Mobilization With Movement for Shoulder Dysfunction in Older Adults: A Pilot Trial

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Abstract

Objective

The purpose of this study was to evaluate the feasibility of the methods proposed to conduct a full randomized clinical trial to assess the effectiveness of mobilization with movement on shoulder functionality in older adults with shoulder dysfunction.

Methods

A pilot, randomized, single-blinded clinical trial was carried out with 44 older adults (83.9±8.2 years) with shoulder dysfunction in 3 nursing homes in Toledo, Spain. Participants were recruited through information sessions and were randomly allocated into 2 groups. The control group (n = 22) intervention consisted of a physical therapy standard protocol proposed by the Spanish Rheumatology Society. Techniques based on Mulligan’s concepts of mobilization with movement were added to the standard protocol for the experimental group (n = 22) intervention. Interventions took place 3 times a week for 2 consecutive weeks and were performed by 2 experienced therapists. Main outcomes were recruitment rates, participation and adherence to interventions, assessment procedures, and the implementation of mobilization with movement. Clinical outcomes were shoulder functionality, active glenohumeral range of motion, and pain intensity. Data were collected at baseline, after each group intervention, and at 1 and 3 months after finishing interventions.

Results

All the participants accepted to be randomized. Participation rates were 97.7% for the experimental group and 95.5% for the control group. The analysis of variance did not show any statistically significant difference between treatment groups for any of the variables (all P values for the group effect were greater than .36) or a change of the difference between groups over time (all P values for the time-treatment interactions were greater than .3).

Conclusion

The research methods tested in this pilot study offer a suitable foundation to conduct a full clinical trial.

Introduction

Shoulder dysfunction is a common problem in older adults with a described prevalence of 21%.1 Shoulder symptoms, such as pain and reduction in active range of motion (AROM) and functionality, might be associated to chronic pain, disability, and a decrease in physical performance over time.1, 2 Upper limbs and shoulder joint proper functionality leads to an adequate independence in activities of daily living (ADLs) and functional performance. Therefore, maintaining independence in ADL and the functional well-being in older adults should be a priority target for health care.3 A successful therapeutic approach depends on understanding that the aging process is responsible for major changes in muscles and joints and may cause muscle disorders and joint stiffness.4

Physical therapy interventions are often recommended as the first choice for a conservative treatment in the most common approaches to treat patients with shoulder dysfunction.5, 6, 7 Regarding physical therapy interventions, there are evidence about the effectiveness of therapeutic exercise,8, 9 and the benefit of manual therapy10, 11 so as to increase shoulder mobility, and a trend in improving pain measures. Enhancements in function and quality of life are still questionable.6, 7

Mobilization with movement (MWM) is a manual therapy technique based on the analysis and correction of any minor positional faults in a joint. According to Mulligan, positional faults are due to various soft tissue and/or bone lesions in/around the joint. The relevance of a correct joint position was argued in a kinematic study in healthy shoulders.12 This technique aims to realign the joints positional faults by performing a manually specific oriented glide to a painful joint, and assessing and adjusting force intensity. Meanwhile, the patient performs an active joint movement so that patient's symptoms are immediately relieved and the maneuvers improve pain and movement.13 Therefore, when a correct mobilization is sustained, pain-free movement is restored. The patient must repeat the movement several times to get an improvement that lasts over time.14, 15 The initial effects of MWM in adults were assessed by Teys et al16 who proved its effectiveness in increasing shoulder AROM and decreasing positional faults. Therefore, it may be an effective technique in the physical therapy treatment for shoulder dysfunction, as this addresses passive and active shoulder structures.17 However, no studies about its effectiveness for shoulder dysfunction in older adults have been found.

Considering the differences between the treatment for shoulder dysfunction in adults and older people, and the little evidence about the treatment in the aged population, it may be useful to carry out a pilot study using the Mulligan MWM technique to assess the possibility of conducting a full randomized controlled trial (RCT).

The purpose of this pilot study was to evaluate the feasibility of the methods proposed to conduct a full RCT to assess the effectiveness of Mulligan concept MWM on shoulder functionality in older adults with shoulder dysfunction. The primary objective was to evaluate the process of recruitment rates, willingness of participants to be randomized, participant attendance and adherence to interventions, assessment procedures, and implementation of MWM. The secondary aim was to undertake a preliminary comparison of patient-reported outcomes and to estimate the variability of these outcomes in older adults with shoulder dysfunction.

Section snippets

Study Design

This study was a feasibility study of a randomized clinical trial with concealed randomization and blinded assessment that was carried out between January 2012 and March 2013. This study was approved by Complejo Hospitalario de Toledo Human Research Ethics Committee. It was registered at the ClinicalTrials.gov register (Trial Registration: NCT2217540 https://register.clinicaltrials.gov/).

Setting

The location of this study was in 3 nursing homes in Toledo, Spain.

Recruitment Process

Study brochures were distributed to all

Results

Flow of participants of this study is shown in Figure 1. Two hundred older adults were screened for eligibility, and 112 (56%) of them were potentially eligible for the study. After excluding 68 (34%) subjects, 44 (22%) participants were randomly assigned to the EG (physical therapy standard protocol + MWM) or the CG (physical therapy standard protocol). Overall, 41 participants completed all assessments: 20 in the EG and 21 in the CG. Participants in the EG received a mean amount of 6

Discussion

To the best of authors’ knowledge, this is the first pilot RCT on the effect of MWM as part of a physical therapy intervention for older adults with shoulder dysfunction. Although few pilot studies about feasibility of physical therapy in older adult have been found, the current literature shows the importance of this type of studies because they can contribute to avoid mistakes in the implementation of a RCT, especially when dealing with older adults.27, 28

With reference to the specific

Conclusions

The research methods tested in this pilot RCT were suitable to conduct a full RCT. Regarding clinical changes, although non–statistically significant results were found, S-SDQ score showed better results in the EG than the CG. Moreover, the consistency of the effect direction in all outcomes may encourage researchers to conduct a full RCT to evaluate the clinical effectiveness of MWM plus the standard treatment vs the usual standard treatment for shoulder dysfunction in older adults. It would

Funding Sources and Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.

Acknowledgments

The authors are grateful to the management of the nursing home for older adults “Mercedes Patiño” in Villarrubia de Santiago, “San Juan de Dios” in Lillo, and “Rio Riansares” in Corral de Almaguer for their consent and for providing optimal conditions and the place to conduct the trial.

The authors also acknowledge the award given to this research study (the VI Physical Therapy Research Award) from Castilla-La Mancha Board of Physical Therapists.

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