Validez Regla Kalterborn en Glenohumeral

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Manual Therapy 12 (2007) 311

Review

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

applied to the glenohumeral joint

Corlia Brandta,, Gisela Soleb, Maria W. Krausea, Mariette Nelc

aDepartment of Physiotherapy, Faculty of Health Sciences, University of the Free State, South AfricabMusculoskeletal and Sports Physiotherapy, School of Physiotherapy, University of Otago, New Zealand

cDepartment 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

Kaltenborns convexconcave 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 0:6111).

Heterogeneity among studies precluded a quantitative meta-analysis. Weighting of the evidence according to Elwoods 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 Kaltenborns convexconcave rule asapplied to the glenohumeral joint, may therefore need to be reconsidered.

r 2006 Elsevier Ltd. All rights reserved.

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52.3. 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

ARTICLE IN PRESS

www.elsevier.com/locate/math

1356-689X/$- see front matter r 2006 Elsevier Ltd. All rights reserved.

doi:10.1016/j.math.2006.02.011

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

E-mail address: [email protected] (C. Brandt).
http://www.elsevier.com/locate/mathhttp://dx.doi.org/10.1016/j.math.2006.02.011mailto:[email protected]:[email protected]://dx.doi.org/10.1016/j.math.2006.02.011http://www.elsevier.com/locate/math


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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 Kaltenborns 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

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 convexconcave 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 patients 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 inthe decreased direction to restore normal movement.

The indirect method of determining the direction of

translational glide was termed the Kaltenborn con-

vexconcave 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 convexconcave

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).

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

convexconcave 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.

2. Methodology

2.1. The search strategy and data selection

An academic, computerized search was conducted.

CINAHL, MEDLINE, The Cochrane Controlled trialsregister of randomized controlled trials, Kovsiedex,

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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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 tomeasure 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).

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 ofthe 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 dont 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: the PEDro scale, 2003).

The mean quality score, the total frequency results, as

well as the frequency results on each item were

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) relevant to human

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).

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

devices or position sensors (n 11), three-dimensional

magnetic resonance imaging (n 4), computertomogra-

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

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

investigation. Eleven studies were conducted in vivo and

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

or actively (n 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 17), (ii) neuromuscular control (n 17),

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

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

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

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 0:611). 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.

According to Elwoods classification (Table 1), one

study fulfilled the criteria for level 2 s evidence, five

for level 3 and 19 studies for level 4 evidence. Thelevel 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 Elwoods

classification, only level 4 evidence was now available,

while the level of evidence according to the AHCPR

rating system, remained unchanged.

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Table 2

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

Level Definition of type of evidence

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

clinical trial (RCT).

B 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.

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

findings in multiple RCTs.

D No research-based evidence: no RCTs.

Table 1

Elwoods hierarchy of evidence

Level Definition of type of evidence

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

1m Results from a meta-analysis of trials.

1s One or more individual trials.

2 Observational studies, namely cohort and casecontrol designs, of appropriately selected groups of subjects.

2m Results from a meta-analysis of such studies.

2s One or more individual studies.

3 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.

4 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.



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4. Discussion

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

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

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COMPUTER-BASED SEARCH

of databases: 555 citations

REFERENCE CHECKING: 26articles identified, 21 retrieved

and screened

5 articles not availableinternationally

Articles included for qualityassessment = 7

2 articles were excluded fromquality assessment because of

study design

9 articles were selected,summarized, and data extracted

RESPONSE FROM EXPERTS:00 articles

Total relevant articles

reviewed = 30

First screening: retrieved and

read 56 articles

21 articles were selected,summarized, and data extracted

Articles included for qualityassessment = 11

10 articles were excluded fromquality assessment because of

study design

6 articles not available

internationally

Fig. 1.



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randomized, which may raise some concern regarding

the appropriateness of the PEDro scale for assessing

these trials (Verhagen et al., 1998). It should be noted,

though, that poor reporting does not necessarily imply

that the criteria were not satisfied during the execution

of the trial (Elwood, 2002).

A quality score of 5060% have been suggested as a

cut-off to distinguish between good and poor quality

studies (Maher et al., 2003; Scholten-Peeters et al.,

2003). The mean quality score of 51.27% together with

the poor inter-rater agreement (k 0:611) necessitated

careful consideration regarding the methodological

quality of the included clinical trials (Oxman et al.,1994; Elwood, 2002; Scholten-Peeters et al., 2003).

The best approach when comparing the agreement

between two raters is to calculate the k statistic. Similar

to other methods, such as McNemars test which was

also calculated (0.3103), small frequency tables (in this

study n 30) present difficulties associated with the use

and interpretation of kappa (Altman, 1996; Elwood,

2002). The problem most cited is that the value of k

depends upon the proportion of subjects in each

category. Landis and Koch (1977), as well as Elwood

(2002), have characterized ranges of values for kappa

with respect to the degree of agreement they suggest.

Values greater than 0.75 may be taken to represent

excellent agreement beyond chance, values below 0.40

may be taken to represent poor agreement beyond

chance, and values between 0.40 and 0.75 may be taken

to represent fair to good agreement beyond chance.

4.2. The evidence on the arthrokinematics of the

glenohumeral joint

The best evidence (level 2 s), as well as many of the

selected studies (n 17), supported the hypotheses of

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Table 4Levels of evidence

Physiological movement Direction of translation of humeral head

Same Opposite Centered Non-uniform

Active: normal joints n 8 n 2 n 5

Level: 3 (n 1) Level: 3 (n 1) Level: 2s (n 1)

4 (n 7) 4 (n 1) 3 (n 1)

4 (n 3)

Level: C Level: C Level: D Level: D

Active: pathological joints n 7 n 3 n 2

Level: 3 (n 1) Level: 2s (n 1) Level: 4 (n 2)

4 (n 6) 3 (n 1)

4 (n 1)


Passive: normal joints n 6 n 2 n 1 n 4

Level: 3 (n 1) Level: 3 (n 1) Level: 4 (n 1) Level: 3 (n 1)

4 (n 5) 4 (n 1) 4 (n 3)


Passive: pathological joints n 7 n 3 n 1 n 2

Level: 3 (n 1) Level: 4 (n 3) Level: 4 (n 1) Level: 3 (n 1)

4 (n 6) 4 (n 1)


Levels of evidence are indicated according to Elwoods classification system (normal print) and according to the AHCPRs guidelines (in italics).

, No evidence; n amount of studies.

Table 3

Summary of the quality scores of clinical trials

Study Mean quality scores

(out of 11)

Level 2s evidence

Paletta et al. 1997 5

Level 4 evidence

Karduna et al. (1997) 7

Harryman et al. (1992) 6

Harryman et al. (1990) 6

McMahon et al. (1995) 4.5

Gohlke et al. (1994) 6

Vaesel et al. (1997) 5Novotny et al. (1998) 4.5

Williams et al. (2001) 6.5

Apreleva et al. (1998) 6

Wuelker et al. (1994) 6

Loehr et al. (1994) 5

Karduna et al. (1996) 6

Thompson et al. (1996) 5

Helmig et al. (1993) 6

Wuelker et al. (1998) 6

Debski et al. (1995) 5

Total mean score 5.64



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capsulo-ligamentous structures and neuromuscular con-

trol influencing the translation of the head of the

humerus (HOH). The capsulo-ligamentous structures

may be responsible for an obligatory translation of the

humeral head at the end range of motion when the

capsule and/or ligaments are tensioned. This was

especially observed during passive motion in the absenceof rotator cuff activity (Howell et al., 1988; Harryman

et al., 1990, 1992; Gohlke et al., 1994; Debski et al.,

1995; Karduna et al., 1996, 1997; Paletta et al., 1997;

Novotny et al., 1998; Rhoad et al., 1998; Baeyens et al.,

2000; Williams et al., 2001). During active movement the

stabilizing effect of the rotator cuff on the humeral head

causes a centring motion (Poppen and Walker, 1976;

Howell et al., 1988; Gohlke et al., 1994; Wuelker et al.,

1994, 1998; Debski et al., 1995; Karduna et al., 1996;

Thompson et al., 1996; Karduna et al., 1997; Paletta

et al., 1997; Apreleva et al., 1998; Rhoad et al., 1998;

Graichen et al., 2000; Williams et al., 2001; Von

Eisenhart-Rothe et al., 2002). Any loss of or defect in

the stabilizing mechanism of the shoulder joint may

increase or disrupt normal translational patterns,

depending on the involved structure and its role in the

gliding of the humeral head (Poppen and Walker, 1976,

1978; McGlynn and Caspari, 1984; Howell et al., 1988;

Ozaki, 1989; Harryman et al., 1990; Helmig et al., 1993;

Loehr et al., 1994; Debski et al., 1995; McMahon et al.,

1995; Deutsch et al., 1996; Thompson et al., 1996;

Karduna et al., 1997; Paletta et al., 1997; Apreleva et al.,

1998; Novotny et al., 1998; Wuelker et al., 1998;

Baeyens et al., 2000, 2001; Graichen et al., 2000; Von

Eisenhart-Rothe et al., 2002). Pain, muscle spasm, andloss of proprioception associated with shoulder dysfunc-

tion may lead to neurophysiological responses. Imbal-

ance/incoordination of the shoulder musculature may

influence the translation of the humeral head (Poppen

and Walker, 1976; Wuelker et al., 1994, 1998; Bertoft,

1999; Graichen et al., 2000; Von Eisenhart-Rothe et al.,

2002).

In correllation with the original theory of MacConaill

and Kaltenborn, some studies did report that geome-

trical factors, such as the size of the humeral head, may

determine translation. Increased head size seems to

distension the capsule and thus reduce translation

(Vaesel et al., 1997; Rhoad et al., 1998).

To relate the findings of this review on the translational

direction of the humeral head to the Kaltenborn rule, the

best evidence will be considered (Elwood, 2002). The level

2 s evidence (quality scoreo50%) found translation to be

in the opposite direction during active horizontal

extension with lateral rotation and in the same direction

during active abduction in anterior unstable joints and

joints with rotator cuff tears. The humeral head remained

centred during active abduction in normal shoulder joints

(Paletta et al., 1997). According to the AHCPR

classification, level C evidence (n 2, quality scores

450%) were contradicting regarding the translational

direction during active and passive lateral rotation in 901

of elevation in normal and reconstructed joints (Karduna

et al., 1997; Williams et al., 2001).

Considering Table 4, interpretations with regards to the

convexconcave rule need to be made with caution due to

the following limitations: (i) the table is not representativeof all physiological movements since certain motion planes

were not investigated by any of the studies; (ii) findings

regarding the direction of translation were inconsistent for

different physiological motion planes, and (iii) hetero-

geneous shoulder pathologies were grouped together,

although these may affect translation in different manners

(Burkhart, 1994; Meister, 2000).

4.3. Relating the findings to Kaltenborns rule and theory

Kaltenborn and MacConaill based their hypotheses

of normal and abnormal intra-articular dynamics on the

geometry of the articulating surfaces and location of the

movement axis alone (MacConaill, 1953; Kaltenborn

and Evjenth, 1989). The evidence indicates (i) different

arthrokinematic behaviour for normal and dysfunc-

tional joints and (ii) that not only the passive subsystem,

but also the active and control subsystems may

determine intra-articular gliding motion.

It appears that Kaltenborns rule for the treatment of

restricted joint motion may be valid if the intention of

the treatment is to stretch a tight capsulo-ligamentous

structure causing limitation of the physiological joint

motion. By gliding the humeral head in the opposite

direction of the restricted physiological bone movement,the restricting capsulo-ligamentous structure may be

stretched. According to the evidence, however, this

motion performed by the therapist may not necessarily

mimic the true gliding taking place due to the tight

structure.

4.4. Implications and recommendations

Clinically authors postulate that the validity of the

Kaltenborn rule might not be accepted dogmatically.

The arthrokinematics of each patient might need to be

considered in the context of existing neuro-musculoske-

letal and biopsychosocial dysfunction which requires the

process of clinical reasoning. Scientifically such a

recommendation still lacks evidence.

Methodologically sound, randomized, clinically con-

trolled, in vivo, and homogeneous primary studies are

needed on this subject. As such studies emerge, this

review should be updated and reproduced. To ensure a

meta-analysis in future reviews, the following criteria

need to be considered: (i) movement should be classified

as active or passive, (ii) the plane and the range of

motion investigated should be similar, (iii) homogeneous

pathologies should be grouped, and (iv) measuring

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instruments, exposures or interventions, as well as the

hypotheses tested, should be similar.

4.5. Limitations of this review

Bias needs to be considered. Only one reviewer was

involved in the initial screening of the 555 citations. Afew articles could not be retrieved internationally and

attempts to retrieve unpublished literature yielded no

results.

Working with such considerable amounts of evidence

could not exclude the possibility of including multiple

publications from the same large trial. Careful inspec-

tion, though, did not reveal any such errors. Informa-

tion from papers concerning the same variables or

cohorts, may influence the quality rating of similar

papers later on. Earlier papers can provide the reviewers

with additional information on validity.

This review lacks statistical strength due to the

preclusion of a meta-analysis and the poor kappa value

calculated for inter-rater agreement. The findings should

be interpreted with caution due to the limitations of a

qualitative/categorical analysis.

5. Conclusion

Inconsistent evidence, poor methodological quality

and heterogeneity among the reviewed studies precluded

the drawing of any firm conclusions regarding the

direction of translation of the humeral head on the

glenoid. The indirect method using Kaltenborns con-vexconcave rule, as applied to the glenohumeral joint,

need to be investigated appropriately by primary studies

to determine its validity. It can only be postulated that

not only the passive subsystem, as proposed by Kalten-

born, but also the active and control subsystems may

need to be considered when determining the direction of

the translational gliding movement of the humeral head.

It is suggested that clinical decisions of appropriate

gliding directions in the assessment and treatment of a

patient with shoulder dysfunction should be considered

carefully at this stage.

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