referral diagnosis: shoulder pain.
Patient #4: A 66-year-old male retired army officer
with a 10-month history of left shoulder pain, stiffness,
and sleep cycle disturbance. Symptoms increased with
shoulder elevation, reaching behind the back, and
reaching across his body (horizontal adduction). This
patient had already received steroid injections without
relief of symptoms or improved shoulder function.
Referral diagnosis: shoulder impingement.
All patients had received prior PT interventions
(shoulder joint mobilization, active and passive mobility
exercise programs, strengthening exercises, and/or mod-
alities) without satisfactory improvement in function or
pain. Two had received prior steroid injections and two
declined this treatment option.
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2.2. Baseline examination
PROM measurements as well as the Shoulder Pain and
Disability Index (SPADI) were used as outcome mea-
sures. PROM measurements were used because these
measurements are important in the diagnosis of AC and
are frequently used as an outcome measure in clinical
research. All PROM measurements were performed as
described by Norkin and White (1999).TheSPADIisa
100-point, 13-item self-administered questionnaire de-
signed to quantify shoulder pain and disability. Michener
and Leggin (2001) reported a high test–retest reliability
and internal consistency for the SPADI, while Williams et
al. (1995) have shown that the instrument is responsive to
change and accurately discriminates between patients
who are improving or worsening. It is reported to have a
moderately strong construct validity and more responsive
to change than the Sickness Impact Profile (SIP), Heald
and Riddle (1997). They also recommend the SPADI
over the SIP for measuring the extent of disability in
patients with shoulder problems. Additionally, a ten-
point change on the SPADI has been identified as the
minimally clinically important change needed to be
confident that a change has actually occurred (Heald
and Riddle, 1997).
The MRI reports for three patients (#2, #3, #4)
demonstrated various degrees of rotator cuff tears.
Physical examination findings for all four patients
included the following: (1) markedly decreased ROM
(flexion, abduction, and internal/external rotation); (2)
essentially equal impairment in both active and passive
shoulder motion; (3) pain at the end of each ROM; (4)
capsular end-feels with passive GH joint mobility
assessment. Based on patient history and the four
physical examination findings listed above, the diag-
nostic clinical criteria for AC were standardized by all
investigators.
As part of the physical examination, Patients #1 and
#4 had pre-manipulation video fluoroscopy studies.
Anterior to posterior views were recorded on both
extremities while the patient actively and repeatedly
abducted the shoulder. The pre-manipulation study for
both patients demonstrated a loss of normal arthrokine-
matics of the GH joint on the involved side. As
described by Maitland (1999) and Levangie and Norkin
(2001), the humeral head should glide inferiorly as the
patient abducts the shoulder. In these two patients, the
humeral head on the involved side failed to move
caudally during physiological shoulder abduction. In
fact, in both cases, the humeral head elevated with
abduction.
2.3. Intervention
As recommended by Placzek et al. (1998), patients
were prescribed a 6-day Medrol Dosepak (Pharmacia
and Upjohn Company, Kalamazoo, MI, USA) by their
referring physicians and started this medication the day
before the manipulation. Patient #3 was not prescribed
this medication because he is diabetic, a contraindica-
tion for taking the drug. After the patients signed the
standard consent form utilized by the facility for all
patients undergoing this procedure, an anesthesiologist
performed a regional interscalene block on each patient.
The blocks were found to last from 4 to 6 h. This
procedure is described elsewhere (Roubal et al., 1996;
Placzek et al., 1998). Patients then proceeded immedi-
ately to the out-patient PT clinic for treatment. A sling
was used in transit to protect the patients’ anesthetized
extremities. Immediately prior to the manipulation
session, the patient’s shoulder PROM was recorded
for flexion, abduction, and internal and external
rotation. End-feels were also assessed to ensure that
(1) the restrictions were still present after the extremity
was anesthetized to ensure true AC and (2) to be sure
that any increase in motion was a direct result of the
manipulation and not the anesthesia.
The reports by Placzek et al. (1998) and Roubal et al.
(1996) describe manipulations that are performed only
in two directions, anterior-to-posterior and superior-to-
inferior. In this case series, the physical therapists
performed these same manipulations. Additionally, the
therapists performed mobilization/manipulation in the
directions of the remaining perceived joint restriction.
To assess GH joint mobility, the therapists grasped the
proximal humerus as close to the GH joint as possible
and then glided the humeral head in anterior, posterior,
caudal, and combined directions, in an attempt to detect
joint hypomobility. This procedure was performed with
the shoulder at various degrees of flexion, abduction,
and internal/external rotation in an attempt to detect the
position and direction of motion where proximal
humeral translation was the most limited (joint hypo-
mobility). Once the therapist identified what he/she
perceived to be joint hypomobility when gliding the
proximal humerus in a specific direction, two to three
30-s bouts of a low-velocity, oscillatory mobilization, or
Maitland Grade IV–IV+ (Maitland, 1999) was applied
in that direction. If this failed to result in immediate
increases in PROM, high-velocity, low-amplitude
(HVLA) (Maitland, 1999) manipulations were per-
formed. To ensure the block did not wear off before
completion of the intervention, it was not possible due
to time constraints to record PROM measurements after
the application of each mobilization/manipulation
technique. However, in our four cases, the addition of
these HVLA thrust techniques appeared to result in
additional gains in shoulder PROM beyond those
attained after the application of the two techniques
previously described by Placzek et al. (1998) and Roubal
et al. (1996). All manipulations performed were short-
lever-arm, low-amplitude procedures. As advocated by
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Placzek et al. (1998) and Roubal et al. (1996), several
measures were taken in attempt to avoid brachial plexus
injury: (1) an assistant stabilized the scapula against the
trunk and in an elevated position; (2) the cervical spine
was positioned in ipsilateral sidebending and (3) the
elbow was never fully flexed or fully extended.
Following the manipulation session, PROM measure-
ments were again recorded. Finally, with the patient
resting in supine and the patient’s hand placed behind
his/her head, the treated shoulder was wrapped in an ice
pack for approximately 20 min. Patients were then
instructed in active assisted ROM (AAROM) exercises
and instructed to perform these exercises every 2 h at
home, when awake, for the next 24 h. The AAROM
exercises included: wand exercises for flexion, abduction,
internal and external rotations. They were also in-
structed to apply ice packs to the shoulder for 20 min
every 2 h with the ice packs circumferentially around the
shoulder while lying supine, hand resting behind their
head (the combined position of abduction and external
rotation). Patients followed-up with the treating physi-
cal therapist daily for 1 week and received further GH
joint mobilization Grade II–IV+ (Maitland, 1999),
ROM exercises, and cryotherapy. Home programs
included active, active assisted and passive shoulder
ROM exercises. After the first week, patients were
treated three times per week to address individual
impairments in shoulder motion and strength, and
typically discharged to a home program after 3 weeks.
See Appendix A for an example of the exercise program
and Appendix B for a sample clinical pathway.
2.4. Outcomes
Pre- and post-manipulation and follow-up SPADI
and PROM scores at baseline, 3-week, 6-week, and 12-
week follow-up are reported in Fig. 1 and the Table 1,
respectively. Throughout the manipulation treatment
and the subsequent follow-up periods, no adverse events
were reported. All patients demonstrated improvements
in both PROM measurements and disability scores
immediately after the manipulative intervention. Most
initial gains in PROM and all improvement in the
disability scores were maintained at the patients’ final
follow-up visit. Additionally, Patients #1 and #2 had
full, pain-free AROM that was equal to the opposite,
non-involved shoulder and full pain-free motion with
activities. Patient #3 missed several post-manipulation
treatment sessions and was unable to reproduce the
home exercise program. Therefore, compliance with the
home program was questionable. Patient #4’s only
remaining symptom was occasionally slight pain after
rolling onto his affected shoulder at night.
Patients #1 and #4 had follow-up video fluoroscopy
studies at the 6-week follow-up visit and Patient #1
again received a video fluoroscopy study at the 12-week
visit. The studies were performed in the same manner as
previously described. In contrast to the baseline video
fluoroscopy studies, the 6- and 12-week follow-up
sessions for Patient #1 and the 6-week follow-up session
for Patient #4, video fluoroscopy demonstrated a
smooth, ‘‘normal’’ GH motion. Figs. 2a and b are
end-range images of Patient #1’s video fluoroscopy
study for the involved versus uninvolved side, respec-
tively, prior to the initiation of the manipulative
intervention. Fig. 3 shows the same patient’s involved
shoulder at the 12-week follow-up evaluation and
illustrates the appropriate gliding of the humeral head
caudally as the patient performs active shoulder abduc-
tion.
3. Discussion
Although a similar treatment approach as described
by Placzek et al. (1998) and Roubal et al. (1996) was
utilized in this case series, several aspects of our patients’
care were unique. After using the techniques described
by these authors, therapists also performed further
mobilization/manipulation in the directions of remain-
ing perceived joint hypomobility. Although not mea-
sured, the additional techniques appeared to yield
immediate and substantial additional gains in shoulder
ROM in every case. These gains were made in light of
the study by Gokeler et al. (2003) that reported no
significant changes in humeral head distances with
traction force applied to the GH joint in the maximally
loose pack position when compared to the closed pack
position. Perhaps this is due to the specific direction and
grade of the mobilization used by the authors in this
study. It should be noted that Hsu et al. (2000a, b) in
two separate cadaver studies reported significant
increases in GH abduction immediately following
anterior–posterior glides and significant increases in
GH abduction immediately following caudal glides.
Although outcomes for only four patients are reported,
it is our opinion that the additional gains in mobility
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Fig. 1. SPADI scores for each patient.
R.E. Boyles et al. / Manual Therapy 10 (2005) 164 –171 167

attained though the utilization of our model of
treatment were important enough that researchers
should consider this approach in future clinical trials.
Placzek et al. (1998) and Roubal et al. (1996) outlined
a extensive post-manipulation protocol. These authors
used many physical modalities in an attempt to decrease
pain and enhance rehabilitation. Patients were also
given an extensive exercise regime to perform both in the
clinic with supervision and as a home program. In
contrast, our post-manipulation rehabilitation program
was designed to maintain gains in shoulder mobility and
specifically address each individual patient’s remaining
impairments while minimizing the amount of time that
the patient had to come to the facility for his/her
rehabilitation. Compared to the protocols used by
Placzek et al. (1998) and Roubal et al. (1996), our
patients were treated with fewer exercises and the use of
physical modalities (except for cryotherapy) was elimi-
nated. Further, our patients required approximately
four to five fewer post-manipulation PT visits than
patients in the previous studies. In our opinion, an
extensive post-manipulation rehabilitation program
may not be necessary; a more parsimonious rehabilita-
tion program may result in favorable gains in mobility
and improvements in disability scores, while conserving
valuable patient and clinic time and resources.
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Table 1
PROM measurements in degrees, for patients at baseline, immediately after the manipulative intervention, and at specific follow-up sessions
Patient 1 Patient 2 Patient 3 Patient 4
Flex Abd IR ER Flex Abd IR ER Flex Abd IR ER Flex Abd IR ER
Pre-treatment 120 90 25 40 115 50 25 5 110 70 20 25 115 85 25 30
Immediately post-Rx 170 155 75 100 135 90 70 35 160 160 90 45 170 160 70 85
3 weeks 165 170 70 105 150 95 70 35
aaaa
135 120 60 65
6 weeks 160 165 65 90 140 130 55 95 130 110 40 40 165 120 40 55
12 weeks 160 165 70 95
aaaa
125 110 70 50 165 120 40 55
a
Denotes measurement not obtained.
Fig. 2. Video fluoroscopic image at end-range abduction in Patient #1:
(a) is the uninvolved shoulder and (b) is the involved shoulder prior to
manipulation. Notice the relation of the humeral head to the glenoid
fossa in each figure.
Fig. 3. This figure is the same patient 12 weeks post-manipulation
using the same video fluoroscopic techniques at end-range abduction.
Notice the improved inferior glide of the humeral head relative to the
glenoid.
R.E. Boyles et al. / Manual Therapy 10 (2005) 164 –171168

Additionally, although many theorize about
the effects that AC has on normal arthrokinematics
(Maitland, 1999) and the effect of an intervention on
the arthrokinematics, documented cases of patients
receiving video fluoroscopy studies to demonstrate a
loss of normal joint kinematics before intervention
and return of more normal joint kinematics after the
application of an intervention have not been found. It is
believed that this is the first attempt to demonstrate
this. Video fluoroscopy of anterior–posterior views
during active shoulder abduction revealed increased
caudal translation of the GH joint following mani-
pulation when compared to the pre-manipulation
video fluoroscopy studies. Because video fluoroscopy
is a non-invasive, low-risk, and expedient imaging
modality it is therefore considered that it may be an
ideal tool to monitor the arthrokinematics of the
GH joint. Researchers should consider including the
use of video fluoroscopy in future studies when
investigating the effects of interventions on the me-
chanics of the GH joint.
Except for the regional interscalene block performed
by the anesthesiologist, all interventions in this
study and others (Roubal et al., 1996;Placzek et al.,
1998) were performed by physical therapists. The
Guide to Physical Therapist Practice (American
Physical Therapy Association, 2001) defines mobiliza-
tion/manipulation as ‘‘a manual therapy technique
comprising a continuum of skilled passive movements
to the joints and/or related soft tissues that are
applied at varying speeds and amplitudes, including a
small-amplitude/high-velocity therapeutic movement’’.
The Guide lists mobilization/manipulation as an
intervention appropriate for the care of patients with
AC. Since physical therapists possess and already
utilize these mobilization/manipulation skills in the care
of patients with AC without anesthetic blocks, it is
our belief that physical therapists are ideally suited to
be the practitioner of choice to perform this treatment
on patients who have received a regional interscalene
block.
4. Conclusion
The AC patients in this case series, treated with
translational manipulation following an interscalene
block, showed rapid improvement in PROM and
improved levels of disability as measured by the SPADI.
The results are consistent with previous reports (Roubal
et al., 1996;Placzek et al., 1998) demonstrating that, in
patients with AC, this type of intervention may result in
positive outcomes that are considerably quicker than
improvements attributed to the natural history of this
disorder. It appears that translational manipulation by a
physical therapist can be a safe and potentially effective
treatment option for these patients, even those present-
ing with underlying rotator cuff pathology as demon-
strated by MRI. It is our opinion that this intervention
should be considered for patients with AC if a trial of
more conventional treatment strategies has failed to
produce satisfactory results. Additionally, the use of
video fluoroscopy may be an ideal imaging modality for
further investigation of the biomechanical changes that
occur in the GH joint after the application of an
intervention in patients with AC. However, before this
treatment method for shoulder AC is advocated for
wide spread use, randomized controlled trials com-
paring this treatment to competing treatments are
warranted.
Appendix A. Post-anesthesia shoulder program
A.1. Same day
Pre-anesthesia PROM measurements.
Mobilizations/manipulations to address capsular re-
strictions.
Post-anesthesia PROM measurements.
Instruct in home exercise program of AAROM for
shoulder flexion. To be performed every 2 h for 5 min
to end range with 5 s holds.
Ice pack around the shoulder for 20–30 min. Patient
should be resting supine with hand behind the head to
encourage continued stretch in external rotation and
abduction.
Use of ice at home 20–30 min following exercise.
A.2. 1–5 days post-manipulation
Patient to attend daily PT sessions for shoulder
mobilization, exercise and ice.
Instruct in AAROM wand exercises for flexion,
abduction, internal and external rotation, self-
stretches for horizontal flexion. Ice to the shoulder
following treatment in supine with hand behind head
for 20–30 min.
Continue with home exercise program every 2 h for
the first week. Ice 20–30 min after treatments.
A.3. Second and third weeks
Continue with clinic sessions three times per week.
Continue with shoulder mobilizations to address
tightness/restrictions.
Advance to rotator cuff strengthening as motion and
pain allows.
Ice following treatment as needed.
Continue with home program.
Discharge at the end of third week to home program.
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R.E. Boyles et al. / Manual Therapy 10 (2005) 164 –171 169

ARTICLE IN PRESS
Appendix B. Pre-manipulation pathway for frozen shoulder patients
Pre-Manipulation Pathway for Frozen Shoulder Patients
Physical Therapist (PT) determines that the shoulder condition
is appropriate for manipulative treatment
PT counsels patient on risks/ benefits of the procedure, as well as other treatment
options. Patient completes a Shoulder Pain and Disability Index (SPADI)
PT coordinates with anesthesia service for interscalene block and
schedules patient’s manipulation session immediately following.
PT coordinates with referring physician for Medrol 6-day dose pack and
instructs patient to take first dose one day prior to procedure.
PT orders plain radiographic films of affected shoulder. MRI may be considered to note
any existing pathology (i.e. rotator cuff tear, labral defect, etc) prior to manipulation.
On the day of procedure, patient will report directly to anesthesia. The patient must arrange for
their own escort to assist them from anesthesia to Physical Therapy, as well as to serve as
designated driver to escort patient home following PT treatment.
PT will take PROM measurements both prior to, and following manipulation and instruct
patient in post-manipulative care and exercise plan.
PT will follow patient daily for at least 1 week to ensure all manipulation gains are
maintained and that the patient is compliant with entire program.
PT may reduce clinic patient visits as appropriate after one week, providing there are no
complications and patient is progressing well with program.
R.E. Boyles et al. / Manual Therapy 10 (2005) 164 –171170

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