ARTICLE IN PRESS

Manual Therapy 13 (2008) 37–42

www.elsevier.com/locate/math

The initial effects of a Mulligan’s mobilization with movement

technique on range of movement and pressure pain threshold in
pain-limited shoulders
Pamela Teys, Leanne Bisset, Bill Vicenzino
Division of Physiotherapy, School of Health and Rehabilitation Sciences, Therapies Building 84A, The University of Queensland,
St Lucia Qld 4072, Australia

Received 15 December 2005; received in revised form 10 May 2006; accepted 21 July 2006

Abstract

There is little known about the specific manual therapy techniques used to treat painfully limited shoulders and their effects on
range of movement (ROM) and pressure pain threshold (PPT). The objective of this study was to investigate the initial effects of a
Mulligan’s mobilization with movement (MWM) technique on shoulder ROM in the plane of the scapula and PPT in participants
with anterior shoulder pain. A repeated measures, double-blind randomized-controlled trial with a crossover design was conducted
with 24 subjects (11 males and 13 females). ROM and PPT were measured before and after the application of MWM, sham and
control conditions. Significant and clinically meaningful improvements in both ROM (15.3%, F (2,46) ¼ 16.31 P ¼ 0:00) and PPT
(20.2%, F ð2; 46Þ ¼ 3:44, P ¼ 0:04) occurred immediately after post treatment. The results indicate that this specific manual therapy
treatment has an immediate positive effect on both ROM and pain in subjects with painful limitation of shoulder movement.
Further study is needed to evaluate the duration of such effects and the mechanism by which this occurs.
r 2006 Elsevier Ltd. All rights reserved.

Keywords: Shoulder pain; MWM; ROM; Pain

1. Introduction and Deyle (2000) and Nicholson (1985), which rated six
and five out of ten, respectively, on the PEDro quality
Shoulder pain with a subsequent restriction of move- rating scale (www.pedro.fhs.usyd.edu.au), reported that
ment is a common problem in both the sporting and supervised exercise combined with manual therapy was
working population. Approximately 1% of adults better than supervised exercise alone in the treatment of
consult a general medical practitioner with an episode shoulder impingement.
of shoulder pain each year (Bridges-Wegg, 1992; Pope Mobilization with movement (MWM) is a class of
et al., 1997). manual therapy techniques that is widely used in the
There is a dearth of high-quality trials that support or management of musculoskeletal pain. It involves the
refute the use of physiotherapy in shoulder pain (Green manual application of a sustained glide by a therapist to
et al., 2004), but there is some support for individuali- a joint while a concurrent movement of the joint is
zed programmes of manual therapy and exercises in actively performed by the patient (Mulligan, 1999).
the treatment of shoulder impingement syndrome Studies using MWM techniques on the elbow and ankle
(Michener et al., 2004). Two trials conducted by Bang have shown them to be effective in reducing pain as
measured by visual analogue scale (VAS) and pressure
Corresponding author. Tel.: +617 33652781; fax: +617 33652775. pain threshold (PPT) and increasing joint range of
E-mail address: [email protected] (B. Vicenzino). movement (ROM) (Vicenzino and Wright, 1995;

1356-689X/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.math.2006.07.011
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38 P. Teys et al. / Manual Therapy 13 (2008) 37–42

O’Brien and Vicenzino, 1998; Chen et al., 1999; Abbott, condition that would exclude the patient from phy-
2001; Abbott et al., 2001; Paungmali et al., 2003a; siotherapy treatment, active inflammatory disease,
Collins et al., 2004). infection, cancer, neuromuscular disorders and fractures
During shoulder movement in participants with no around the shoulder. The participants were also
pathology the humeral head remains relatively centered screened for involvement of the cervical spine that
in the glenoid, predominantly through small translatory may have contributed to the shoulder condition and
glides in the glenoid (Harryman et al., 1990). Earlier excluded if there was evidence of cervical spine referral
studies have identified that altered shoulder kinematics of pain to the shoulder. A physiotherapist who holds a
are associated with shoulder pain (Howell et al., 1988; post-graduate Sports physiotherapy degree and has
Ludewig and Cook, 2000, 2002; Halder et al., 2001). greater than 15 years clinical experience performed all
Kinematic studies of patients with impingement, rotator screening examinations.
cuff tears, loss of capsuloligamentous integrity or Ethical clearance was obtained from the University of
neuromuscular fatigue, have demonstrated abnormal or Queensland’s Medical Research Ethics Committee and
excessive superior and/or anterior translation of the signed informed consent was gained from all partici-
humeral head in the glenoid fossa (Fu et al., 1991; pants prior to their inclusion in the study.
Kamkar and Irrgang, 1993; Flatow et al., 1994). It would
appear that excessive translation of the humeral head 2.2. Outcome measures (dependent variables)
along the glenoid results in pain and functional impair-
ment (Matsen et al., 1993). It has been suggested that the The outcome measures were taken by an investigator
application of a posterior glide MWM to the shoulder skilled in their application and who remained blind to
may correct this fault and allow optimal pain-free motion the allotted treatment condition. The outcome measures
to occur (Mulligan, 1999). Hsu et al. (2000) in a study of used were range of glenohumeral elevation in the plane
11 cadavers, found the application of an anterior– of the scapula and PPT over the anterior shoulder.
posterior glide towards the end of range of abduction
was effective in improving the range of glenohumeral 2.2.1. Pain-free range of movement in the scapular plane
abduction. To date, no studies have investigated the A universal goniometer was used to measure the
effects of the MWM in people with shoulder pain and ROM in the plane of the scapula. This has been shown
reduced ROM. The aim of our study was to evaluate the to demonstrate good intra-tester reliability if consistent
effect of a MWM on shoulder ROM and PPT. landmarks are used (Hayes et al., 2001). The plane of the
scapula is defined as 301 anterior to the coronal plane.
This was calculated by aligning the axis of the
2. Methods goniometer along the superior aspect of the shoulder
and moving one arm of the goniometer 301 forward
A repeated measures, crossover, double-blinded from that frontal plane whilst the other arm of the
randomized, placebo-controlled trial was conducted to goniometer remained in the frontal plane. The patient
evaluate the initial effects of a shoulder MWM on ROM was then asked to move the affected arm in that plane
and PPT. This design was used to reduce the effects of through a small arc of movement short of pain, by
individual variation and strengthen internal validity. aligning the arm movement to a vertical line drawn up
the wall. The line on the wall was used to aid test–retest
2.1. Participants repeatability.
Goniometric measurement of elevation in the plane of
Twenty-four participants (11 males and 13 females) the scapula was achieved by aligning the centre of the
aged between 20 and 64 years (mean 46.1 years goniometer with the centre of the glenohumeral joint,
SD+9.86) were recruited from the general population one arm of the instrument along the lateral border of the
in southeast Queensland. The primary inclusion criter- scapula and the other along the humerus in line with the
ion was the inability to elevate the arm greater than 1001 lateral epicondyle aided by skin markers. A measure of
in the plane of the scapula because of the presence of active ROM was taken. The participant was asked to
pain over the anterior aspect of either shoulder. The move the arm into elevation along the plane of the
duration of the pain had to be greater than one month scapula just to the onset of pain and this process was
to ensure that there was an established shoulder repeated three times. This technique was in accordance
condition and for less than one year so as to limit the with guidelines of goniometric measurement as outlined
study population to those whose pain was not likely to by Moore (Gerhardt, 1992).
be a result of such conditions as recalcitrant frozen
shoulder. The main exclusion criterion was shoulder 2.2.2. Pressure pain threshold
pain that was deemed not to be musculoskeletal in A quantitative measure of pain was obtained by the
origin. Other exclusion criteria were any medical use of pressure pain algometry, which has demonstrated
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P. Teys et al. / Manual Therapy 13 (2008) 37–42 39

good inter- and intra-rater correlation and reliability in other hand was placed over the anterior aspect of the
other studies (Pontinen, 1998). head of the humerus. A posterior gliding force was
The most sensitive point was located over the anterior applied to the humeral head. The participant was then
aspect of the shoulder by manual palpation and marked asked to raise the affected arm in the plane of the
with a permanent marker so that the same point could scapula to the point of pain onset while the therapist
be used for pre- and post-condition application mea- sustained the gliding force to the humeral head, with
sures. As in previous work carried out in this laboratory, care to avoid the sensitive coracoid process. Three sets
(Sterling et al., 2001; Paungmali et al., 2003a; Collins of 10 repetitions were applied with a rest interval of 30 s
et al., 2004) pressure was applied via a digital pressure between each set. The therapist endeavored to maintain
algometer (Somedic AB, Farsta, Sweden) applied the glide at right angles to the plane of movement
perpendicular to the skin at a rate of 40 kPa/s through throughout the entire range. The participant was
a rubber-tipped probe (area 1 cm2). The patient was instructed that the MWM procedure, including arm
instructed to activate a button as soon as a change of elevation, was to be pain free, and must be ceased
sensation from one of pressure to one of pain was immediately if any pain was experienced during the
experienced (threshold of pain). This process was application (Mulligan, 1999; Exelby, 2002).
repeated three times with a 30-s rest period between The sham condition replicated the treatment condi-
each measurement. tion except for the hand positioning. The therapist stood
on the opposite side of the participant and placed one
2.3. Experimental conditions (independent variables) hand along the clavicle and sternum and the other on
the posterior aspect of the humeral head of the affected
There were two independent variables in the research shoulder. A simulated anterior glide was performed but
design; treatment condition and time (pre-, post- with minimal pressure actually applied. The participant
application). Treatment condition had three levels, was asked to elevate the affected shoulder in the plane of
which included the MWM, a sham and a control the scapula through half of their available pain-free
condition. A physiotherapist who was blind to the pre- range to minimize the likelihood of pain provocation.
and post-outcome measures (i.e. played no part in The number of repetitions and sets were as per the
taking the outcome measures) applied all conditions. treatment group.
This physiotherapist held both musculoskeletal and In the control condition the participant was seated for
sports post-graduate degrees with more than 10 years the same length of time but no manual contact between
clinical experience. the therapist and the participant took place.
The treatment condition consisted of the application
of a postero-lateral glide (MWM) to the affected 2.4. Procedure
shoulder (Fig. 1). The participant was seated and the
therapist stood beside the participant on the opposite Participants were initially assessed for their suitability
side to the affected shoulder. One hand was placed over for inclusion in the study and underwent a physical
the scapula posteriorly while the thenar eminence of the screening of the affected shoulder and cervical spine by
an experienced post-graduate Sports physiotherapist
with more than 15 years of clinical experience. This
session was also used to familiarize the participant with
the testing procedures, laboratory environment and
investigators.
Participants attended three sessions at approximately
the same time each day to prevent any diurnal variations
in joint range and pain potentially confounding results
and with at least an intervening 24 h interval to reduce
the influence of any carry-over effect. Testing was
conducted in a temperature and humidity controlled
laboratory. The participants were requested to avoid
factors that may influence their shoulder pain, such as
analgesics and/or anti-inflammatory medication during
the week of testing.
At each experimental session, following the recording
of baseline measures, each participant received one of
Fig. 1. The MWM technique in which the therapist applies a postero-
the three treatment conditions (MWM, sham, control),
lateral glide to the humeral head along the plane of the glenohumeral in a randomized order known only to the treating
joint while stabilizing the scapula with the other hand. therapist. The treatment allocation sequence was block
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40 P. Teys et al. / Manual Therapy 13 (2008) 37–42

randomized using the drawing of lots and concealed test the hypothesis that MWM produced changes in
from the investigator who took the outcome measure- excess of sham and control from pre- to post-application
ments. Following the application, outcome measures (P ¼ 0:05).
were again taken. Participant blinding was facilitated by
recruitment of people who had no experience of the
manipulative therapy techniques applied to the shoulder 5. Results
and by careful instruction that did not refer to the
study’s aims of evaluation of a treatment technique. 5.1. Range of movement
Subjects were informed that the study was investigating
the effects of manual handling on shoulder pain. An exit There was a significant Time by Condition interaction
questionnaire assessed the adequacy of patient blinding. effect for ROM (F ð2;46Þ ¼ 16:3, P ¼ 0:000) with a
Results of the exit questionnaire showed that three significant mean improvement of 161 (P ¼ 0:000) pre-
participants (12%) correctly guessed they had only to post-treatment after the application of the MWM
received active treatment and none had correctly compared with 4 1 (P ¼ 0:06) for the sham application
guessed that they had received either a sham or control. and no change (P ¼ 0:84) for the control condition
(Table 1). The mean differences between the MWM and
Sham (101) and MWM and Control (111) were
3. Reliability statistically different after application; Po:02; where
they were not different at baseline.
Acceptable intra-rater reliability was determined
through analysis of pre- to post-control measures of
ROM and PPT. For this study the intra-class correla- 5.2. Pressure pain threshold
tion coefficient (ICC 2,1) and standard error of the
measurement (SEM) for ROM were estimated to be 0.98 There was a significant Time by Condition interaction
and 1.331 respectively. The ICC 2,1 and the SEM for for PPT (F ð2;46Þ ¼ 3:4, P ¼ 0:04), which demonstrated a
PPT were estimated to be 0.96 and 10.7 kPa respectively. mean improvement of 63 kPa following the application
This indicates that both the size of the error (SEM) and of the MWM (P ¼ 0:000) pre- to post-treatment app-
the ICC are indicative of reliable measures. lication compared with 26 kPa (P ¼ 0:05) for the sham
application and 20 kPa (P ¼ 0:07) for the Control
application. The mean differences between the MWM
4. Data management and analysis and Sham (45 kPa; P ¼ 0:04 and between MWM and
Control (46 kPa; P ¼ 0:02 were statistically significant.
Two independent variables were incorporated into the There were no significant differences pre-application.
research design: treatment (MWM, sham, control) and
time (pre- and post-application). Dependent variables 5.3. Methodological considerations
included ROM and PPT. Prior to analysis, the average
of triplicate measures of ROM and PPT were calculated. There was no loss to follow-up and no adverse effects
A two-factor analysis of variance (ANOVA) and reported. There was no carry-over effect when the pre-
appropriate post-hoc tests of simple effects were then application data for all experiment sessions (i.e. before
performed on each of the two dependent variables to each intervention was applied) were evaluated.

Table 1
The mean (95% CI) for range of movement (ROM) in degrees and pressure pain threshold (PPT) in kPa for the mobilization with movement
treatment technique (MWM), Sham (S) and Control (C). Also included are the mean differences (95% CI) between pre- and post-intervention, as
well as the differences between MWM-S and MWM-C

MWM Mean (95% CI) Condition mean differences (95% CI)

Sham Control MWM-S MWM-C

ROM Pre 102.2 (94.5 to 109.9) 103.9 (96.4 to 111.5) 106.2 (96.9 to 115.5) 1.8 (8.7 to 5.2) 3.9 (11.4 to 3.5)
Post 117.8 (110.2 to 125.5) 107.9 (98.7 to 117.1) 106.4 (96.7 to 116.2) 9.9 (4.3 to 15.6) 11.4 (2.3 to 20.5)
Diff 15.6 (10.1 to 21.1) 3.9 (0.1 to 7.9) 0.27 (2.4 to 3) N/A N/A
PPT Pre 310.8 (258.8 to 362.9) 302.5 (252.3 to 352.6) 307.1 (254.7 to 359.5) 8.4 (27.7 to 44.6) 3.8 (36.7 to 44.2)
Post 373.4 (313.6 to 433.1) 328.3 (275.6 to 381.0) 327.1 (271.1 to 383.0) 45.1 (1.7 to 88.4) 46.3 (9.1 to 83.6)
Diff 62.6 (33.6 to 91.5) 25.9 (0.2 to 51.6) 20 (1.5 to 41.5) N/A N/A
 Denotes a statistical significant difference Po0:05.
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6. Discussion proposed that manipulative therapy may provide

sufficient sensory input to activate the endogenous pain
This study demonstrated that the application of the inhibitory systems. Further studies need to be conducted
Mulligan’s MWM technique to participants with a in the shoulder to determine if endogenous pain
painful restriction of shoulder movement produced an inhibitory systems are involved in manipulation-induced
immediate and significant improvement in ROM and changes of PPT in the shoulder.
PPT pre- to post-intervention when compared to sham The comparison between the MWM and Sham
or control conditions. There are no other published conditions should also take into account that the latter
studies of the effects of this technique on participants limited abduction to half available range: that is, some
with shoulder pain. However, these findings are of the difference between MWM and Sham may be
consistent with studies conducted in other joints of the attributable to the MWM utilizing a greater range of
body that have shown similar effects with the MWM abduction. Certainly, ethically it was undesirable to ask
techniques (O’Brien and Vicenzino, 1998; Abbott et al., participants to experience repeated pain and pragmati-
2001; Paungmali et al., 2003b; Collins et al., 2004). cally it is difficult to ensure compliance with return visits
The clinical relevance of the magnitude of improve- to the experiment if the subject was experiencing
ment in ROM gained following the MWM compared to repeated painful movements at these visits.
the Sham (101) after only one treatment session is A limitation of this study was that only the initial
arguably comparable to 421 improvement in abduction effects of the MWM were measured and the time-course
following four sessions of intensive massage (van den of these effects is as yet unknown. Therefore inferences
Dolden and Roberts, 2003) and 221 improvement after drawn from this study should be limited to those seen in
4–10 sessions of individualized shoulder treatment a single treatment session. Another limitation is that
(mainly exercises) over a month (Ginn et al., 1997). only measures of impairment (ROM, PPT) were made,
Wright (1995) has postulated that the mechanisms but no measures of function or disability. Several case
responsible for manual therapy treatment effects (e.g. as studies/series have shown that continued treatment with
in the increases in ROM and PPT in our study) may a MWM coincided with a resolution of the condition on
feasibly involve changes in the joint, muscle, pain and function and disability measures (Vicenzino and Wright,
motor control systems. In our study the standardized 1995; Hseih et al., 2002; Kochar and Dogra, 2002).
mean difference (SMD) for ROM (1.2) was greater than Further studies to evaluate such issues as the time-
the SMD for PPT (0.9). The change in ROM was not course of the effect of this particular MWM, and the
related to the change in PPT (Pearson’s correlation outcome on disability and function after a course of
coefficient R ¼ 0:29 P ¼ 0:17) possibly indicating that treatment are warranted.
the underlying mechanisms of the MWM may be related
to local joint or muscle structures rather than the pain
system.
7. Conclusion
The technical difference between the MWM and sham
application was that the MWM involved the application The results from this study indicate that the shoulder
of a postero-lateral joint glide while the patient
MWM may be a useful manual therapy technique to
performed an active movement compared with the sham
apply to participants with a painful limitation of
that involved no glide. This data, when considered along
shoulder elevation in order to predominantly gain an
with studies showing that forward translation of the
initial improvement in ROM and PPT.
humeral head painfully limits shoulder movement,
(Ludewig and Cook, 2000) leads us to speculate that
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