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Manual Therapy 12 (2007) 3–11

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Review

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

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 ¼ �0:6111).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.

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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

see front matter r 2006 Elsevier Ltd. All rights reserved.

ath.2006.02.011

ing author. P.O. Box 339 (G30), Bloemfontein 9300, South Africa. Tel: +514013297; fax: +51 4013290.

ress: gnftcb.md@mail.uovs.ac.za (C. Brandt).

ARTICLE IN PRESSC. Brandt et al. / Manual Therapy 12 (2007) 3–114

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

Dysfunction of the shoulder girdle is one of the mostcommon musculoskeletal conditions to be treated inprimary care. Thirty-four per cent of the generalpopulation may suffer from shoulder pain at least oncein their lifetime (Green et al., 2002). In addition to thehigh incidence rate, shoulder dysfunction is oftenpersistent and recurrent (Winters et al., 1999).

Physiotherapy for shoulder dysfunction may includemanual 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 theapplication of passive mobilization techniques followingthe convex–concave rule (Kaltenborn and Evjenth, 1989).

The latter approach is based on direct and indirectassessment of translational glides. Using the directmethod, the passive translational gliding movementsare performed by the therapist to the patient’s painfuland/or stiff joint to determine which direction may belimited (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 oftranslational glide was termed the ‘‘Kaltenborn con-vex–concave rule’’ (Kaltenborn and Evjenth, 1989). Thisrule was first described by MacConaill (1953). Followingthis method, the therapist examines active and passivephysiological movements such as flexion, extension,abduction and lateral rotation (Kaltenborn andEvjenth, 1989). The direction of the glide would thenbe determined by considering the geometry of themoving articular surfaces. In the glenohumeral joint,the glenoid fossa (concave surface) was considered to bestable (fixed) while the humeral head (convex surface)would be moved (mobilized) during a physiologicalshoulder movement. According to the convex–concaverule, the convex surface (humeral head) would glidein the opposite direction to the bone movement.Thus, during abduction of the arm, the humeral headwould glide caudally. Kaltenborn and Evjenth (1989)proposed that for restricted shoulder extension andlateral rotation, the humeral head should be glidedventrally (anteriorly), and for restricted flexion andmedial rotation, the humeral head should be glideddorsally (posteriorly).

Kaltenborn and Evjenth (1989) thus based the clinicalreasoning of appropriate direction of translational glidemainly on the anatomy of the osseous articulatingsurfaces. More recently it has been suggested that otherfactors, such as the concept of functional stability(Panjabi, 1992), may also need to be considered in theassessment of the arthrokinematics of the glenohumeraljoint (Hess, 2000). The question thus arose whether theconvex–concave rule is valid in the clinical reasoning of themost appropriate direction of translational glide applied inthe assessment and treatment of shoulder dysfunction.

The aim of this study was to investigate the evidenceon the arthrokinematics of the glenohumeral jointsupporting or negating the validity of the MacConailland 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 weresearched from 1966 to October 2003. The search waslimited to English and human studies. Keywords such asshoulder, glenohumeral, kinematics, arthrokinematics,mechanics, translation(al), roll(-ing) and/or glide(-ing),accessory movement, and Kaltenborn were optimallycombined. The search was continued over a period often months (Hoepfl, 2002).

The titles and the abstracts of the retrieved citationswere screened for relevance by the primary investigator.The reference lists of the relevant articles were checkedby one reviewer to identify additional publications. Fiveclinical experts in the field of shoulder orthopaedics werealso contacted in order to retrieve data (Oxman et al.,1994; Mays and Pope, 1999; Green et al., 2002; Tugwellet al., 2003).

The second screening consisted of the blinded assess-ment of the full papers’ Method and Results sections bytwo independent reviewers. The reports were numbered atrandom and the authors‘ names and affiliations, the nameof the journal, the date of publication, and the acknowl-edgements were erased to ensure blinded assessment. Alltypes of study designs were included in the systematic

ARTICLE IN PRESSC. Brandt et al. / Manual Therapy 12 (2007) 3–11 5

review to increase its clinical value (Mays and Pope, 1999;Elwood, 2002; Hoepfl, 2002; Fritz and Cleland, 2003). Invivo and in vitro studies were assessed. The investigatedpopulation had to be human (male and/or female), a meanage of 15 years or older, with or without shoulderpathology. The study had to investigate a variable factorregarding glenohumeral joint translation and had tomeasure the direction of translation of the humeral headon the glenoid fossa during normal or simulated, active orpassive physiological shoulder movement. The reviewersdecided upon inclusion by means of consensus (Oxman etal., 1994; Jadad et al., 1996).

Data were extracted from the included reports andsummarized on a standardized data collection form bytwo independent, masked reviewers. The form providedfor 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 meansof consensus) as stated in the report. Where data wereunclear and biased recording a possibility, it was clearlyindicated (Scholten-Peeters et al., 2003).

2.2. Quality assessment of the clinical trials

The quality of the clinical trials were assessed by meansof the 11-item Physiotherapy Evidence Database (PEDro)scale which was developed by the Centre for evidence-based Physiotherapy, University of Sydney. The PEDroscale measures the internal validity and the sufficiency ofthe statistical information provided by a clinical trial. Thescale assesses criteria such as random allocation, conceal-ment of allocation, comparibility of groups at baseline,blinding of patients, therapists and assessors, analysis byintention to treat, adequacy of follow-up, between groupstatistical comparisons, report of point estimates, andmeasures of variability. Though the PEDro scale does notusually assess the external validity of a trial, this item fromthe Delphi list (upon which the PEDro scale is based), wasincluded in the assessment. Verhagen et al. (1998)reported that external validity should form part of anyconcept of quality (Verhagen et al., 1998; Woolf, 2000;‘‘PEDro: frequently asked questions’’, 2003).

Two masked reviewers independently scored the qualityof the studies (Jadad et al., 1996; Moher et al., 1996;Dickersin & Berline, 1997). Criteria were rated as yes whenthey were clearly satisfied on reading of the report, as no

when an unbiased decision could be made that the criteriawere not satisfied, and as don’t know when the informationwas 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, aswell as the frequency results on each item were

calculated. A study was considered as high quality if itsatisfied at least 50% of the criteria (X5.5 points)(Maher et al., 2003; Scholten-Peeters et al., 2003). The kstatistic and the 95% confidence level provided formeasurement 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 etal., 1995; Woolf, 2000). The following study characteristicswere compared by two independent reviewers in order toidentify the possibility of statistical pooling of results: (i)the study populations, (ii) the interventions, (iii) the samplesizes, (iv) the availability and format of the results, (v) thestatistical methodology used for analysis, and (vi) thehypotheses tested (Dickersin and Berline, 1997).

2.4. Weighting of the evidence

The strength of the scientific evidence was rated by twoanalysts according to two classification systems (Moheret al., 1996; Elwood, 2002; Mays and Pope, 2002) namely,(i) a hierarchy of evidence (Table 1) relevant to humanhealth studies (Elwood, 2002) and (ii) the modifiedclassification of the Agency for Health Care Policy andResearch (AHCPR) guidelines (Table 2) on acute lowback problems in adults (Ejnisman et al., 2002).

3. Results

3.1. Study characteristics

Fig. 1 depicts the results yielded by the search andselection process. Eighteen clinical trials, seven compara-tive, and five descriptive studies were included in thereview. Summary of the data indicated major methodolo-gical heterogeneity. Researchers used various protocolsand measuring instruments such as magnetic trackingdevices or position sensors (n ¼ 11), three-dimensionalmagnetic 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) forinvestigation. Eleven studies were conducted in vivo and19 in vitro. Movements were either done passively (n ¼ 15)or actively (n ¼ 14); simulated, static or continuous, whilethe plane of motion also varied. Data were gathered oneight different physiological movements performedthrough a variety of ranges of motion. The movementsof active flexion, active extension, and passive horizontalextension were not included in any investigation.

The literature indicated six main factors to explainthe 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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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

Elwood’s 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 case–control 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.

C. Brandt et al. / Manual Therapy 12 (2007) 3–116

(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 thedata extracted on the sample and methodologicalcharacteristics. Disagreement occurred only on thestudy design in two of the studies which was resolvedby means of consensus.

3.2. Methodological quality

The mean PEDro score of the clinical trials equalled51.27%. Table 3 summarizes the individual results. Theinter-rater agreement for quality assessment was poor(k ¼ �0:611). This was confirmed by the 95% con-fidence level of [�0.8661;�0.3562].

3.3. Meta-analysis

Heterogeneity among studies, insufficient reporteddata, and poor study quality precluded statisticalpooling of results.

3.4. Level of the evidence

Twenty-five of the reviewed studies were analysedqualitatively. Five studies were excluded due insufficientinformation provided for classification purposes.

According to Elwood’s classification (Table 1), onestudy fulfilled the criteria for level 2 s evidence, fivefor level 3 and 19 studies for level 4 evidence. Thelevel 2 s evidence found (i) translation to be in theopposite direction during active physiological move-ment in pathological joints and (ii) the humeralhead to remain centered during active physiologi-cal movement in normal joints (Paletta et al., 1997).For all other stratified movement planes, only levels3 and 4 evidence were found. Table 4 summar-izes the amount and level of evidence found on thedirection of the translational movement of the humeralhead.

According to the AHCPR rating system (Table 2),level C evidence is contradictory on the direction oftranslation during active and passive lateral rotation in901 of elevation in normal and reconstructed joints(Karduna et al., 1997; Williams et al., 2001). Onlyinconsistent, level D evidence could be found on thetranslation occurring during physiological movementsin other planes.

Inclusion of only higher quality clinical trials (qualityscore X54.5%) in the weighting of the evidence indu-ced the following changes: according to Elwood‘sclassification, only level 4 evidence was now available,while the level of evidence according to the AHCPRrating system, remained unchanged.

ARTICLE IN PRESS

COMPUTER-BASED SEARCHof 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 articlesreviewed = 30

First screening: retrieved andread 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 availableinternationally

Fig. 1.

C. Brandt et al. / Manual Therapy 12 (2007) 3–11 7

4. Discussion

4.1. Methodological quality of the clinical trials

Analysis of the methodology used by some of theincluded studies lead to serious concerns regarding thebiomechanical and neurophysiological validity of their

results (to be discussed in the next section). According tothe PEDro scale, methodological shortcomings of theclinical trials concerned mostly the insufficient reportingof random allocation, insufficient reporting of conceal-ment of allocation, and insufficient or unclear descrip-tion of blinding of therapists and assessors. This mayindicate that many of the clinical trials were, in fact, not

ARTICLE IN PRESSC. Brandt et al. / Manual Therapy 12 (2007) 3–118

randomized, which may raise some concern regardingthe appropriateness of the PEDro scale for assessingthese trials (Verhagen et al., 1998). It should be noted,though, that poor reporting does not necessarily implythat the criteria were not satisfied during the executionof the trial (Elwood, 2002).

Table 4

Levels of evidence

Physiological movement Direction of translation of humeral head

Same Opposite

Active: normal joints n ¼ 8 n ¼ 2

Level: 3 (n ¼ 1) Level: 3 (n

4 (n ¼ 7) 4 (n

Level: C Level: C

Active: pathological joints n ¼ 7 n ¼ 3

Level: 3 (n ¼ 1) Level: 2s (n

4 (n ¼ 6) 3 (n

4 (n

Level: C Level: C

Passive: normal joints n ¼ 6 n ¼ 2

Level: 3 (n ¼ 1) Level: 3 (n

4 (n ¼ 5) 4 (n

Level: C Level: C

Passive: pathological joints n ¼ 7 n ¼ 3

Level: 3 (n ¼ 1) Level: 4 (n

4 (n ¼ 6)

Level: C Level: C

Levels of evidence are indicated according to Elwood’s classification system

—, No evidence; n ¼ 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) 5

Novotny 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

A quality score of 50–60% have been suggested as acut-off to distinguish between good and poor qualitystudies (Maher et al., 2003; Scholten-Peeters et al.,2003). The mean quality score of 51.27% together withthe poor inter-rater agreement (k ¼ �0:611) necessitatedcareful consideration regarding the methodologicalquality of the included clinical trials (Oxman et al.,1994; Elwood, 2002; Scholten-Peeters et al., 2003).

The best approach when comparing the agreementbetween two raters is to calculate the k statistic. Similarto other methods, such as McNemar’s test which wasalso calculated (0.3103), small frequency tables (in thisstudy n ¼ 30) present difficulties associated with the useand interpretation of kappa (Altman, 1996; Elwood,2002). The problem most cited is that the value of kdepends upon the proportion of subjects in eachcategory. Landis and Koch (1977), as well as Elwood(2002), have characterized ranges of values for kappawith respect to the degree of agreement they suggest.Values greater than 0.75 may be taken to representexcellent agreement beyond chance, values below 0.40may be taken to represent poor agreement beyondchance, and values between 0.40 and 0.75 may be takento 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 theselected studies (n ¼ 17), supported the hypotheses of

Centered Non-uniform

n ¼ 5 —

¼ 1) Level: 2s (n ¼ 1)

¼ 1) 3 (n ¼ 1)

4 (n ¼ 3)

Level: D Level: D

n ¼ 2 —

¼ 1) Level: 4 (n ¼ 2)

¼ 1)

¼ 1)

Level: D Level: D

n ¼ 1 n ¼ 4

¼ 1) Level: 4 (n ¼ 1) Level: 3 (n ¼ 1)

¼ 1) 4 (n ¼ 3)

Level: D Level: D

n ¼ 1 n ¼ 2

¼ 3) Level: 4 (n ¼ 1) Level: 3 (n ¼ 1)

4 (n ¼ 1)

Level: D Level: D

(normal print) and according to the AHCPR’s guidelines (in italics).

ARTICLE IN PRESSC. Brandt et al. / Manual Therapy 12 (2007) 3–11 9

capsulo-ligamentous structures and neuromuscular con-trol influencing the translation of the head of thehumerus (HOH). The capsulo-ligamentous structuresmay be responsible for an obligatory translation of thehumeral head at the end range of motion when thecapsule and/or ligaments are tensioned. This wasespecially observed during passive motion in the absenceof rotator cuff activity (Howell et al., 1988; Harrymanet 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 thestabilizing effect of the rotator cuff on the humeral headcauses 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; Palettaet al., 1997; Apreleva et al., 1998; Rhoad et al., 1998;Graichen et al., 2000; Williams et al., 2001; VonEisenhart-Rothe et al., 2002). Any loss of or defect inthe stabilizing mechanism of the shoulder joint mayincrease or disrupt normal translational patterns,depending on the involved structure and its role in thegliding 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; VonEisenhart-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 mayinfluence the translation of the humeral head (Poppenand 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 MacConailland Kaltenborn, some studies did report that geome-trical factors, such as the size of the humeral head, maydetermine translation. Increased head size seems todistension the capsule and thus reduce translation(Vaesel et al., 1997; Rhoad et al., 1998).

To relate the findings of this review on the translationaldirection of the humeral head to the Kaltenborn rule, thebest evidence will be considered (Elwood, 2002). The level2 s evidence (quality scoreo50%) found translation to bein the opposite direction during active horizontalextension with lateral rotation and in the same directionduring active abduction in anterior unstable joints andjoints with rotator cuff tears. The humeral head remainedcentred during active abduction in normal shoulder joints(Paletta et al., 1997). According to the AHCPRclassification, level C evidence (n ¼ 2, quality scores

450%) were contradicting regarding the translationaldirection during active and passive lateral rotation in 901of elevation in normal and reconstructed joints (Kardunaet al., 1997; Williams et al., 2001).

Considering Table 4, interpretations with regards to theconvex–concave rule need to be made with caution due tothe following limitations: (i) the table is not representativeof all physiological movements since certain motion planeswere not investigated by any of the studies; (ii) findingsregarding the direction of translation were inconsistent fordifferent 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 Kaltenborn‘s rule and theory

Kaltenborn and MacConaill based their hypothesesof normal and abnormal intra-articular dynamics on thegeometry of the articulating surfaces and location of themovement axis alone (MacConaill, 1953; Kaltenbornand Evjenth, 1989). The evidence indicates (i) differentarthrokinematic behaviour for normal and dysfunc-tional joints and (ii) that not only the passive subsystem,but also the active and control subsystems maydetermine intra-articular gliding motion.

It appears that Kaltenborn’s rule for the treatment ofrestricted joint motion may be valid if the intention ofthe treatment is to stretch a tight capsulo-ligamentousstructure causing limitation of the physiological jointmotion. By gliding the humeral head in the oppositedirection of the restricted physiological bone movement,the restricting capsulo-ligamentous structure may bestretched. According to the evidence, however, thismotion performed by the therapist may not necessarilymimic the true gliding taking place due to the tightstructure.

4.4. Implications and recommendations

Clinically authors postulate that the validity of theKaltenborn rule might not be accepted dogmatically.The arthrokinematics of each patient might need to beconsidered in the context of existing neuro-musculoske-letal and biopsychosocial dysfunction which requires theprocess of clinical reasoning. Scientifically such arecommendation still lacks evidence.

Methodologically sound, randomized, clinically con-trolled, in vivo, and homogeneous primary studies areneeded on this subject. As such studies emerge, thisreview should be updated and reproduced. To ensure ameta-analysis in future reviews, the following criterianeed to be considered: (i) movement should be classifiedas active or passive, (ii) the plane and the range ofmotion investigated should be similar, (iii) homogeneouspathologies should be grouped, and (iv) measuring

ARTICLE IN PRESSC. Brandt et al. / Manual Therapy 12 (2007) 3–1110

instruments, exposures or interventions, as well as thehypotheses tested, should be similar.

4.5. Limitations of this review

Bias needs to be considered. Only one reviewer wasinvolved in the initial screening of the 555 citations. Afew articles could not be retrieved internationally andattempts to retrieve unpublished literature yielded noresults.

Working with such considerable amounts of evidencecould not exclude the possibility of including multiplepublications from the same large trial. Careful inspec-tion, though, did not reveal any such errors. Informa-tion from papers concerning the same variables orcohorts, may influence the quality rating of similarpapers later on. Earlier papers can provide the reviewerswith additional information on validity.

This review lacks statistical strength due to thepreclusion of a meta-analysis and the poor kappa valuecalculated for inter-rater agreement. The findings shouldbe interpreted with caution due to the limitations of aqualitative/categorical analysis.

5. Conclusion

Inconsistent evidence, poor methodological qualityand heterogeneity among the reviewed studies precludedthe drawing of any firm conclusions regarding thedirection of translation of the humeral head on theglenoid. The indirect method using Kaltenborn‘s con-vex–concave rule, as applied to the glenohumeral joint,need to be investigated appropriately by primary studiesto determine its validity. It can only be postulated thatnot only the passive subsystem, as proposed by Kalten-born, but also the active and control subsystems mayneed to be considered when determining the direction ofthe translational gliding movement of the humeral head.It is suggested that clinical decisions of appropriategliding directions in the assessment and treatment of apatient with shoulder dysfunction should be consideredcarefully at this stage.

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