The Combined Effect of Mulligan Mobilization, Pain Neuroscience-Based Training, and Core Stabilization Exercises in Frozen Shoulder Patients

The purpose of this randomized controlled study is to investigate the effects of a combined rehabilitation program consisting of Mulligan Mobilization with Movement (MWM), Pain Neuroscience Education (PNE), and core stabilization exercises in individuals with adhesive capsulitis (frozen shoulder).

The main questions this study aims to answer are:

Does the combination of Mulligan mobilization, Pain Neuroscience Education, and core stabilization exercises reduce pain in individuals with adhesive capsulitis? Does this combined intervention improve shoulder range of motion, shoulder function, quality of life, scapular dyskinesis, and pain catastrophizing compared with conventional physical therapy?

Participants diagnosed with adhesive capsulitis will be randomly assigned to one of two groups. The intervention group will receive Mulligan mobilization, Pain Neuroscience Education, and core stabilization exercises, while the control group will receive conventional physical therapy, including TENS, hot-pack application, passive joint mobilization, and stretching exercises. Both groups will participate in treatment sessions three times per week for six weeks. Outcome measures will be assessed at baseline and after completion of the 6-week intervention period.

Study Overview

• Status: Recruiting
• Conditions: Frozen Shoulder
• Intervention / Treatment: Behavioral: Pain Neuroscience Education (PNE); Procedure: Mulligan Mobilization With Movement (MWM); Behavioral: Core Stabilization Exercises; Other: Conventional Physical Therapy

Detailed Description

Adhesive capsulitis, commonly known as frozen shoulder, is a musculoskeletal disorder characterized by shoulder pain, progressive restriction of active and passive range of motion, and functional disability. The condition negatively affects activities of daily living and quality of life and is most frequently observed in individuals between 40 and 65 years of age. Despite the widespread use of conventional physiotherapy interventions, optimal treatment strategies remain under investigation.

Mulligan Mobilization with Movement (MWM) is a manual therapy technique that combines sustained accessory joint glides with active pain-free movement. Previous studies have demonstrated beneficial effects of Mulligan mobilization on pain reduction and functional improvement in individuals with adhesive capsulitis. Pain Neuroscience Education (PNE) is an educational approach designed to improve patients' understanding of pain mechanisms and reduce maladaptive beliefs related to pain. Core stabilization exercises, particularly those based on Dynamic Neuromuscular Stabilization (DNS) principles, aim to improve postural control, neuromuscular coordination, and movement efficiency.

Although the effectiveness of Mulligan mobilization has been investigated in patients with adhesive capsulitis, there is limited evidence regarding the use of Pain Neuroscience Education in this population, and the effects of DNS-based core stabilization exercises have not been adequately studied. Furthermore, no previous study has examined the combined effects of Mulligan mobilization, Pain Neuroscience Education, and core stabilization exercises in individuals with adhesive capsulitis.

This randomized controlled trial aims to evaluate the short-term effects of a combined intervention consisting of Mulligan mobilization, Pain Neuroscience Education, and core stabilization exercises on pain intensity, shoulder range of motion, shoulder function, pain catastrophizing, scapular dyskinesis, core stability, and health-related quality of life in individuals with adhesive capsulitis.

Participants diagnosed with adhesive capsulitis will be randomly allocated to one of two groups. The experimental group will receive Mulligan mobilization, Pain Neuroscience Education, and DNS-based core stabilization exercises. The control group will receive conventional physical therapy consisting of transcutaneous electrical nerve stimulation (TENS), hot-pack application, passive joint mobilization, and stretching exercises. Both groups will participate in treatment sessions three times per week for six weeks. Assessments will be conducted at baseline and after completion of the intervention period.

The findings of this study may contribute to the development of a more comprehensive rehabilitation approach for individuals with adhesive capsulitis and provide evidence regarding the effectiveness of combining manual therapy, pain education, and core stabilization strategies in clinical practice.

• Study Type: Interventional
• Enrollment (Estimated): 36
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Dilay Döner; Phone Number: +90 0535 019 58 83; Email: dilay.doner@std.yeditepe.edu.tr

Study Locations

• Turkey (Türkiye)
  • Istanbul, Turkey (Türkiye)
    • Recruiting
    • Life Med Tıp Merkezi
    • Contact: Murat Gökhan Döner; Phone Number: +90 532 342 98 15; Email: fztgokhandoner@gmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Adults aged 18 to 65 years
• Diagnosis of adhesive capsulitis confirmed by an orthopedic surgeon or a physical medicine and rehabilitation physician
• Presence of shoulder pain and limitation of shoulder range of motion
• Ability to communicate verbally
• Ability to understand study procedures and educational content
• Willingness to participate and provide written informed consent
• Mini-Mental State Examination (MMSE) score of 24 or higher
• Ability to attend treatment and assessment sessions regularly

Exclusion Criteria:

• MMSE score below 24
• Severe cognitive impairment
• Severe psychiatric disorders
• Active infectious disease
• Active malignancy
• Uncontrolled cardiovascular disease
• Presence of a cardiac pacemaker
• Contraindications to transcutaneous electrical nerve stimulation (TENS)
• Neurological disorders that may affect participation or outcomes
• Systemic diseases that may interfere with the safe implementation of the intervention
• Inability to comply with the study protocol or attend scheduled sessions

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Experimental - Combined Treatment Group; Mulligan Mobilization + Pain Neuroscience Education + Core Stabilization Exercises	Behavioral: Pain Neuroscience Education (PNE); Participants will receive Pain Neuroscience Education focused on the biopsychosocial nature of pain, central sensitization, the distinction between pain and tissue damage, and strategies to reduce fear of movement. The initial educational session will last approximately 15-20 minutes, followed by 5-10 minute reinforcement sessions throughout the intervention period. Education will be delivered through verbal explanations and interactive discussion.; Procedure: Mulligan Mobilization With Movement (MWM); Participants will receive Mulligan Mobilization with Movement techniques applied to the glenohumeral joint, including posterolateral glide with active abduction, inferior glide with shoulder flexion, and posterior glide with internal rotation. Mobilizations will be performed within a pain-free range of motion. Each technique will be administered in 3 sets of 10 repetitions with 30 seconds of rest between sets. Treatment will be provided three times per week for six weeks; Behavioral: Core Stabilization Exercises; Participants will perform Dynamic Neuromuscular Stabilization (DNS)-based core stabilization exercises. The program will include diaphragmatic breathing, supine 90/90 positioning, abdominal bracing, and progression to dead bug, bird-dog, and modified plank exercises as tolerated. Exercises will be performed in 2-3 sets of 8-12 repetitions with 10-20 second isometric holds. Progression will occur from stable to unstable surfaces and from static to dynamic activities
Active Comparator: Active Comparator - Conventional Physical Therapy Group; Conventional Physical Therapy (TENS + hot-pack + ROM Exercises + Stretching Exercises)	Other: Conventional Physical Therapy; Participants in the control group will receive conventional physical therapy consisting of transcutaneous electrical nerve stimulation (TENS) applied at a sensory level for 20 minutes, hot-pack application for 20 minutes, passive shoulder joint mobilization exercises, pendulum exercises, and wand exercises. Treatment sessions will be conducted three times per week for six weeks.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain Intensity	Pain intensity during movement will be assessed using the Visual Analog Scale (VAS). Higher scores indicate greater pain intensity.	Baseline and week 6
Shoulder Function	Shoulder pain, function, and patient satisfaction will be evaluated using the Penn Shoulder Score (PSS). Higher scores indicate better shoulder function.	Baseline and week 6
Shoulder Range of Motion	Active shoulder flexion, abduction, internal rotation, and external rotation range of motion will be measured using a goniometer.	Baseline and week 6

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Pain Catastrophizing	Pain-related catastrophic thinking will be assessed using the Pain Catastrophizing Scale (PCS). Higher scores indicate greater pain catastrophizing.	Baseline and week 6
Core Stability	Core stability and neuromuscular control will be assessed using the Sahrmann Core Stability Test.	Baseline and week 6
Change in Scapular Dyskinesis	Scapular movement patterns and dyskinesis will be evaluated using the Scapular Dyskinesis Test.	Baseline and week 6
Change in Health-Related Quality of Life	Health-related quality of life will be assessed using the 12-Item Short Form Health Survey (SF-12).	Baseline and week 6

Collaborators and Investigators

• Sponsor: Yeditepe University

Publications and helpful links

General Publications

• Leggin BG, Michener LA, Shaffer MA, Brenneman SK, Iannotti JP, Williams GR Jr. The Penn shoulder score: reliability and validity. J Orthop Sports Phys Ther. 2006 Mar;36(3):138-51. doi: 10.2519/jospt.2006.36.3.138.
• Doner G, Guven Z, Atalay A, Celiker R. Evalution of Mulligan's technique for adhesive capsulitis of the shoulder. J Rehabil Med. 2013 Jan;45(1):87-91. doi: 10.2340/16501977-1064.
• Razzaq A, Nadeem RD, Akhtar M, Ghazanfar M, Aslam N, Nawaz S. Comparing the effects of muscle energy technique and mulligan mobilization with movements on pain, range of motion, and disability in adhesive capsulitis. J Pak Med Assoc. 2022 Jan;72(1):13-16. doi: 10.47391/JPMA.1360.
• Sullivan MJL, Bishop SR, Pivik J. The Pain Catastrophizing Scale: Development and validation. Psychological Assessment. 1995;7(4):524-532.

Study record dates

Study Major Dates

• Study Start (Actual): April 21, 2026
• Primary Completion (Estimated): June 1, 2026
• Study Completion (Estimated): June 1, 2026

Study Registration Dates

• First Submitted: June 19, 2026
• First Submitted That Met QC Criteria: June 19, 2026
• First Posted (Actual): June 25, 2026

Study Record Updates

• Last Update Posted (Actual): June 25, 2026
• Last Update Submitted That Met QC Criteria: June 19, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Musculoskeletal Diseases; Joint Diseases; Bursitis; Musculoskeletal Physiological Phenomena; Musculoskeletal and Neural Physiological Phenomena; Physiological Phenomena; Movement
• Other Study ID Numbers: Dilay Döner

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No