Mulligan Concept Mobilisation With Movement for Shoulder Dysfunction in Older Adults
Mulligan Concept Mobilisation With Movement for Shoulder Dysfunction in Older Adults
Objective: To pilot the methods proposed for conducting a full randomised clinical trial to
 evaluate the effect of Mulligan concept mobilization with movement on shoulder functionality
 in older adults with shoulder dysfunction.

 Design: Pilot randomised, single-blinded clinical trial. Setting: Three nursing homes,
 Toledo, Spain. Participants: 44 older adults with shoulder dysfunction. Interventions:
 Participants will be randomly allocated into control group (n=22) treated with a
 physiotherapy standard protocol proposed by the Spanish Rheumatology Society; and
 experimental group (n=22) treated with the same physical therapy standard protocol and
 Mulligan concept mobilisation with movement. Both interventions will take place three times a
 week for 2 consecutive weeks.

 Main outcomes: Primary outcome is shoulder functionality measured with Shoulder Disability
 Questionnaire (S-SDQ) Spanish version, and secondary outcomes are active glenohumeral range
 of motion and pain intensity. Data will be collected at baseline, after each group
 intervention, and 1 and 3 months after finishing interventions.
Shoulder dysfunction is a common problem in older adults reaching up to 21% of prevalence.
 Shoulder symptoms, such as pain and reduced shoulder active range of motion (AROM) and
 function, might be associated to chronic pain, disability and decline in physical performance
 over time. Upper limbs and shoulder joint proper functionality leads to an adequate
 independence in activities of daily living (ADL) and functional performance. Therefore,
 maintaining independence in ADL and functional well-being in older adults should be a
 priority target for health care. A successful therapeutic approach depends on the
 understanding that the aging process is the responsible of major changes involving muscle
 disorders and joint stiffness.

 Among the most common approaches to treating in¬dividuals with shoulder dysfunction,
 physiotherapy interven¬tion is often recommended as the first choice for a conservative
 treatment. Physiotherapy treatment usually includes therapeutic exercises, manual therapy,
 and various modalities and there are controversies about the most effective approach for pain
 reduc¬tion, increase in AROM and function, and decrease in disability in people with shoulder
 dysfunction. There is evidence about the effectiveness of thera¬peutic exercise, and the
 benefit of manual therapy for improvements in mobility and a trend in improving pain
 measures, while increases in function and quality of life are still questionable.

 Some evidence was found about the effects of therapeutic exercise programs for overall
 performance improvement in older adults, but not specifically shoulder dysfunction. Regarding
 manual therapy in elderly, Knebl et al. developed a study about the effectiveness of Spencer
 manipulative technique in shoulder pain and found an improvement in functionality, shoulder
 AROM and pain intensity. Van den Dolder et al. investigated the effect of soft tissue massage
 on shoulder ROM, pain and dysfunction in patients with a mean age of 64 years old and found
 statistically significant results. Therefore, manual therapy techniques may be an option for
 correcting joint mechanics, promoting adhesion removal and restoring passive shoulder
 mobility in older adults.

 Mobilisation with movement (MWM) is a manual therapy technique based on the analysis and
 correction of any minor positional fault in a joint. According to Mulligan, positional faults
 are due to various soft tissue and/or bone lesions in/around the joint and were explained in
 patients with shoulder pain by a kinematic study. This technique aims to realign joints
 positional faults by applying a manually specific oriented glide to a painful joint,
 assessing and adjusting force intensity, while the patient actively performs joint movement,
 so that patient's symptoms are immediately relieved and the maneuvers improve pain and
 movement. Therefore, when a correction mobilization is sustained, pain-free movement is
 restored and several repetitions are performed in order to get an improvement that lasts over
 time. The initial effects of MWM were assessed by Teys et al. in adults; who proved its
 effectiveness in increasing shoulder AROM and decreasing positional faults. Therefore, MWM
 may be an effective technique in physiotherapy treatment for shoulder dysfunction, as this it
 addresses passive and active shoulder structures. However, no studies about MWM effectiveness
 for shoulder dysfunction in older adults have been found.

 The purpose of this pilot clinical trial is to pilot the methods proposed to conduct a full
 randomised controlled clinical trial to determine the effect of Mulligan concept MWM for
 shoulder dysfunction in older adults. The primary objectives are to evaluate the feasibility
 of recruitment, randomisation, retention, assessment procedures, and implementation of
 Mulligan concept MWM intervention. A secondary aim is to undertake a preliminary comparison
 of patient reported-outcomes and to estimate the variability of these outcomes in older
 adults with shoulder dysfunction.
Inclusion Criteria:

 -  to be over 65 years old

 -  diagnosed with shoulder dysfunction (shoulder pain and/or limited AROM in the last 4
 weeks) by their physician

 -  dependent on at least 1 ADL

 -  with a limited glenohumeral AROM of 25% - 75%

 -  resident in the nursing homes where the study took place.

 Exclusion Criteria:

 -  subjects with moderate or severe cognitive impairment

 -  specific rheumatic diseases, osteoarthritis, neoplasms

 -  shoulder joint instability

 -  circulatory disorders (hemophilia, clotting problems)

 -  skin problems aggravated by contact with the skin

 -  traumas in the past month

 -  bilateral shoulder disorders