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Robert J. Fluegel, PT, COMT
MAPS Faculty, Fellow in Training, MAPS Orthopedic Manual Therapy Fellowship

Chris R. Showalter, PT, OCS, COMT, FAAOMPT, Fellowship Program Director

Mobilization combined with Stabilization is SUPERIOR compared to Stabilization alone in Non-Specific Mechanical Neck Pain (NSMNP)

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Maitland Grade IV Shoulder Mobilizations Significantly Improved Outcomes in Chronic Frozen Shoulder Patients Compared to Standardized PT Care

July 10, 2012


Chris Showalter PT, OCS, COMT, FAAOMPT

MAPS Clinical Director

Maitland Grade IV Shoulder Mobilizations Significantly Improved Outcomes in Chronic Frozen Shoulder Patients Compared to Standardized PT Care

Frozen shoulder syndrome (FSS) is a debilitating condition with a largely unknown etiology.  According to the American Academy of Orthopedic Surgeons, FSS affects approximately 2% of the population, or roughly 6.2 million people in the U.S. alone.  Manual therapists have long noted the significant clinical benefits of end range shoulder mobilization for chronic frozen shoulder patients.

In this month’s Research Commentary I discuss an interesting 2012 Randomized Controlled Trial (RCT) by Yang JI, et al (PubMed Abstract and weblink below).

The RCT showed that Maitland end-range Humeral mobilization and Scapula mobilizations resulted in significantly improved outcomes on patients suffering from FSS after 2 sessions per week for 8 weeks.  

Take Home Message:

This article continues to build on a body of research that convincingly supports the use of end-range Maitland humeral mobilizations, and scapular mobilizations, as a highly effective treatment for chronic FSS patients. The authors also introduce a potentially useful CPR for FSS patients.

The Study Details:

32 chronic (> 3 months), FSS patients participated (included if >50% loss of Gleno-humeral ROM in two or more directions of movement)

Group allocations:  10 Control, 12 Criteria-controlled, 10 Criteria-intervention

Criteria-control: this group was used as the authors were also investigating a developing CPR for FSS. This group had at least 2 of the following 3 criteria: < 8°of scapular posterior tipping, < 97° of humeral elevation, and < 39°of humeral external rotation during arm elevation.

Interventions…Control and Criteria-controlled groups: Passive mid-range humeral mobilization, Flexion and Abduction Stretching, Active exercises and physical modalities (US, SWD, unspecified Electrotherapy)

Interventions…Criteria-intervention group: This group received the standardized care above as well as 10-15 seconds of Maitland Grade IV AP humeral mobilization at maximum available humeral elevation AND scapular mobilizations including inferior-superior glide, bilateral rotations, and lateral distraction each for 10 sets of 10 repetitions with 30 second rest periods.  

Data Collection: Data was collected at intake, 4 and 8 weeks for Shoulder ROM (IR, ER, Hand-behind back), FLEX-SF (Shoulder disability index) and the FASTRAK shoulder kinematics motion analysis system.


Criteria-intervention improvements compared with both control and criteria-control

Measure                                                                       4 Weeks                              8 Weeks

Humeral ER (ROM)                                                        +18.1°                                 +26.4°

Normalized hand behind back (ratio)                             +0.2                                     +0.31                                  

FLEX-SF (Disability Index)                                             +4.9 Pts.                             +7.4 Pts.


The authors state…“Our results support the findings of previous studies showing improvement after mobilization in a frozen shoulder (Vermeulen et al 2000, Yang et al 2007). Specifically, we found efficacy of improvement at 4 and 8 weeks with the specific humeral end range mobilization and scapular mobilization in our homogenous groups�

The authors continue…“Mobilization techniques performed in the specific plane close to the end range improve the corresponding extensibility of the shoulder capsule and stretch the specific tightened tissues to induce beneficial effects (Maitland 1991, Lin et al 2008). Our results support this premise and indicate that this effect can be achieved with specific mobilization techniques�

And finally…“End–range intensive Grade IV antero-posterior (AP) mobilization techniques combined with scapula mobilization techniques can be advocated in subjects with FSS who have < 8°of scapular posterior tipping, < 97° of humeral elevation, and < 39°of humeral external rotation during arm elevation�. These final figures represent the criteria in the prior developed CPR.

Cheers and Enjoy

Chris R Showalter

© Chris R. Showalter and Maitland Australian Physiotherapy Seminars

Not to be reproduced, copied or retransmitted in any manner without author’s express written permission

Directing others to the MAPS website ( is permissible.

Article Follows (with weblink to Pubmed)

Man Ther. 2012 Feb;17(1):47-52.

Effectiveness of the end-range mobilization and scapular mobilization approach in a subgroup of subjects with frozen shoulder syndrome: a randomized control trial.

Yang JL, Jan MH, Chang CW, Lin JJ.


Treatment strategies targeting abnormal shoulder kinematics may prevent pathology or if the pathology develops, shorten its duration. We examined the effectiveness of the end-range mobilization/scapular mobilization treatment approach (EMSMTA) in a subgroup of subjects with frozen shoulder syndrome (FSS). Based on the kinematics criteria from a prediction method, 34 subjects with FSS were recruited. Eleven subjects were assigned to the control group, and 23 subjects who met the criteria were randomly assigned to the criteria-control group with a standardized physical therapy program or to the EMSMTA group. Subjects attended treatment sessions twice a week for 8 weeks. Range of motion (ROM), disability score, and shoulder complex kinematics were obtained at the beginning, 4 weeks, and 8 weeks. Subjects in the EMSMTA group experienced greater improvement in outcomes compared with the criteria-control group at 4 weeks (mean difference=0.2 of normalized hand-behind-back reach) and 8 weeks (mean difference=22.4 degrees humeral external rotation, 0.31 of normalized hand-behind-back reach, 7.5 disability, 5 degrees tipping and 0.32 rhythm ratio). Similar improvements were found between the EMSMTA group and control group. The EMSMTA was more effective than a standardized physical therapy program in a subgroup of subjects who fit the criteria from a prediction method.

Where to find the Articles


Yang JL, Jan MH, Chang CW, Lin JJ Effectiveness of the end-range mobilization and scapular mobilization approach in a subgroup of subjects with frozen shoulder syndrome: a randomized control trial. Man Ther. 2012 Feb;17(1):47-52.


Vermeulen HM, Obermann WR, Burger BJ, Kok GJ, Rozing PM, van Den Ende CH End-range mobilization techniques in adhesive capsulitis of the shoulder joint: A multiple-subject case report. Phys Ther. 2000 Dec;80(12):1204-13.


Yang JL, Chang CW, Chen SY, Wang SF, Lin JJ. Mobilization techniques in subjects with frozen shoulder syndrome: randomized multiple-treatment trial. Phys Ther. 2007 Oct;87(10):1307-15.

Maitland GD, Peripheral Manipulation, London, Butterworth-Heinemann, 3rd  Ed, 1991


Lin HT, Hsu AT, An KN, Chang Chien JR, Kuan TS, Chang GL. Reliability of stiffness measured in glenohumeral joint and its application to assess the effect of end-range mobilization in subjects with adhesive capsulitis. Man Ther. 2008 Aug;13(4):307-16.   

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