Iseki Hydraulic Manual Patient

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Published online 2016 Aug 31. doi: 10.1589/jpts.28.2393
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Iseki Hydraulic Manual Patient


[Purpose] This study aimed to develop a clinical protocol for the treatment of frozenshoulder using applied hydraulic distension plus manual therapy. [Subjects and Methods]Patients were randomly assigned to 2 groups: 60 patients in group A were treated withhydraulic distension plus manual therapy, and 61 in group B were treated with hydraulicdistension alone. Treatment effects were assessed using the Visual Analog Scale (VAS)(pain and satisfaction), and active range of motion of the shoulder (forward flexion,internal and external rotation) before treatments and at 2, 6, 12, 24 weeks, and 1 yearafter the last injections. [Results] Patients in group A achieved faster pain relief andbetter satisfaction than patients in group B during the 6 weeks after treatment. However,no significant difference in VAS was observed between the groups at final follow-up. AROMof the shoulder was improved at final follow-up in both groups. [Conclusion] Hydraulicdistension plus manual therapy provided faster pain relief, a higher level of patientsatisfaction, and an earlier improvement in AROM of the shoulder than hydraulic distensionalone in patients with frozen shoulder.

Key words: Hydraulic distension, Manual therapy, Frozen shoulder


The main symptoms of a frozen shoulder are pain and stiffness in the glenohumeraljoint). It has been reported that 40% offrozen shoulder patients without proper treatment suffered from persistent pain and limitedrange of motion, and 11% showed permanent shoulder dysfunction, ).

The primary therapeutic approaches to frozen shoulder include conservative treatments suchas physical therapy, nonsteroidal anti-inflammatory medication, and intra- or subacromialsteroid injection, ). However, the use of invasive approaches such as hydraulicdistension and manual therapy by a physical therapist is considered when the patient doesnot want long-term conservative treatment or does not show signs of recovery despitetreatment for a period of time, ). However, there is a lack of evidence for the effect ofconservative treatment, and invasive methods are controversial).

Therefore, the purpose of this study was to analyze the clinical results and efficacy ofhydraulic distension plus manual therapy on patients with a frozen shoulder and to develop auseful clinical protocol.


The study was approved by KONIBP (Korea National Institute for Bioethics Policy) and allthe participants provided written informed consent. A total of 140 patients with frozenshoulders were registered as the subjects for this prospective randomized study, which wasconducted from April 2013 to January 2015. The inclusion criteria were as follows: age 19 to70 years, symptoms lasting more than 3 months, pain and limitation in range of motion in atleast 2 directions (less than 120° of forward flexion and less than 50% of normal internaland external rotation on the normal side), and no special abnormal findings on radiographicstudy). Those with a diagnosis otherthan frozen shoulder, such as osteoarthritis, cervical disorders, or history of shoulderinjury, were excluded.

Of 140 subjects, 11 were excluded before the test. In addition, 6 patients met theexclusion criteria and 2 were absent from the experiment. Therefore, 121 patients withfrozen shoulder were divided into 2 groups according to a randomized controlled statisticalprogram processed by another researcher.

Table 1 shows the general characteristics of the subjects. The 60 patients in group Areceived 30 minutes of manual therapy by a physical therapist 3 times a day, for 4 weeksafter hydraulic distension. Manual therapy based on the Kaltenborn-Evjenth concept wasapplied, based on the patient’s symptom duration, because there is no official guideline formanual therapy for frozen shoulder. The patients then performed home rehabilitationexercise. The 61 patients in group B performed home rehabilitation exercise after hydraulicdistension. Both groups were provided with a home-based exercise program guidebook beforeexercise.

Table 1.

CharacteristicGroup AGroup B
Number of patients6061
Gender (male/female)25/3520/41
Age (yrs)52.1 ± 6.4a53.9 ± 5.9a
Duration (mo)6.7 ± 2.36.3 ± 2.1
Side (dom/nondom) 45/1546/15

aMean ± SD. dom: dominant; nondom: nondominant

Pain index and satisfaction level were evaluated with the Visual Analog Scale (VAS) in eachmeasurement period. For the range of motion (ROM), the active ranges of forward flexion,external rotation, and internal rotation were measured 3 times with a goniometer bendingiron (29–5900, Pakistan) using a standardized method, and the mean value was calculated).

For the statistical analysis, demographic characteristics of the subject were analyzed withthe χ2 test and independent t-test. A repeated measures analysis of variance(ANOVA) was used to examine the differences between the measuring periods. This study usedan independent t-test to analyze the differences between the groups in each period.Statistical analysis was performed using PASW Statistics Version 18.0 Windows (SPSS Inc.,Chicago, IL, USA). The statistical significance level was set to α=0.05.


Both groups showed similarities in average ages, symptom duration, gender distribution, anddominant shoulder. There was no statistically significant difference in generalcharacteristics (Table 1).

The pain index decreased more rapidly in group A and the difference between the groups wasmaintained until 12 weeks after treatment (p<0.05). However, the difference between thegroups at 1 year after treatment was not significant. The satisfaction level increased morerapidly in group A and the difference between the groups was maintained until 6 weeks aftertreatment (p<0.05). However, the difference between the groups at 1 year after treatmentwas not significant (Table 2).

Table 2.

VASGroupBefore2 wk6 wk12 wk6 mon1 year
Pain*A6.8 ± 1.0a2.4 ± 1.22.0 ± 0.81.8 ± 0.51.8 ± 0.81.6 ± 0.9
B6.6 ± 1.24.9 ± 0.74.2 ± 0.72.7 ± 0.91.9 ± 0.91.7 ± 0.7
Satisfaction*A1.8 ± 1.16.9 ± 0.97.1 ± 1.07.3 ± 0.97.6 ± 0.97.6 ± 1.1
B1.7 ± 0.74.5 ± 1.14.8 ± 1.16.9 ± 0.97.5 ± 0.97.5 ± 1.0

aMean ± SD. *Significantly different from baseline (p<0.05). Significantly different between the groups (p<0.05)

The range of forward flexion increased more rapidly in group A and the difference betweenthe groups was maintained until 6 weeks after treatment (p<0.05). However, the differencebetween the groups at 1 year after treatment was not significant. The ranges of externalrotation and internal rotation also increased more rapidly in group A, and the differencesbetween the groups were maintained until 6 weeks after treatment (p<0.05). However, thedifferences in the ranges of external rotation and internal rotation between the groups at1 year after treatment were not significant (Table3).

Table 3.

Range of motion for each treatment group over time
ROMGroupBefore2 wk6 wk12 wk6 mon1 year
FF*A96.3 ± 17.5a132.6 ± 17.2144.5 ± 15.0154.6 ± 13.2161.5 ± 12.1169.0 ± 10.1
B97.4 ± 13.6123.2 ± 11.7133.6 ± 19.0153.4 ± 12.1160.9 ± 11.8168.2 ± 9.1
ER*A16.7 ± 5.645.8 ± 10.647.7 ± 8.254.5 ± 9.057.7 ± 8.766.8 ± 11.3
B19.0 ± 7.027.8 ± 7.031.7 ± 7.051.2 ± 10.154.2 ± 7.762.5 ± 8.2
IR*A11.5 ± 1.315.5 ± 1.816.0 ± 1.616.9 ± 1.417.9 ± 2.219.0 ± 1.7
B11.4 ± 1.013.1 ± 1.814.0 ± 2.116.5 ± 1.317.5 ± 2.018.5 ± 1.6

aMean ± SD. FF: forward flexion; ER: external rotation; IR: internal rotation. *Significantly different from baseline (p<0.05). Significantly different between the groups (p<0.05)


This study analyzed the effect of hydraulic distension plus manual therapy in patients withfrozen shoulder by comparing the differences between hydraulic distension plus manualtherapy and hydraulic distension alone. From 6 weeks to 12 weeks after treatment, thehydraulic distension plus manual therapy group showed a more rapid decrease in pain,increase in patient satisfaction, and improvement in range of motion than the other group.In addition, both groups showed significant increases in the pain index, satisfaction level,and range of motion after treatment at each time period. However, both groups showed similarresults at 1 year after treatment.

A study by Russell et al.) showed that 75patients with frozen shoulder who underwent manual therapy including a home-based exerciseprogram had a satisfactory result. Harmon and Hearty) reported that suprascapular nerve block without manual therapy waseffective for temporary relief of pain in patients with frozen shoulder, but did not improvethe range of motion. Clinical results for various conservative treatments have beenreported, but most showed a short-term treatment effect of less than 6 months. However,patients with frozen shoulder received conventional conservative treatment and were observedfor 1 year, with positive treatment results. There are few studies related to frozenshoulder treatment that included hydraulic distension with manual therapy and compared themprospectively. This study produced results similar to those of previous studies, that is,rapid onset of treatment effects and maintenance until 6 weeks after hydraulic distensionplus manual therapy of the pain index, satisfaction level, and range of motion). These results occurred because hydraulicdistension performed with manual therapy induced increased joint volume in a short time,permitting sufficient joint movement).

Limitations of this study included the low accuracy of the diagnosis of frozen shoulder anddifferent individual symptom durations among subjects. This study was based on physicalexamination, medical history, and imaging diagnosis, but it was very hard to differentiatefrozen shoulder from other shoulder diseases. However, the results of this study seemsignificant due to the long-term (1 year) observation.

Hydraulic distension plus manual therapy decreased shoulder pain and improved shoulderfunction. Specifically, pain, satisfaction, and range of motion showed quick improvementfrom 6 weeks to 12 weeks after treatment. The treatment results of this study can be usedfor frozen shoulders. Various manual therapies for a frozen shoulder should be performed toanalyze persistence of clinical efficacy in further studies.


1. Neviaser AS, Hannafin JA: Adhesive capsulitis: a review of currenttreatment. Am J Sports Med, 2010,38: 2346–2356. [PubMed] [Google Scholar]

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