SHOULDER AX- KALTERNBORN RULE VALIDATION.pdf

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Manual Therapy 12 (2007) 3–11

www.elsevier.com/locate/math

Review

An evidence-based review on the validity of the Kaltenborn rule as

applied to the glenohumeral joint

Corlia Brandt a, , Gisela Sole b , Maria W. Krause a , Mariette Nel c

a Department of Physiotherapy, Faculty of Health Sciences, University of the Free State, South Africa

b Musculoskeletal and Sports Physiotherapy, School of Physiotherapy, University of Otago, New Zealand

c Department of Biostatistics, Faculty of Health Sciences, University of the Free State, South Africa

Received 25 January 2005; received in revised form 26 January 2006; accepted 15 February 2006

Abstract

Kaltenborn’s convex–concave rule is a familiar concept in joint treatment techniques and arthrokinematics. Recent investigations

on the glenohumeral joint appear to question this rule and thus accepted practice guidelines. An evidence-based systematic review

was conducted to summarize and interpret the evidence on the direction of the accessory gliding movement of the head of the

humerus (HOH) on the glenoid during physiological shoulder movement. Five hundred and eighty-one citations were screened.

Data from 30 studies were summarized in ﬁve evidence tables with good inter-extracter agreement. The quality of the clinical trials

rated a mean score of 51.27% according to the Physiotherapy Evidence Database scale (inter-rater agreement: k ¼0:6111).

Heterogeneity among studies precluded a quantitative meta-analysis. Weighting of the evidence according to Elwood‘s classiﬁcation

and the Agency for Health Care Policy and Research classiﬁcation guidelines indicated that evidence was weak and limited. Poor

methodological quality, weak evidence, heterogeneity and inconsistent ﬁndings among the reviewed studies regarding the direction

of translation of the HOH on the glenoid, precluded the drawing of any ﬁrm conclusions from this review. Evidence, however,

indicated that not only the passive, but also the active and control subsystems of the shoulder may need to be considered when

determining the direction of the translational gliding of the HOH. The indirect method, using Kaltenborn’s convex–concave rule as

applied to the glenohumeral joint, may therefore need to be reconsidered.

Keywords: Glenohumeral; Translational glide; Evidence-based; Kaltenborn

Contents

1. Introduction/background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2. Methodology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2.1. The search strategy and data selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2.2. Quality assessment of the clinical trials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2.3. Meta-analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2.4. Weighting of the evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

3.1. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

3.2. Methodological quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

3.3. Meta-analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

3.4. Level of the evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Corresponding author. P.O. Box 339 (G30), Bloemfontein 9300, South Africa. Tel: +51 4013297; fax: +51 4013290.

E-mail address: gnftcb.md@mail.uovs.ac.za (C. Brandt).

doi: 10.1016/j.math.2006.02.011

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C. Brandt et al. / Manual Therapy 12 (2007) 3–11

4. Discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

4.1. Methodological quality of the clinical trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

4.2. The evidence on the arthrokinematics of the glenohumeral joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

4.3. Relating the ﬁndings to Kaltenborn‘s rule and theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

4.4. Implications and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

4.5. Limitations of this review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1. Introduction/background

Kaltenborn and Evjenth (1989) thus based the clinical

reasoning of appropriate direction of translational glide

mainly on the anatomy of the osseous articulating

surfaces. More recently it has been suggested that other

factors, such as the concept of functional stability

( Panjabi, 1992 ), may also need to be considered in the

assessment of the arthrokinematics of the glenohumeral

joint ( Hess, 2000 ). The question thus arose whether the

convex–concave rule is valid in the clinical reasoning of the

most appropriate direction of translational glide applied in

the assessment and treatment of shoulder dysfunction.

The aim of this study was to investigate the evidence

on the arthrokinematics of the glenohumeral joint

supporting or negating the validity of the MacConaill

and Kaltenborn rule and theory.

Dysfunction of the shoulder girdle is one of the most

common musculoskeletal conditions to be treated in

primary care. Thirty-four per cent of the general

population may suffer from shoulder pain at least once

in their lifetime ( Green et al., 2002 ). In addition to the

high incidence rate, shoulder dysfunction is often

persistent and recurrent ( Winters et al., 1999 ).

Physiotherapy for shoulder dysfunction may include

manual therapy joint techniques to treat pain or stiffness.

Various approaches to treatment have been proposed,

such as the Maitland approach ( Maitland, 1998 ), move-

ment with mobilization ( Mulligan, 1999 ), and the

application of passive mobilization techniques following

the convex–concave rule ( Kaltenborn and Evjenth, 1989 ).

The latter approach is based on direct and indirect

assessment of translational glides. Using the direct

method, the passive translational gliding movements

are performed by the therapist to the patient’s painful

and/or stiff joint to determine which direction may be

limited ( Kaltenborn and Evjenth, 1989 ). Joint mobiliza-

tions would then be performed as a treatment method in

the decreased direction to restore normal movement.

The indirect method of determining the direction of

translational glide was termed the ‘‘Kaltenborn con-

vex–concave rule’’ ( Kaltenborn and Evjenth, 1989 ). This

rule was ﬁrst described by MacConaill (1953) . Following

this method, the therapist examines active and passive

physiological movements such as ﬂexion, extension,

abduction and lateral rotation ( Kaltenborn and

Evjenth, 1989 ). The direction of the glide would then

be determined by considering the geometry of the

moving articular surfaces. In the glenohumeral joint,

the glenoid fossa (concave surface) was considered to be

stable (ﬁxed) while the humeral head (convex surface)

would be moved (mobilized) during a physiological

shoulder movement. According to the convex–concave

rule, the convex surface (humeral head) would glide

in the opposite direction to the bone movement.

Thus, during abduction of the arm, the humeral head

would glide caudally. Kaltenborn and Evjenth (1989)

proposed that for restricted shoulder extension and

lateral rotation, the humeral head should be glided

ventrally (anteriorly), and for restricted ﬂexion and

medial rotation, the humeral head should be glided

dorsally (posteriorly).

2. Methodology

2.1. The search strategy and data selection

An academic, computerized search was conducted.

CINAHL, MEDLINE, The Cochrane Controlled trials

South African Studies and Sport Discussion were

searched from 1966 to October 2003. The search was

limited to English and human studies. Keywords such as

shoulder, glenohumeral, kinematics, arthrokinematics,

mechanics, translation(al), roll(-ing) and/or glide(-ing),

accessory movement, and Kaltenborn were optimally

combined. The search was continued over a period of

ten months ( Hoepﬂ, 2002 ).

The titles and the abstracts of the retrieved citations

were screened for relevance by the primary investigator.

The reference lists of the relevant articles were checked

by one reviewer to identify additional publications. Five

clinical experts in the ﬁeld of shoulder orthopaedics were

also contacted in order to retrieve data ( Oxman et al.,

1994 ; Mays and Pope, 1999 ; Green et al., 2002 ; Tugwell

et al., 2003 ).

The second screening consisted of the blinded assess-

ment of the full papers’ Method and Results sections by

two independent reviewers. The reports were numbered at

random and the authors‘ names and afﬁliations, the name

of the journal, the date of publication, and the acknowl-

edgements were erased to ensure blinded assessment. All

types of study designs were included in the systematic

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C. Brandt et al. / Manual Therapy 12 (2007) 3–11

review to increase its clinical value ( Mays and Pope, 1999 ;

Elwood, 2002 ; Hoepﬂ, 2002 ; Fritz and Cleland, 2003 ). In

vivo and in vitro studies were assessed. The investigated

population had to be human (male and/or female), a mean

age of 15 years or older, with or without shoulder

pathology. The study had to investigate a variable factor

regarding glenohumeral joint translation and had to

measure the direction of translation of the humeral head

on the glenoid fossa during normal or simulated, active or

passive physiological shoulder movement. The reviewers

decided upon inclusion by means of consensus ( Oxman et

al., 1994 ; Jadad et al., 1996 ).

Data were extracted from the included reports and

summarized on a standardized data collection form by

two independent, masked reviewers. The form provided

for the gathering of information on the study design,

subgroups, exposure or intervention, study population,

research methodology, data analysis, main results,

hypotheses, and any other relevant data ( Oxman et al.,

1994 ; Elwood, 2002 ; Scholten-Peeters et al., 2003 ;

Tugwell et al., 2003 ). The data were recorded (by means

of consensus) as stated in the report. Where data were

unclear and biased recording a possibility, it was clearly

indicated ( Scholten-Peeters et al., 2003 ).

calculated. A study was considered as high quality if it

satisﬁed at least 50% of the criteria (X5.5 points)

( Maher et al., 2003 ; Scholten-Peeters et al., 2003 ). The k

statistic and the 95% conﬁdence level provided for

measurement of interobserver agreement ( Maher et al.,

2003 ; Scholten-Peeters et al., 2003 ).

2.3. Meta-analysis

Clinical trials were considered for meta-analysis regard-

less of their quality score in order to reduce bias ( Guyatt et

al., 1995 ; Woolf, 2000 ). The following study characteristics

were compared by two independent reviewers in order to

identify the possibility of statistical pooling of results: (i)

the study populations, (ii) the interventions, (iii) the sample

sizes, (iv) the availability and format of the results, (v) the

statistical methodology used for analysis, and (vi) the

hypotheses tested ( Dickersin and Berline, 1997 ).

2.4. Weighting of the evidence

The strength of the scientiﬁc evidence was rated by two

analysts according to two classiﬁcation systems ( Moher

et al., 1996 ; Elwood, 2002 ; Mays and Pope, 2002) namely,

(i) a hierarchy of evidence ( Table 1 )relevanttohuman

health studies ( Elwood, 2002 ) and (ii) the modiﬁed

classiﬁcation of the Agency for Health Care Policy and

Research (AHCPR) guidelines ( Table 2 ) on acute low

back problems in adults ( Ejnisman et al., 2002 ).

2.2. Quality assessment of the clinical trials

The quality of the clinical trials were assessed by means

of the 11-item Physiotherapy Evidence Database (PEDro)

scale which was developed by the Centre for evidence-

based Physiotherapy, University of Sydney. The PEDro

scale measures the internal validity and the sufﬁciency of

the statistical information provided by a clinical trial. The

scale assesses criteria such as random allocation, conceal-

ment of allocation, comparibility of groups at baseline,

blinding of patients, therapists and assessors, analysis by

intention to treat, adequacy of follow-up, between group

statistical comparisons, report of point estimates, and

measures of variability. Though the PEDro scale does not

usually assess the external validity of a trial, this item from

the Delphi list (upon which the PEDro scale is based), was

included in the assessment. Verhagen et al. (1998)

reported that external validity should form part of any

concept of quality ( Verhagen et al., 1998 ; Woolf, 2000 ;

‘‘PEDro: frequently asked questions’’, 2003 ).

Two masked reviewers independently scored the quality

of the studies ( Jadad et al., 1996 ; Moher et al., 1996 ;

Dickersin & Berline, 1997 ). Criteria were rated as yes when

they were clearly satisﬁed on reading of the report, as no

when an unbiased decision could be made that the criteria

were not satisﬁed, and as don’t know when the information

was insufﬁcient or unclear and a biased decision possible.

Points were allocated for all the clearly satisﬁed items

( Verhagen et al., 1998 ;‘‘PEDro:thePEDro scale’’, 2003).

The mean quality score, the total frequency results, as

well as the frequency results on each item were

3. Results

3.1. Study characteristics

Fig. 1 depicts the results yielded by the search and

selection process. Eighteen clinical trials, seven compara-

tive, and ﬁve descriptive studies were included in the

review. Summary of the data indicated major methodolo-

gical heterogeneity. Researchers used various protocols

and measuring instruments such as magnetic tracking

devicesorpositionsensors(n ¼ 11), three-dimensional

magnetic resonance imaging (n ¼ 4), computertomogra-

phy (n ¼ 3), ultrasonic devices (n ¼ 2), potentiometers

(n ¼ 3), radiographs (n ¼ 6), and arthroscopy (n ¼ 1) for

investigation. Eleven studies were conducted in vivo and

19 in vitro. Movements were either done passively (n ¼ 15)

or actively (n ¼ 14); simulated, static or continuous, while

the plane of motion also varied. Data were gathered on

eight different physiological movements performed

through a variety of ranges of motion. The movements

of active ﬂexion, active extension, and passive horizontal

extension were not included in any investigation.

The literature indicated six main factors to explain

the translational behaviour of the humeral head namely,

the inﬂuence of (i) the capsulo-ligamentous structu-

res (n ¼ 17), (ii) neuromuscular control (n ¼ 17),

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C. Brandt et al. / Manual Therapy 12 (2007) 3–11

Table 1

Elwood’s hierarchy of evidence

Level Deﬁnition of type of evidence

Randomized intervention trials, properly performed on an adequate number of subjects, in a human situation.

Results from a meta-analysis of trials.

One or more individual trials.

Observational studies, namely cohort and case–control designs, of appropriately selected groups of subjects.

Results from a meta-analysis of such studies.

One or more individual studies.

Comparative studies that compares groups of subjects representative of different populations or subject groups. For example:

correlation studies of populations in which data on each individual are not assessed separately and informal comparisons between

patients.

Case series, descriptive studies, professional experience. The evidence is largely anecdotal, unsystematically recollected (for example

‘‘clinical judgement’’ and ‘‘experience’’), conclusions based on traditional practice, information derived from other species, in vitro

testing, basic physiological principles and indirect assessments.

Table 2

The modiﬁed classiﬁcation of the AHCPR guidelines on acute low back problems in adults

Level

Deﬁnition of type of evidence

Strong research-based evidence provided by generally consistent ﬁndings in multiple (more than one) high-quality randomized

clinical trial (RCT).

Moderate research-based evidence provided by generally consistent ﬁndings in one high-quality RCT and one or more low-quality

RCT, or generally consistent ﬁndings in multiple low quality RCTs.

Limited research-based evidence provided by one RCT (either high or low quality) or inconsistent or contradictory evidence

ﬁndings in multiple RCTs.

No research-based evidence: no RCTs.

(iii) articular geometry/congruency/conformity (n ¼ 8),

(iv) negative intra-articular pressure (n ¼ 4), (v) rigidi-

ﬁcation of musculature (n ¼ 1), and (vi) gravity (n ¼ 1).

Agreement between the reviewers were 100% for the

data extracted on the sample and methodological

characteristics. Disagreement occurred only on the

study design in two of the studies which was resolved

by means of consensus.

According to Elwood’s classiﬁcation ( Table 1 ), one

study fulﬁlled the criteria for level 2 s evidence, ﬁve

for level 3 and 19 studies for level 4 evidence. The

level 2 s evidence found (i) translation to be in the

opposite direction during active physiological move-

ment in pathological joints and (ii) the humeral

head to remain centered during active physiologi-

cal movement in normal joints ( Paletta et al., 1997 ).

For all other stratiﬁed movement planes, only levels

3 and 4 evidence were found. Table 4 summar-

izes the amount and level of evidence found on the

direction of the translational movement of the humeral

head.

According to the AHCPR rating system ( Table 2 ),

level C evidence is contradictory on the direction of

translation during active and passive lateral rotation in

901 of elevation in normal and reconstructed joints

( Karduna et al., 1997 ; Williams et al., 2001 ). Only

inconsistent, level D evidence could be found on the

translation occurring during physiological movements

in other planes.

Inclusion of only higher quality clinical trials (quality

score X54.5%) in the weighting of the evidence indu-

ced the following changes: according to Elwood‘s

classiﬁcation, only level 4 evidence was now available,

while the level of evidence according to the AHCPR

rating system, remained unchanged.

3.2. Methodological quality

The mean PEDro score of the clinical trials equalled

51.27%. Table 3 summarizes the individual results. The

inter-rater agreement for quality assessment was poor

(k ¼0:611). This was conﬁrmed by the 95% con-

ﬁdence level of [0.8661;0.3562].

3.3. Meta-analysis

Heterogeneity among studies, insufﬁcient reported

data, and poor study quality precluded statistical

pooling of results.

3.4. Level of the evidence

Twenty-ﬁve of the reviewed studies were analysed

qualitatively. Five studies were excluded due insufﬁcient

information provided for classiﬁcation purposes.

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C. Brandt et al. / Manual Therapy 12 (2007) 3–11

COMPUTER-BASED SEARCH

of databases: 555 citations

6 articles not available

internationally

First screening: retrieved and

read 56 articles

Articles included for quality

assessment = 11

21 articles were selected,

summarized, and data extracted

10 articles were excluded from

quality assessment because of

study design

REFERENCE CHECKING : 26

articles identified, 21 retrieved

and screened

5 articles not available

internationally

Articles included for quality

assessment = 7

9 articles were selected,

summarized, and data extracted

2 articles were excluded from

quality assessment because of

study design

RESPONSE FROM EXPERTS :

00 articles

Total relevant articles

reviewed = 30

Fig. 1.

4. Discussion

results (to be discussed in the next section). According to

the PEDro scale, methodological shortcomings of the

clinical trials concerned mostly the insufﬁcient reporting

of random allocation, insufﬁcient reporting of conceal-

ment of allocation, and insufﬁcient or unclear descrip-

tion of blinding of therapists and assessors. This may

indicate that many of the clinical trials were, in fact, not

4.1. Methodological quality of the clinical trials

Analysis of the methodology used by some of the

included studies lead to serious concerns regarding the

biomechanical and neurophysiological validity of their

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