Effectiveness of passive mobilization on the deleterious effects of immobilization in patients with musculoskeletal problems: a systematic review

ABSTRACT

Introduction

Joint immobilization may be necessary in some situations, such as in cases of fractures and osteomyoarticular injuries. However, it is known that there are several harmful effects of immobilization, which can cause muscle weakness, loss of motor function, reduced range of motion and increased local pain, and it is important to understand the possible forms of treatment to alleviate the effects of immobilization, focusing on passive mobilization.

Objective

To address articles that evaluate the effects of passive mobilization on immobilized patients.

Methodology

The search was carried out in national and international electronic databases (PubMed, Pedro, Web of Science, Scopus, Embase, Lilacs and Cochrane), in addition to gray literature (Google Scholar, Open Gray and Livivo), using the following descriptors: PASSIVE MOBILIZATION and IMMOBILIZATION, being carried out blindly, by two main researchers, concluding the selection with 6 articles on the subject.

Results

The studies indicate that passive mobilization was able to reverse the negative aspects of immobilization in relation to the recovery of strength, range of movement, local pain and motor function, as its action provides tissue sliding, increasing circulation and the repair process tissue.

Conclusion

Although the effects are smaller compared to active exercises, it can be considered that passive mobilization can mitigate the harmful effects of immobilization.

Introduction

Prolonged immobilization tends to generate a high number of complications due to the restriction of movement. Joint contractures occur which reduce flexibility and joint mobility, and/or increase resistance to passive joint movement, even generating joint degeneration [1,2]. Changes in the muscles, both in the contractile and non-contractile parts, are responsible for a significant loss of tensile strength, with a reduction in muscle diameter, thickening of the connective tissue and neurological changes. In addition, there is a dose-response relationship in which more extensive joint contractures occur with prolonged immobility [3,4].

These capsular adhesions and movement deficits can become permanent if not treated correctly. Multiple prevention and treatment strategies are aimed at minimizing these losses. These include passive joint mobilization techniques, continuous passive movement therapy, muscle stretching techniques, active exercises, flexible splints, neuromuscular electrical stimulation, therapeutic ultrasound, serial plaster applications and botulinum toxin [3,5–8].

Passive mobilization techniques are commonly used in post-operative treatments and in conservative treatments of orthopedic dysfunctions [9,10]. The aim of passive joint mobilization is to reduce pain and increase range of movement. It is carried out by passive oscillatory movements of small or large amplitude and sustained stretching that generate intra-articular movements and concentration of traction forces in the shortened tissues around the joint, including ligaments and joint capsule [11–15].

Among passive mobilization techniques, there is a wide variety in the way they are applied. They can be applied while respecting the existing range of joint movement, applied at the limit of joint traction, in an oscillatory or sustained manner, manually or mechanically. Despite being widely used in clinical practice, there is controversy over which technique is more satisfactory in terms of pain, range of motion and muscle strength gain [16–18]. The aim of this study was to carry out a systematic review of the effectiveness of passive mobilization on the deleterious effects in musculoskeletal tissue of patients who have undergone total or partial limb immobilization, with the primary outcome being an increase in the range of joint motion.

Materials and methods

Protocol and registration

This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. It is registered in the Open Science Framework (OSF), identification https://doi.org/10.17605/OSF.IO/XZFSY.

Eligibility criteria

The acronym PICOS was used to formulate the question focused on in this study: P – population: immobilized patients; I – intervention: passive mobilization; C – comparison: immobilized patients without passive mobilization; O – outcomes: Improvement in pain, muscle atrophy and range of movement; and S – study design: Systematic review. No period or language was restricted.

The inclusion criteria used were: studies in which the patients underwent a period of immobilization, which were treated with passive mobilization and characterized as clinical trials. Exclusion criteria: studies that used passive mobilization with continuous passive motion (CPM), that were treated with other techniques associated with passive mobilization, animal studies, and studies that were not found in their entirety.

Sources of information

A comprehensive and sensitive search was carried out, with no restrictions on period or language. The initial search was conducted using keywords from the PubMed database, the Medical Subject Headings (MeSH) medical metadata system and free terms. The search strategy used the following keywords: (Immobilization OR ‘Experimental Hypokinesia’ OR ‘Experimental Hypokinesias’ OR ‘Physical Restraints’ OR ‘Physical Restraint’ OR ‘Physical Immobilization’ OR ‘Muscle Disuse’) AND (‘Early Ambulation’ OR ‘Accelerated Ambulation’ OR ‘Early Mobilization’ OR ‘Musculoskeletal Manipulations’ OR ‘Manipulation Therapy’ OR ‘Manipulative Therapies’ OR ‘Manipulative Therapy’ OR ‘Manipulation Therapies’ OR ‘Manual Therapies’ OR ‘Manual Therapy’ OR ‘Passive Mobilization’ OR ‘Manual Mobilization’). The following databases were consulted: PubMed, Embase, Cochrane, the Physiotherapy Evidence Database (PEDro), Web of Science, Scopus and LILACS. In addition, the gray literature was consulted via Google Scholar, LIVIVO and Open Grey. All searches were carried out on 12 April 2023, being updated on 6 October 2023.

Study selection and data collection process

Two independent reviewers (1 R and 2 R) selected the included articles in two phases. In a first phase (Phase 1), the two reviewers assessed the titles and abstracts according to the eligibility criteria; in a second phase (Phase 2), they examined the full texts and selected the articles according to the same criteria as in Phase 1; they then verified all the information found. In the presence of disagreements, a third reviewer (3 R) participated before a final decision was made in both phases.

Data collected

Data was collected on the characteristics of the studies (authors, year of publication, country), the sample (sample size, average age and gender), modality and type of intervention, evaluation times, results and conclusion. The outcomes assessed were pain, range of motion, muscle strength and other functional characteristics of skeletal muscle.

Individual assessment of the risk of bias in studies

The risk of bias was assessed using the Cochrane tools ROB 2 and ROBINS I [19,20], by two independent reviewers (R1 and R2), and disagreements resolved between them or when necessary by the third reviewer (R3). The randomized trials were assessed in five domains: bias in the randomization process; deviations from the intended intervention; bias due to missing data; bias in the measurement of outcomes and bias in the selection of reported results. For each of these domains, the results could be: low risk, unclear or high risk (Figures 2 and 3). Non-randomized clinical trials with ROBINS I were assessed in 7 domains: confounding bias; bias in the selection of participants; bias in the classification of interventions; bias due to deviation from the intended interventions; bias due to missing data; bias in the measurement of outcomes and bias in the selection of reported results. Each domain was classified as serious, moderate, low or not informed (Figure 4).

Figure 2.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Figure 3.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study – RoB 2 tool.

Figure 4.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study – ROBINS I tool.

Assessing the risk of publication bias

To reduce the likelihood of publication bias, an exhaustive search was carried out without limitations as to language, period and with the inclusion of gray literature [21]. As a result, the risk of publication bias could be mitigated, but not eliminated.

Results

Selection of studies

During the search, 4,324 records were found, 4,144 in the main databases and 180 in the gray literature. After removing duplicates, 2,644 titles and abstracts were analyzed, and after passing the inclusion and exclusion criteria, 30 manuscripts were read in full, of which only six manuscripts remained for analysis (Figure 1).

Figure 1.

PRISMA 2020 flowchart.

Results of individual studies

The studies included a total of 180 participants, ranging in age from 2 to 82 years (Table 1).

Table 1.

Summary characteristics of the sample and immobilization of the clinical trials included in this review.

	Groups	Structure and Lesion	Gender	Age	Immobilization time	Type of immobilization
[22]	Passive mobilization group (n = 25) Immobilization group (n = 25)	50 flexor tendons repair of the hand	–	23,35	2 to 5 days	Splint
[23]	Superficial and deep flexor tendondivision group (n = 36) Isolated deep flexor tendondivision group (n = 15)	51 flexor tendons repair of the hand	29 men and 9 women	Between 2 and 60 years old (28)	6 weeks	Plaster
[24]	Treatment group (n = 8)	8 Colle’s fracture	8 women	Between 31 and 82 years old (64.5)		Plaster
[25]	Continuous passive movement group (n = 18) Immobilization group (n = 18)	50 idiopatic club foot	27 boys and 11 girls	Between 5 and 12 years old (8.2)	10 days	Plaster
[26]	Immobilization group (n = 4) Initial passive movement group (n = 5) Initial active movement group (n = 9)	24 extensor tendons repair of the hand	17 men and 1 woman	31.6 ± 3.8	5 days	Plaster and splint
[27]	Treatment group (n = 9) Control group (n = 8)	17 accute lateral ankle sprain		19.76 ± 1.35	Between 24 hours and 7 days	Hiking boots

Measuring instruments

A goniometer [23,24] and a bubble inclinometer [27] were used to assess the main outcome of range of motion. A hand-held dynamometer [26] was used to assess the grip strength outcome. The digital performance measure [22], FADI self-reported function [27], total active movement calculation [26] and Dimeglio clubfoot score [25] were used to assess functionality. VAS (Visual Analogue Scale) [24,26] or FADI (Foot And Ankle Disability Index) [27] were used to assess pain intensity.

Patient condition and joint involved

Hand flexor tendon surgery - zone II and III

In the study by Strickland et al. [22] the sample consisted of individuals who had undergone flexor tendon reconstruction surgery in Zone II. Nine patients had a tendon rupture in the second finger, 14 had a tendon rupture in the third, 15 in the fourth and 12 in the fifth finger, consecutively the involvement was in the metacarpophalangeal or proximal interphalangeal joints, varying according to the region of the tendon affected. In the study by Bullon et al. [23] the participants underwent primary repair surgery of the flexor tendons of the hand, with 33 cases compromising Zone II, three cases Zone III and 15 cases Zone I. Compromising the carpal, metacarpophalangeal, proximal interphalangeal and distal joints.

Hand extensor tendon surgery - zone V and VI

In the study by Hall et al. [26] volunteers underwent repair of hand extensor tendons in Zones V and VI, with Zone V, which corresponds to the metacarpophalangeal joint, having the highest number of affected digits (16) and Zone VI, which corresponds to the carpal bone joints, having the lowest number (eight).

Colles fracture type I or III

Coyle et al. [24] presented patients with type I or III Colles’ fractures treated conservatively, compromising the radiocarpal joint.

Surgery for idiopathic clubfoot

Zeifang et al. [25] treated children who had undergone surgical correction of idiopathic clubfoot compromising the talocrural joint.

Acute lateral ankle sprain – grade I and II

The study by Cosby et al. [27] involved volunteers after acute lateral ankle sprains in grades I and II, compromising the talocrural joint.

Intervention protocols

The intervention protocol varied in all the studies included in this review.

In the study by Strickland et al. [22] the participants were allocated to two groups after flexor tendon reconstruction surgery: immobilization and passive mobilization. In the immobilization group, the protocol consisted of placing the wrist in moderate flexion and the fingers in a balanced position for 34 weeks; from the 34th week onwards, passive and active flexion and active extension were allowed for a further two weeks. In the passive mobilization group, from the second to the fifth day, a dorsal orthoplast splint was applied which immobilized the wrist in moderate flexion and the fingers in a balanced position. Digital extension was prevented by a dorsal foam wedge and a twice-daily passive movement program was implemented allowing almost complete interdigital joint extension and flexion for four and a half weeks. From this phase, a simple cuff with an elastic band set was employed with gentle active extension and passive mobilization exercises in flexion were encouraged. Unprotected digital movement was allowed from the fifth week and dynamic splinting was employed in order to prevent contractures.

In Bullon et al. [23] the participants had their forearm immobilized with a plaster cast keeping the fingers in maximum extension, but the surgical finger was kept free. As the intact finger flexor tendons are stretched to the maximum, it is impossible to actively flex the sutured tendons, allowing only passive movements. The day after surgery and for the following three weeks, the interphalangeal joints of the affected finger were moved passively several times, three times a day.

In the study by Coyle et al. [24] all participants received their first treatment within three days of the plaster being removed. Each individual attended two treatment sessions per week for three weeks. Each participant was treated using two passive treatment techniques in each session. All interventions were applied to the radiocarpal joint only. The two treatment techniques used were the oscillatory technique (O) and sustained stretching (S). The oscillatory technique allowed a large amplitude oscillation parallel to the joint surface and in the second half of the available range of motion, the oscillation was in a postero-anterior direction to a point of maximum resistance in relation to pain at each oscillation. This technique was comparable to a Maitland grade III technique. The oscillations were applied for 60 seconds (one oscillation per second) followed by 60 seconds of rest, repeated twice. Sustained stretching was applied with a single glide parallel to the joint surface, moving in a postero-anterior direction to the point of maximum resistance in relation to pain. This technique is comparable to the grade III Kaltenborn technique. The technique was maintained for 60 minutes with a protocol similar to that mentioned for the oscillatory technique.

In the study by Zeifang et al. [25] after surgery, the feet were randomly assigned to a plaster immobilization or continuous passive mobilization group. In bilateral cases, both feet received similar post-operative treatment. In both groups of patients, plaster was applied for the first ten days. Afterward, plaster was continued for another four and a half weeks for the patients assigned to the plaster group, while the continuous passive mobilization group received computer-assisted three-dimensional therapy with a Kinetic 5090 Ankle machine. During rest periods, removable splints were applied to the feet. From the tenth day after the operation, the one-dimensional range of motion of the ankle in plantar flexion/dorsiflexion was gradually increased for 14 days. Three-dimensional movement of the subtalar joint was started on the 24th postoperative day and continued until the 42nd postoperative day. Each foot had a minimum treatment period of 4 hours per day. After six weeks, each foot was treated with an orthosis at night and physiotherapy continued for a further six months in both groups. When the children started walking, conventional shoes with heels were used to stabilize the feet.

In the study by Hall et al. [26] the participants were referred for therapy within five days of surgery. Postoperatively, all participants were immobilized in a volar plaster cast with the wrist in extension from 30° to 45°, the metacarpophalangeal joints in flexion from 0° to 30° and the proximal interphalangeal joints immobilized in neutral. They were then allocated to three groups: immobilization, initial passive mobilization and initial active mobilization. In the immobilization group, the patients received a resting splint and were immobilized for three weeks. Patients in the passive mobilization group received a dorsal dynamic extension splint and started controlled passive movement early in the first five days after surgery. The active mobilization patients were fitted with a simple palmar locking splint and started early active movement within the first five days.

In the study by Cosby et al. [27] participants previously immobilized with a walking boot were allocated to the control or treatment group. The treatment group received a thirty-second session of grade III anteroposterior talocrural mobilization performed at a rate of one mobilization per second. The control participants received no treatment and no physical contact from the therapist.

Outcomes

Tables 2 summarize the findings of the outcomes included in this review: range of motion, pain, functionality and handgrip.

Table 2.

Characteristics of the interventions in the included studies.

	Patient condition	Therapeutic intervention	Articulation evaluated	Duration of intervention	Evaluating the result	Reassessment
[22]	After flexor tendon II repair	Passive mobilization vs. prolonged immobilization	Proximal interphalangeal and distal interphalangeal joints	2× a day	Digital performance	125 and 160 days
[23]	After primary repair of flexor tendons I, II and III of the hand	Passive mobilization	Metacarpophalangeal (MP), proximal interphalangeal (PI) and distal interphalangeal (DI) joints	3× a day for 3 weeks	ROM	2, 4, 8 and 12 weeks
[24]	After type I and III colles fractures	Maitland grade III mobilization for 60’ 2× (OT) X Kaltenborn grade III mobilization for 60’ (ST)	Radiocarpal joint	2× a week for 3 weeks	Active wrist extension (goniometer); Pain (VAS); Grip strength (dynamometer)	After each intervention
[25]	After surgical treatment of idiopathic clubfoot in infants	Continuous passive movement vs. prolonged plaster immobilization	Equinox in the sagittal plane, varus deviation in the frontal plane, deviation of the calcaneo-forefoot block around the the talus and adduction of the forefoot over the rearfoot in the horizontal plane	4 hours a day for 32 days	Dimeglio clubfoot score (classification on a four-point scale)	6, 12, 18 and 48 months
[26]	Post-operative extensor tendon repair in zones V and VI of the hand	Controlled passive movement X early active movement X prolonged immobilization	Metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints	20 h in splint X10 h in splint X immobilization for 3 weeks	Self-reported functional capacity (VAS); Extension delay (scale); ROM (finger goniometer); Grip strength (dynamometer)	3, 6 and 12 weeks
[27]	After acute lateral ankle sprain grade I and II	Grade III AP talocrural joint mobilizations III performed at a rate of 1 mobilization/second	Talocrural joint – dorsiflexion	30s/single session	ROM (bubble inclinometer); Self-reported function and pain (FADI)	Immediately after and 24 hours after

Legend: AP: anteroposterior; OT: oscillatory technique; ST: sustained technique; MP: metacarpophalangeal; PI: proximal interphalangeal; DI: distal interphalangeal; ROM: range of motion; VAS: visual analog scale; FADI: foot and ankle disability index.

Primary outcome - range of motion

In the study by Strickland et al. [22] the average range of movement of the three joints of the immobilized fingers was 168° in the immobilized group, compared to 213° in the mobilized fingers, with significant advantages for the group with early mobilization. The study by Bullon et al. [23] used the Buck-Gramcko coefficient with excellent results in six tendons (11.7%), good in 31 (60.7%), fair in 10 (10.6%) and poor in two tendons (3.9%). In the study by Hall et al. [26] it was observed that patients undergoing active mobilization had less extension delay over 12 weeks, however, there were no differences in terms of function, pain and grip.

In the study by Cosby et al. [27] there was no significant improvement in dorsiflexion ROM attributable to joint mobilization treatment. The results indicate that there was no significant change in talus translation immediately after the intervention or at 24-hour follow-up. And in the study by Coyle et al. [24] oscillations also produced a greater percentage increase in the wrist extension range if used in the first three treatment sessions.

Secondary outcome - pain

Coyle et al. [24] observed that when passive mobilization in the form of oscillations was the first technique used, there was a greater reduction in pain than when sustained stretching was initially performed.

In the study by Cosby et al. [27], a 20% reduction in pain was also noted for the treatment group after a single session of grade III AP talocrural joint mobilizations at 24-hour follow-up when compared to the control group. In the study by Hall et al. [26] it was observed that patients undergoing active mobilization showed no differences in terms of pain.

Secondary outcome - functionality

In the study by Strickland et al. [22] 56% excellent and good results in the passive movement group were statistically significant (p ≤ 0.005) when compared to 12% in the immobilized group. Comparing the excellent, good and fair groups (72% for the passive movement group and 40% for the immobilized group) was also significant (p ≤ 0.05). In the study by Cosby et al. [27], self-reported function by the FADI showed no significant difference between the control and treatment groups.

In the study by Zeifang et al. [25] after surgery and treatment with a cast, the Dimeglio clubfoot score improved from 10.3 preoperatively to 4.17 at 12 months and to 3.89 at 48 months. After surgery and treatment with continuous passive mobilization, the Dimeglio clubfoot score improved from 9.68 to 3.11 at 12 months, but worsened to 4.47 at 48 months. Analysis of variance adjusted for baseline values indicated a significantly better result in the continuous passive mobilization group at six and twelve months after surgery (p = 0.013 and p = 0.009), but at 18 and 48 months the result was similar. In the study by Hall et al. [26] it was observed that patients who underwent active mobilization showed no differences in terms of function.

Secondary outcome - handgrip strength

In the study by Hall et al. [26] patients who underwent active mobilization had no differences in handgrip when compared to controls.

Analysis of the risk of bias in studies

This review selected 6 clinical trials, 2 randomized [25,27] and 4 non-randomized [22–24,26] that met the eligibility criteria of the PICOS acronym.

Regarding the randomization process, the two randomized studies included had some concerns about this process. The study of Cosby et al. [27] was considered to have some relevant problems and the study by Zeifang et al. [25] was indicated as having a high risk of bias (Figures 2 and 3). With regard to non-randomized studies, in the overall result of the bias analysis, all four studies were classified as high risk of bias (Figure 4).

Discussion

The aim of this study was to carry out a systematic review of the effectiveness of passive mobilization on the deleterious effects of patients who have undergone total or partial limb immobilization, with the primary outcome being an increase in the range of joint motion. Analyzing the literature regarding the use of mobilizations after periods of joint mobilization, finding different mobilization protocols in several different joints. The results showed that passive mobilization was advantageous in terms of gaining joint range of motion, reducing pain intensity and improving muscle function.

Different evaluation instruments were used, such as goniometer [23,24] and a bubble inclinometer [27] to assess the main outcome of range of motion; hand-held dynamometer [26] to assess the grip strength outcome; digital performance measure [22], FADI self-reported function [27], total active movement calculation [26] and Dimeglio clubfoot score [25] were used to assess functionality; and finally VAS [24,26] or FADI [27] were used to assess pain intensity. All standardized forms of evaluation and already well discussed in the literature.

According to the study by Liebler et al. [28], the arthrokinetic reflex (AKR) is responsible for improving muscle strength and function because it links the central nervous system to the skeletal muscles. The regulators of this reflex are the joint mechanoreceptors located in the synovial joint capsules, with improved tone which directly contributes to improved muscle function. The receptors in the joint capsule, types I – IV, have a reflex effect on muscle tone. The afferent nerve fibers from these receptors project to motor neurons within the central nervous system (CNS), thus flowing to the muscle spindle. When a stretch in the joint capsule is initiated, related to passive or active mobilization of the joint, the mechanoreceptors exert reciprocally coordinated influences on muscle tone and on the excitability of the stretch reflexes in the striated muscles. This reflex inhibits the muscles from recruiting the maximum number of motor units and protects the body from overloading restricted joint structures. The receptors of the capsule, through reflex action, maintain the first line of defense in detecting extremes, alerting the CNS to impending injury. Improvements in strength can be achieved by mobilizing restricted joints, thus removing inhibitory reflexes [29,30].

The results of the study by Yeris et al. [31] showed a significant difference between the experimental and control groups, with a 14% increase in strength for the experimental group in gluteus maximus strength after three minutes of grade IV postero-anterior mobilization of the anterior hip capsule. They theorized that a retracted anterior capsule would facilitate the iliopsoas muscle while reflexively inhibiting the gluteus maximus. In addition, according to Pfluegler et al. [9] grade IV inferior mobilization of the hip joint increases hip abductor strength and grade IV posteroanterior mobilization of the hip joint increases hip extensor strength.

In the study by Pozsgai et al. [32], in individuals with moderate to severe knee osteoarthritis, the effect of Maitland mobilization on the pressure pain threshold and functional measures in knee osteoarthritis was evaluated. They observed an immediate decrease in the Timed Up and Go Test (TUG) time which can be understood as a consequence of an observed hypoalgesic effect of Maitland’s end range mobilization. However, Pflueger et al. [33] argued that for passive mobilization aimed at gains in muscle function, it seems to be more important for individuals to have deficiencies in muscle function at the start of the study, rather than pain.

The other factors presented in the studies, such as pain and range of motion, are also influenced by immobilization and passive mobilization. The longer the immobilization time, the greater the reduction in the nociceptive threshold [31]. Although pain was not assessed in all the studies included in this review, Coyle et al. [24] and Hall et al. [26] showed that individuals who only underwent the immobilization process had greater pain compared to those who underwent passive mobilization as a form of treatment. In experimental studies with animals, immobilization generates an increase in inflammatory cells, atrophy, with the possibility of tissue necrosis, favoring local hypersensitivity due to these adaptations [34], such characteristics are difficult to find in studies with humans, due to the aggressiveness of the form of immobilization and analysis. Furthermore, this increase in pain in immobilized patients can be explained by the excessive stimulation of the orthosis in the immobilized region, generating central sensitization [35].

Passive mobilization causes joint sliding, optimizing circulation and lubrication of the region, allowing better tissue reorganization, favoring regeneration and controlling inflammation caused by immobilization [36], These statements are in line with the information presented in the studies by Coyle et al. [24] and Hall et al. [26] which showed an improvement in pain in patients who were treated with passive mobilization compared to patients who were only immobilized.

With regard to range of motion, it is clear from the studies by Strickland and Glogovac [22], and Bullon and Novo [23], that passive mobilization improved range of motion compared to immobilization. Bearing in mind that the lack of joint movement generates an increase in the amount of tissue macrophages and a change in the deposition of connective tissue, favoring joint stiffening [37,38], the importance of joint mobilization aimed at returning joint range of motion is highlighted. In addition, passive mobilization allows the mechanoreceptors to be more stimulated, optimizing joint recovery, reducing pain and promoting tissue organization, thus avoiding greater accumulation of connective tissue and, consequently, fibrosis [33].

The study’s limitations include the fact that all the articles selected had patients who were immobilized (even if at different times), and who were treated only with passive mobilization (even if compared with other treatment groups). However, the assessment methods were different, and each manuscript presented a different assessment for strength, pain, range of movement and muscle function, thus limiting a better perception of the results, implying the inability to carry out a meta-analysis. In addition, the immobilized site was different in the studies, varying the joints immobilized, which can have a certain influence on recovery and the results found. Another limitation is the date of publication of the articles, which is old, indicating that there are no current studies on passive mobilization after periods of immobilization, thus requiring updated studies in this area. In addition, the wide variation in the age of research participants should be understood as a limitation, since different characteristics of vascularization, lubrication, among others, occur and thus the therapeutic effects may also vary.

In summary, while immobilization causes damage to the joint’s range of motion, passive mobilization increases it [22]. When active mobilization was compared with passive mobilization [26] the results for pain, range of motion and grip strength were better in the active mobilization group, but passive mobilization proved superior to immobilization. Range of motion with continued passive mobilization was better than immobilization at 12 months, but at 18 months no difference was found [25]. Large amplitude oscillations were more effective at the beginning of a session and sustained oscillations were more effective in the latter part of the session [24]. Finally, it has been shown that a single mobilization session was not effective in increasing ankle dorsiflexion ROM, decreasing posterior sliding of the talus or improving self-reported function [27].

Conclusion

The biases found in the studies analyzed do not indicate clear evidence for passive mobilization. However, there is evidence that passive mobilization improves mobility, reduces pain and increases muscle function. However, more is still needed studies in this area.

Biographies

Pâmela Andressa Pauletto – Physiotherapist, Master’s student in the Biosciences and Health Program at Unioeste.

Fernanda Teixeira Furlan Chico – Physiotherapist, Master’s and PhD student in Biosciences and Health at Unioeste.

Luiz Carlos Gracioli Vieira – Veterinarian, special student in the Biosciences and Health Program at Unioeste.

Dernival Bertoncello – Physiotherapist, PhD in Physiological Sciences from the Federal University of São Carlos (UFSCAR), Full Professor of the Physical Education and Physiotherapy Program at the Federal University of Triângulo Mineiro (UFTM).

Márcia Rosângela Buzanello – Physiotherapist, PhD in Production Engineering from the Federal University of Santa Catarina, Associate Professor of the Health Sciences Program at Unioeste.

Alberito Rodrigo de Carvalho – Physiotherapist, PhD in Human Movement Sciences from the Federal University of Rio Grande do Sul (UFRGS), Adjunct Professor of the Biosciences and Health Program at Unioeste.

Gladson Ricardo Flor Bertolini – Physiotherapist, PhD in Health Sciences Applied to the Locomotor System from the Ribeirão Preto Medical School / University of São Paulo, Associate Professor of the Biosciences and Health Program at Unioeste.

Funding Statement

I would like to thank CAPES for the help in the form of a master’s scholarship.

Disclosure statement

No potential conflict of interest was reported by the author(s).