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

Manual Therapy 10 (2005) 164–171
Case report
Manipulation following regional interscalene anesthetic block for
shoulder adhesive capsulitis: a case series
Robert E. Boyles
, Timothy W. Flynn
, Julie M. Whitman
US Army-Baylor University Doctoral Program in Physical Therapy, AMEDDC & S, Fort Sam Houston, TX 78234, USA
Regis University, Denver, CO 80221, USA
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
and not the US Armed Services.
Corresponding author. Tel.: +1-210-221-7387; fax: +1-210-221-
E-mail address: (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
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.
R.E. Boyles et al. / Manual Therapy 10 (2005) 164 –171 165
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
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
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
R.E. Boyles et al. / Manual Therapy 10 (2005) 164 –171166
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-
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
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.
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
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
125 110 70 50 165 120 40 55
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
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
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
Appendix A. Post-anesthesia shoulder program
A.1. Same day
Pre-anesthesia PROM measurements.
Mobilizations/manipulations to address capsular re-
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
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
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.
R.E. Boyles et al. / Manual Therapy 10 (2005) 164 –171 169
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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... It is scored from 0 to 100 with lower scores reflecting lower levels of pain/disability [32]. It is commonly used in studies involving patients with AC [30,33,34] and has been shown to have adequate construct validity in this population [35]. The SPADI has also shown good to excellent test-retest reliability and responsiveness in populations with AC [32,36,37]. ...
... caudal, posterior, anterior) to improve mobility [29]. Several studies have observed large short-term improvements in range of motion, pain, and shoulder function in individuals undergoing tMUA [27,28,30]. Only one study so far has reported long-term clinical outcomes [27]. ...
... There have been no adverse events reported in the literature involving tMUA for AC [20,[27][28][29][30]. However, there are no studies available reporting arthroscopic findings immediately following this procedure. ...
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Study Design: Case series study. Objectives: Although there have been no reported complications from translational manipulation under anesthesia (tMUA) for individuals with adhesive capsulitis (AC) there are no cases reporting surgical findings post tMUA. Also, there are no studies evaluating health care utilization following tMUA. The purpose of this study was to: (1) report clinical outcomes following tMUA, (2) describe relevant health care costs and utilization following tMUA, and (3) summarize findings from two cases receiving joint arthroscopy following tMUA. Methods: Fourteen Individuals with AC underwent tMUA. Range of motion (ROM) and Shoulder Pain and Disability Index (SPADI) values were collected at baseline and six weeks follow-up. Shoulder-related health care cost and utilization were analyzed for a five-year period following tMUA. Two additional patients with AC underwent tMUA followed by arthroscopic assessment for evidence of iatrogenic injury. Results: Thirteen patients completed the six-week follow-up. Mean change scores for ROM and SPADI values were flexion; +38.5°, abduction; +71.1°, external rotation (shoulder abducted); +49.8°, internal rotation (shoulder abducted); +26.6°, SPADI scores; +44.4. 13 patient records were analyzed for health care utilization. Ten of the 13 patients utilized no additional shoulder-related health care. Surgical evaluation revealed no evidence of iatrogenic injury. Discussion: Clinical outcomes were similar to previous studies. Utilization data indicated that for the majority of patients, little shoulder-related health care was utilized. Surgical evaluation provided further evidence that tMUA performed by a physical therapist is safe. Future research will be required to establish a causal relationship between tMUA and the results observed in this study. Level of Evidence: Therapy, Level 4.
... Similarly, interventions directed only to a particular region, such as the shoulder, do not consider the role of neighboring structures such as the cervicothoracic spine and ribs [8]. Although evidence supports manual physical therapy intervention of the spine in the management of patients with shoulder pain [9][10][11][12][13][14][15], the effects of cervicothoracic and thoracic thrust and non-thrust manipulation on individuals with a primary complaint of upper quarter pain remain to be reported in a systematic review. Therefore, the purpose of this systematic review was to determine the effectiveness of manual physical therapy in the treatment of pain and disability in individuals with upper extremity MSDs as outlined above. ...
... While previous studies [9][10][11][12][13][14][15] suggested the effectiveness of thoracic manipulation in the treatment of uppers quarter MSDs, the evidence from this review is less conclusive. Favorable outcomes related to cervicothoracic or thoracic manipulation were found when comparing the intervention to an active control [19], when comparing thoracic manipulation intervention to other interventions [18,24,30], and when assessing patient perception of long-term recovery [27,29]. ...
Study Design Systematic review. Background Physical therapists often use cervicothoracic and thoracic manual techniques to treat musculoskeletal disorders of the upper quarter ,however, the overall effectiveness of this approach remains to be elucidated. Objective This systematic review explored studies that examined the short- and long-term effectiveness of manual physical therapy directed at the cervicothoracic and thoracic region in the management of upper quarter musculoskeletal conditions. Methods The electronic databases MEDLINE, AMED, CINAHL, and Embase were searched from their inception through 30 October 2020. Eligible clinical trials included those where human subjects treated with cervicothoracic and/or thoracic manual procedures were compared with a control group or other interventions. The methodological quality of individual studies was assessed using the PEDro scale. Results The initial search returned 950 individual articles. After the screening of titles and abstracts, full texts were reviewed by two authors, with 14 articles determined to be eligible for inclusion. PEDro scores ranged from 66 to 10 (out of a maximum score of 10). In the immediate to 52-week follow-up period, studies provided limited evidence that cervicothoracic and thoracic manual physical therapy may reduce pain and improve function when compared to control/sham or other treatments. Conclusions Evidence provides some support for the short-termeffectiveness of cervicothoracic and thoracic manual physical therapy in reducing pain and improving function in people experiencing upper quarter musculoskeletal disorders. Evidence is lacking for long-term effectiveness as only two studies explored outcomes beyond 26 weeks and this was for patient-perceived improvement. Prospero ID CRD42020219456
... Manipulation under anaesthesia involves a controlled and forced, end range positioning of the humerus relative to the glenoid in physiologic planes of motion (flexion, abduction, rotation) in patients with an anaesthetic block to the brachial plexus [2]. Contraindication to manipulation under anaesthesia do exist and include: history of fracture or dislocation, moderate bone loss, or an inability to follow through with post procedure or an inability to follow through with post procedure care [6,7]. Although manipulation under anaesthesia has been shown to be effective in improving function and motion in patients with adhesive capsulitis, it is necessary to have randomized controlled trials comparing this treatment to competing treatments before widespread use is advocated [6,7]. ...
... Contraindication to manipulation under anaesthesia do exist and include: history of fracture or dislocation, moderate bone loss, or an inability to follow through with post procedure or an inability to follow through with post procedure care [6,7]. Although manipulation under anaesthesia has been shown to be effective in improving function and motion in patients with adhesive capsulitis, it is necessary to have randomized controlled trials comparing this treatment to competing treatments before widespread use is advocated [6,7]. Modalities, such as hot packs, can be applied before or during treatment. ...
... The anesthesiologist may suggest a particular medicine or combination of medications to aid patient recovery before and after treatment [9]. The anesthetic agent must be administered according to the treating institution's guidelines [43]. Monitored anesthesia care is employed, with parenteral Diprivan (propofol) or Versed (midazolam) being the most common medications [7,31]. ...
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Manipulation under anesthesia (MUA) is a multidisciplinary method for treating musculoskeletal conditions. Although several medical experts practice it, only those having experience in MUA research and accreditation in the technique are supposed to perform MUA procedures. MUA helps regain the optimum range of motion (ROM). It provides the intended result in 2-4 sessions. It is based on improving mobility in gradual amounts, rather than large amounts, each day to achieve desired effects in ROM and pain reduction. Although the literature supports the positive results achieved from MUA, data on treatment effectiveness are limited. Furthermore, published studies are often poor in methodological rigor and vary across domains, preventing generalization. This review discusses the history and analyzes studies on the benefits and standardization of diagnosis, procedure, certification, and treatment of MUA.
... Physiotherapy management of patients with adhesive capsulitis may vary in many ways from management of patients with other shoulder conditions. Conventional physiotherapy for adhesive capsulitis includes hot packs, Codman's pendular exercises, finger ladder exercises and active range of motion exercises 5 . Manual Therapy had been demonstrated to reduce pain and improve function in patients with adhesive capsulitis. ...
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BACKGROUND: The pathological changes in adhesive capsulitis occurs surrounding the intrinsic structure tightness. Movement with mobilization mostly works on intracapsular & sleeper's stretch mainly acts on capsule. There are some studies which supports that M.W.M. is more effective in patients with adhesive capsulitis. At the same time, some studies have been done which proves sleeper's stretch to be beneficial in capsular tightness. As a result, present study thought to determine the combined effects of M.W.M.& Sleeper's Stretch on adhesive capsulitis. OBJECTIVES: To find the effects of M.W.M. on R.O.M., pain and functional disability in populations with adhesive capsulitis. To find the effects of M.W.M. and sleeper's stretch on R.O.M., pain and functional disability in populations with adhesive capsulitis. To compare the effects of M.W.M. and M.W.M. with sleeper's stretch on R.O.M., pain and functional disability in populations with adhesive capsulitis. METHODOLOGY: A Randomized, controlled, single blinded study, 50 patients with adhesive capsulitis were selected based on the inclusion and exclusion criteria. Pre-assessment of pain, R.O.M. and disability index had been taken. The patients are randomly allocated into two groups. 25 patients in Group 'A' with adhesive capsulitis was treated with M.W.M. alone where as another 25 patients in Group 'B' with adhesive capsulitis was treated with M.W.M. plus, sleeper's stretch. Both the groups were given the conventional therapy which includes hot packs, pendular exercises, finger ladder exercises and active range of motion exercises. Post assessment was done. RESULTS: In total, 50 patients were randomized to the study interventions. The flexion R.O.M. in pre and post mean values
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TTBACKGROUND: Cervicothoracic manual therapy has been shown to improve pain and disability in individuals with shoulder pain, but the incremental effects of manual therapy in addition to exercise therapy have not been investigated in a randomized controlled trial. TTOBJECTIVES: To compare the effects of cervicothoracic manual therapy and exercise therapy to those of exercise therapy alone in individuals with shoulder pain. TTMETHODS: Individuals (n = 140) with shoulder pain were randomly assigned to receive 2 sessions of cervicothoracic range-of-motion exercises plus 6 sessions of exercise therapy, or 2 sessions of high-dose cervicothoracic manual therapy and range-of-motion exercises plus 6 sessions of exercise therapy (manual therapy plus exercise). Pain and disability were assessed at baseline, 1 week, 4 weeks, and 6 months. The primary aim (treatment group by time) was examined using linear mixedmodel analyses and the repeated measure of time for the Shoulder Pain and Disability Index (SPADI), the numeric pain-rating scale, and the shortened version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH). Patientperceived success was assessed and analyzed using the global rating of change (GROC) and the Patient Acceptable Symptom State (PASS), using chi-square tests of independence. TTRESULTS: There were no significant 2-way interactions of group by time or main effects by group for pain or disability. Both groups improved significantly on the SPADI, numeric pain-rating scale, and QuickDASH. Secondary outcomes of success on the GROC and PASS significantly favored the manual therapy-plus-exercise group at 4 weeks (P = .03 and P<.01, respectively) and on the GROC at 6 months (P = .04). TTCONCLUSION: Adding 2 sessions of high-dose cervicothoracic manual therapy to an exercise program did not improve pain or disability in patients with shoulder pain, but did improve patientperceived success at 4 weeks and 6 months and acceptability of symptoms at 4 weeks. More research is needed on the use of cervicothoracic manual therapy for treating shoulder pain. TTLEVEL OF EVIDENCE: Therapy, level 1b. Prospectively registered March 30, 2012 at www. (NCT01571674). J Orthop Sports Phys Ther 2016;46(8):617-628.
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Long term effects of glenohumeral joint translational (gliding) manipulation on range of motion, pain, and function in patients with adhesive capsulitis were studied. Thirty-one patients underwent brachial plexus block followed by translational manipulation of the glenohumeral joint. Changes in range of motion and pain were assessed before manipulation with the patient under anesthesia, immediately after manipulation with the patient still under anesthesia, at early followup (5.3 +/- 3.2 weeks), and at long term followup (14.4 +/- 7.3 months). Passive range of motion increased significantly for flexion, abduction, external rotation, and internal rotation. Significant decreases in visual analog pain scores between initial evaluation and the followup assessments also occurred. Furthermore, Wolfgang's criteria score increased significantly between initial evaluation and followup assessments. Translational manipulation provides a safe, effective treatment option for adhesive capsulitis.
This retrospective study investigated current physiotherapy treatment of primary frozen shoulder. The results showed that 11 different physiotherapy modalities/techniques had been used in the treatment of this condition. Exercise was the most popular treatment method (98%), closely followed by mobilisations (93%). The least popular treatment methods included cryotherapy, laser therapy and hydrotherapy.
Aim: Purpose of the present study was to compare the rehabilitation success after shoulder manipulation followed by physiotherapy either supported by conventional pain treatment, or continuous interscalene block. Subjects and methods: 72 patients with frozen shoulder underwent manipulation under general anesthesia from 1970 to 1981. 79 further patients were mobilized under interscalene block from 1982 to 1996. The first group was administered conventional analgesic therapy, whereas the latter received pain relief by maintaining the interscalene block continuously for a further 2 to 6 days. Both groups were compared preoperatively and 1 day, 6 weeks, 6 months, and at on average 13 years after manipulation. As the Constant-score cannot be applied to very short times after intervention, VAS too was applied. Results: As expected, both collectives showed comparable results as the first and the last examinations. Yet at the other times, differences between the two groups were imposing, especially 1 day after mobilization. Conclusions: The experience in this study indicates that the interscalene block provides sufficient pain relief for physical exercises, and, therefore, optimizes the rehabilitation success after shoulder manipulation.
EDITOR—The systematic review by Green and colleagues of interventions for treating shoulder pain concluded that there is little evidence to support the use of any of the common interventions for the management of shoulder pain.1 This is a negative message that is likely to inhibit practitioners from treating patients with shoulder pain and to dissuade them from referring these patients to specialists. While we agree with the other conclusions of the study, we disagree with the negative message about treatment for several reasons. Rheumatologists make decisions about the treatment of musculoskeletal disorders such as shoulder pain based on the duration of the condition, its severity, and a careful examination to define the exact site of the lesion.2 It is generally taught, for example, that the injection of corticosteroids will only work if done soon after the onset of any shoulder disorder and if the injection has been precisely localised to the anatomical site of the problem, such as a specific tendon or bursa within the rotator cuff.3 In the systematic review of the evidence great weight was given to the quality of the studies, but no weight was given to the quality of the clinical input to the studies, or to any of the three clinical criteria described above. We would agree that the assessment of the value of treatments for shoulder pain is difficult because of the overall poor quality of published studies, the absence of agreed outcome measures, and a lack of uniformity of definitions; some recent rheumatological research has addressed the problem of definitions.4 However, the methods used to assess quality in this review are not transparent or validated, and it is unclear on what basis the authors chose to combine studies; this throws into question the validity of their conclusions. Furthermore, if, as the authors of this and other reviews of interventions to treat shoulder pain contend, the methodological scores for most studies are low, surely it is erroneous to conclude that treatments do not work. The poor quality of the evidence discredits the negative conclusions as well as the positive ones. References1.↵Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy. BMJ 1998;316:354-360. (31 January.)
A pilot study using acupuncture in the treatment of 31 patients with frozen shoulder showed marked improvement in 24 and improvement in 6. Patients with idiopathic or arthritic frozen shoulder responded better than those with post-traumatic aetiology. There was no relationship between response to acupuncture and age. Although this study involved no control group, the high level of improvement together with the author’s clinical experience suggests that acupuncture should be considered an effective option in the treatment of frozen shoulder; the more so since conventional medical therapy has a low expectation of benefit. Aetiology pathology and clinical management are described in both Western medical and traditional Chinese terms and details of acupuncture treatment methods are given.