A PRELIMINARY REPORT
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Audioanalgesia as an Adjunct
to Mobilization of the
Chronic Frozen Shoulder
JOHN L. ECHTERNACH, M.S.
PHYSICAL THERAPISTS often are called on
to treat patients with chronic shoulder dis­
abilities that result in markedly limited range
of motion of the shoulder joint. Passive mobil­
ization in addition to active and resistive exer­
cises frequently is indicated in mobilizing the
shoulder joint. Patients often have difficulty
achieving relaxation when passive mobilization
is attempted by the physical therapist. This
deters successful mobilization of the involved
joint.
The author thought that audioanalgesia might
be useful in promoting maximal relaxation of
the patient with a chronic shoulder disability
during the passive mobilization treatment and
that mobilization might be achieved and func­
tion regained more rapidly. This paper reports
the preliminary findings in this study.
Deputy Chief, Physical Therapy Department, U. S. Pub­
lic Health Service Outpatient Clinic, New York, New
York.
This study was supported by Division of Hospitals, Pub­
lic Health Service Grant No. P-64-3.
August 1966 • Volume 46 • Number 8
REVIEW OF THE LITERATURE
Gardner and Licklider, in reporting on the
use of stereophonic music which was heard
through earphones by dental patients, believed
the procedure was useful in reducing ten­
sions.1 They reported a year later on adding
"white sound" to the stereophonic music.
"White sound" is random noise of all audible
frequencies which resemble the sound of water­
fall or a water tap fully opened.2 The term
"white sound" is an analogy to white light
which is light of all visible frequencies. They
believed the combination of music and white
sound was more effective than music alone in
obtaining the patient's relaxation and distrac­
tion during dental treatment. "Audioanalgesia"
was the term coined by these authors for this
procedure.
Schermer, who in 1951 reported on the use
of audioanalgesia with dental patients believed
it to be effective with 90 per cent of selected
patients and 76 per cent of all patients.3
Monsey also reported on the effectiveness of
839
I AUDIOANALGESIA WITH MOBILIZATION
OF THE CHRONIC FROZEN SHOULDER
this procedure in dental patients and found that
82 per cent of the applications gave excellent
results.4
Favorable results have also been reported
with obstetrical patients.5 Burt and Korn con­
sidered audioanalgesia a useful adjunct in the
relief of pain during labor, with no adverse
effects noted.5 Results were evaluated as good
in two-thirds of their patients: the patients who
received audioanalgesia required less anesthesia
during labor than a control group.
Applications of audioanalgesia to podiatry
were reported by Bob who found that patients
achieved relaxation and were diverted during
surgical procedures; less analgesic agents were
required.6 Other clinical situations in which
audioanalgesia has been used and reported are
during cardiac catheterization in children and
for patients who are poor surgical risks where
reduced amounts of anesthesia are indicated.7
Davis and Glorig 8 and Lawrence 9 have dis­
cussed the responsibility of the otologist in the
use of audioanalgesia. These authors believe
that experimental use of audioanalgesia should
have otological supervision and that baseline
audiograms should probably be obtained. They
state that audioanalgesia is contraindicated for
patients who have a history of vertigo, stapes
mobilization, or fenestration operations. Nu­
merous safety requirements have been de­
veloped for audioanalgesia equipment, and
commercial equipment now has safety features
built into the apparatus which prevent overex­
posure of the patient to high sound levels.10,11
Laboratory studies have been conducted to
evaluate the effectiveness of audioanalgesia.
The results of these studies have been inconclu­
sive with no effects reported by some and good
results obtained by others.
Carlin et al., using an electrical tooth stimu­
lator, failed to find statistically significant proof
that audioanalgesia raised the threshold to pain
in teeth.12 Carlson, using essentially the same
technique, believed that pain thresholds were
raised significantly and that music and white
sound used together were most effective.13
Robson and Davenport tested superficial pain
thresholds in a group of subjects receiving au­
dioanalgesia and in a control group by applying
a heated platinum wire to the thenar eminence
of the thumb.14 They concluded that no sig­
nificant influence on pain threshold was obtain­
able with audioanalgesia. Clutton-Brock ap­
840
plied pressure over the surface of the tibia and
found an increase in pain threshold and anal­
gesia with audioanalgesia.15
An explanation for the effectiveness of audio­
analgesia has been suggested by Gardner and
Licklider.2 They hold that auditory and pain
stimuli come together in several places in the
reticular formation and lower thalamus and that
the interaction of the two systems is largely in­
hibitory, resulting in direct suppressive effects
as well as diversion of attention and anxiety
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reduction.
Allison and other dentists have cited the
effects of distraction as well as suggestion on the
part of the dentist when explaining the hoped-
for results to the patient.3' 4>16 Rosenberg be­
lieves that audioanalgesia in restricting the pa­
tient's sensory input to auditory stimuli alone is
the same as the concentration of attention dur­
ing hypnosis and that the achievement of re­
laxation is similar to a light trance achieved by
hypnosis.17 Baer reported on hypnosis as an
adjunct to treatment of neuromuscular diseases
in 1960 and stated that the mechanism for pain
reduction in the trance state was the blocking
of sensory impulses at the thalamic level.18
Burt and Korn have suggested that the rea­
son for failure of some laboratory studies to
confirm the effects of audioanalgesia noted by
clinicians is that experimental study of pain is
difficult and audioanalgesia may have its effect
on modification of the reaction component of
pain rather than on the original sensation of
pain.5 They also believe that while subjective
results are suspect in the eyes of some in this
day of double-blind studies, this should not
deter the use of audioanalgesia.
METHOD
Patient Selection
Thirty-two patients met the criteria for in­
clusion in the study; there were sixteen pa­
tients in a control group and sixteen in an ex­
perimental group. Patients in each group were
matched as closely as possible, case for case,
regarding diagnosis, age, length of disability,
and time since onset of disability preceding
treatment. All patients had significant loss of
motion of the shoulder joint, related to a med­
ical diagnosis of chronic bursitis, bicipital ten­
dinitis, or rotator cuff injuries in which there
was no contraindication to passive mobilization
of the involved shoulder joint.
Both groups received the prescribed thermo-
JOURNAL OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION
 FIG. 1. Equipment used for
audioanalgesia includes, as
indicated by numbers, (1)
stereo tape recorder or rec­
ord player, (2) source of
white sound, (3) earphones,
(4) control box, (5) monitor­
ing device, (6) internal
speaker system, (7) method
for limiting frequency re­
sponse of stereophonic mu­
sic, (8) taped music.
therapy (diathermy, hot packs, or ultrasound)
preceding the mobilization portion of the treat­
ment. The experimental group also received
audioanalgesia during the mobilization proce­
dures. The control group was treated in the
same manner, but had no audioanalgesia. The
same mobilization techniques were used on
both groups. Both groups performed active
and resistive exercises as indicated for shoul­
der girdle weakness.
Patients in the audioanalgesia group were
examined preceding treatment in the ear, nose,
and throat clinic for history of deafness, oper­
ative procedures, and current ear complaints.
Audiograms were also done to establish a base­
line of hearing status. Patients with a signifi­
cant hearing loss, previous operative treatment
for ear problems, or otosclerosis were excluded
from the audioanalgesia group.
Bilateral range of motion was recorded ini­
tially for all patients and repeated every two
weeks or when obvious increases were noted.
The same physical therapist did all the gonio-
August 1966 • Volume 46 • Number 8
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metric measurements with a full 360-degree in­
strument. Active ranges of motion were
recorded.
Apparatus
Equipment needed (see Fig. 1) for audio­
analgesia includes a stereo tape recorder or a
record player. Tape recorders offer the ad­
vantage of longer playing time. There must
be a source of white sound, a white sound gen­
erator or taped white sound. A white sound
generator offers the advantage of allowing both
stereophonic music and sound to be heard si­
multaneously. Earphones are necessary for
the patient to listen to the music and white
sound. Good quality and good accoustical
seal to eliminate external noise are important
features. A control box is required so the pa­
tient can control the volume of music or sound
or both. There must be a monitoring device to
show the operator the volume and type of sound
to which the patient is listening. In addition,
an internal speaker system is needed to permit
I AUDIOANALGESIA WITH MOBILIZATION
OF THE CHRONIC FROZEN SHOULDER

TABLE 1
COMPARISON OF SIXTEEN PATIENTS TREATED FOR CHRONIC FROZEN SHOULDER WITH THERMOTHERAPY AND MOBILIZA­
TION AND AUDIOANALGESIA WITH SIXTEEN PATIENTS TREATED FOR CHRONIC FROZEN SHOULDER WITH
THERMOTHERAPY AND MOBILIZATION WITHOUT AUDIOANALGESIA

Audioanalgesia Group Control Group

Range of Numt)er of
Trea tments

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Motion
Patient Initial Before Final With Use of Patient Initial Final Total
Age and Range of Audio- Range of Audio- Audio- Age and Range of Range of Number of
Diagnosis Motion" analgesia Motion analgesia Total analgesia Diagnosis Motion Motion Treatments
1A 57 0-50 Same as 0-50 22 52 Music and IB 44 0-50 0-50 74
Rotator 0-130 initial 0-160 White Rotator 0-140 0-160
cuff 0-80 0-170 Sound cuff injury 0-105
injury 0-30 0-60 0-45
0-60 0-85 0-50
2A 47 0-40 0-40 0-50 22 40 Music & 2B 45 0-30 0-30 59
Calcific 0-125 0-130 0-150 Occa­ Calcific 0-95 0-110
bursitis 0-90 0-100 0-130 sional tendinitis 0-70 0-80
0-45 0-45 (170)b White or 0-40 0-50
0-28 0-30 0-70 Sound bursitis 0-20 0-50
0-70
3A 63 0-60 0-60 0-60 22 54 Music & 3B 63 0-40 0-45 70
Rotator 0-140 0-140 0-160 White Rotator 0-80 0-120
cuff 0-105 0-100 0-180 Sound cuff injury 0-60 0-95
injury 0-15 0-15 0-58 0-35 0-60
0-45 0-40 0-75 0-50 0-70
4A 67 0-40 Same as 0-50 42 49 Music & 4B 61 0-50 0-50 61
Rotator 0-105 initial 0-145 Occa­ Rotator 0-130 0-135
cuff 0-80 0-120 sional cuff injury 0-85 0-95
injury 0-40 0-55 White 0-40 0-70
0-25 0-55 Sound 0-85 0-85
5A 60 0-30 Same as 0-45 28 56 Music and 5B 61 0-40 0-40 57
Chronic 0-110 initial 0-140 White Calcific 0-120 0-135
bursitis 0-80 0-135 Sound tendinitis 0-85 0-95
0-30 0-60 0-45 0-55
0-20 0-45 0-45 0-50
6A 54 0-50 0-55 0-55 10 26 Music and 6B 51 0-25 0-40 43
Chronic 0-90 0-90 0-160 occa­ Chronic 0-95 0-120
subdeltoid 0-75 0-75 0-160 sional peri­ 0-120 0-135
bursitis 0-50 0-40 0-60 White tendinitis 0-70 0-70
0-35 0-35 0-75 Sound 0-50 0-65
7A 62 0-40 0-40 0-50 22 40 Music & 7B 62 0-40 0-40 74
Chronic 0-110 0-130 0-150 White Bursitis 0-130 0-140
bursitis; 0-90 0-100 0-130 Sound and 0-84 0-110
rotator 0-45 0-45 (170) Rotator 0-40 0-45
cuff injury 0-28 0-30 0-75 cuff injury 0-40 0-70
0-75
8A 36 0-50 0-50 0-50 21 68 Music & 8B 43 0-45 0-60 67
Rotator 0-110 0-125 0-132 White Rotator 0-110 0-140
cuff 0-80 0-95 0-95 Sound cuff tear 0-60 0-95
bursitis 0-25 0-40 (120) 0-50 0-55
0-35 0-50 0-35 0-10 0-40
0-55
a Range of motion is listed in the following order: extension, flexion, abduction, internal rotation, external rotation.
b Figures in parenthesis indicate abduction with slight flexion.

842 JOURNAL OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION

 TABLE 1 (Continued)
COMPARISON OF SIXTEEN PATIENTS TREATED FOR CHRONIC FROZEN SHOULDER WITH THERMOTHERAPY AND MOBILIZA­
TION AND AUDIOANALGESIA WITH SIXTEEN PATIENTS TREATED FOR CHRONIC FROZEN SHOULDER WITH
THERMOTHERAPY AND MOBILIZATION WITHOUT AUDIOANALGESIA

Audioanalgesia Group Control Group

Number of
Range of
Treatments

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Motion
Patient Initial Before Final With Use of Patient Initial Final
Age and Range of Audio- Range of Audio- Audio- Age and Range of Range of
Diagnosis Motion'1 analgesia Motion analgesia Total analgesia Diagnosis Motion Motion
9A 61 0-35 Same as 0-45 36 68 Music & 9B 66 0-60 0-60
Chronic 0-100 initial 0-145 Occa­ Chronic 0-130 0-145
subdeltoid 0-90 0-130 sional bicipital 0-70 0-110
bursitis 0-25 (170) White tendinitis 0-45 0-45
0-40 0-60 Sound 0-50 0-55
0-70

10A 62 0-50 0-50 0-50 12 72 Music 10B 64 0-35 0-45

Rotator 0-115 0-120 0-150 Only Rotator 0-90 0-115
cuff tear 0-90 0-90 0-135 cuff tear 0-65 0-85
0-40 0-40 0-70 0-30 0-45
0-85 0-90 0-90 0-60 0-80

11A 50 0-30 0-45 0-55 8 15 White 11B 48 0-35 0-35

Bursitis 0-100 0-110 0-140 Sound & Bursitis 0-100 0-120
0-90 0-90 0-100 Music 0-70 0-80
0-40 0-60 0-60 0-5 0-20
0-30 0-25 0-40 0-30 0-50

12A 56 0-45 0-35 0-45 28 53 White 12B 60 0-50 0-50

Rotator 0-130 0-130 0-160 Sound & Rotator 0-120 0-135
cuff injury 0-90 0-105 0-150 Music cuff injury 0-65 0-85
0-30 0-30 0-50 0-40 0-50
0-35 0-50 0-85 0-50 0-90

13A 45 0-30 0-45 0-50 22 83 White 13B 41 0-40 0-40

Rotator 0-110 0-125 0-145 Sound & Rotator 0-95 0-143
cuff injury 0-75 0-85 0-110 Music cuff injury 0-55 0-125
0-45 0-35 0-60 0-40 0-45
0-0 0-40 0-60 0-10 0-55

14A 42 0-50 0-50 0-55 34 63 Music 14B 44 0-50 0-50

Calcific 0-90 0-95 0-165 Only Bicipital 0-110 0-140
tendinitis 0-80 0-90 0-170 tendinitis 0-80 0-110
0-40 0-40 0-70 0-20 0-35
0-40 0-40 0-80 0-30 0-60

15A 43 0-50 0-50 0-50 20 50 Music 15B 45 0-40 0-45

Chronic 0-110 0-150 0-170 Only Calcific 0-100 0-125
calcific 0-85 0-90 0-165 bursitis 0-70 0-90
bursitis 0-60 0-45 0-75 0-20 0-30
0-45 0-35 0-90 0-25 0-40

16A 58 0-45 Same as 0-50 16 23 Music 16B 61 0-45 0-45

Bursitis 0-120 initial 0-150 Only Rotator 0-125 0-130
and 0-80 0-130 cuff injury 0-90 0-105
rotator 0-65 (160) 0-60 0-60
cuff injury 0-35 0-60 0-75 0-75
0-60
a Range of motion is listed in the following order: extension, flexion, abduction, internal rotation, external rotation.
b Figures in parenthesis indicate abduction with slight flexion.

August 1966 • Volume 46 • Number 8 843

I AUDIOANALGESIA WITH MOBILIZATION
OF THE CHRONIC FROZEN SHOULDER
the physical therapist to communicate with the
patient, to give directions for positioning, and
to ask questions. A method is needed for lim­
iting the frequency response of the stereophonic
music to a restricted range, if necessary. Taped
music of good quality is needed. A selection
from which the patient can choose is helpful.
Mobilization Techniques
The methods of mobilization used have been
described in detail by Murray 19 and Mennell.20
The motions under voluntary control, such as
flexion, internal and external rotation and ab­
duction of the shoulder, were stretched with the
patient supine. Particular attention was paid
to scapular stabilization. Motions not under
voluntary control were used to assist in freeing
the humeral head so that it would glide on the
glenoid fossa in the manner required for nor­
mal movement. Briefly, these procedures in­
cluded (1) caudad traction or moving the
humeral head downward on the glenoid, (2)
lateral traction or moving the humeral head out­
ward from the glenoid, (3) horizontal abduc­
tion, and (4) forcing the humeral head dor-
sally on the glenoid.
As the patient improved, with improvement
taking place with some motions more than with
others, the stress on various motions was ad­
justed.
Technique of Audioanalgesia
After the procedure and equipment were ex­
plained to the patient, he was instructed how to
wear earphones and use the music and white
sound volume controls. The reason for using
audioanalgesia was also explained. During the
first session mild mobilization was used and
the patient was instructed to turn the volume
of music or white sound or both up as discom­
fort from mobilization procedures increased.
The patient was instructed to raise the volume
of the white sound to a point where the music
could be barely heard through the white sound
and he had to concentrate to follow the music.
RESULTS
The control group of sixteen patients was
compared to the sixteen patients in the audio­
analgesia group.
Results were evaluated by (1) final active
range of motion of the involved shoulder com­
844
pared with the initial range recorded, (2) rate
at which motion was regained in the affected
shoulder, and (3) length of time required to
achieve maximum results after the onset of
treatment.
The results in the control and audioanalgesia
groups is shown in Table 1. The audioanal­
gesia group obtained better results with respect
to improvement of range of motion, rate of re­
gaining motion, and length of time required to
achieve the results.
The rate of return of range of motion was
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much faster in the audioanalgesia group. The
control group regained 0 to 10 per cent of
shoulder motion during the period of a month
while the audioanalgesia group regained 15 per
cent to 40 per cent in range of motion in the
same time.
The average number of treatments in the
control group was seventy. The average num­
ber of treatments after audioanalgesia was be­
gun in the audioanalgesia group was twenty-
three treatments (this represents almost a two-
thirds reduction in number of treatments).
All patients in the audioanalgesia group were
under treatment for at least one week before
audioanalgesia was attempted. This was con­
sidered necessary to allow time for the comple­
tion of audiometric testing. Twelve patients in
the audioanalges ia group were under treatment
for one month or longer (two patients required
four months) before audioanalgesia was begun.
These patients were already under treatment
when the project was initiated. A typical prog­
ress chart is shown in Figure 2 from the initia­
tion of treatment to the point where audioanal­
gesia was instituted. Continuing to the end of
treatment, it shows that the rate at which mo­
tion was regained was much faster when audio­
analgesia was used as an adjunct to treatment.
Two patients in the audioanalgesia group
were dropped from the series; one patient com­
plained of dizziness following exposure to au­
dioanalgesia. The other had a hearing loss re­
vealed by audiometric tests prior to treatment
which proved to be severe enough to limit the
effectiveness of the technique. The one pa­
tient in the audioanalgesia group who did not
do well compared to his control tolerated the
mobilization position poorly, was apprehensive,
and had poor tolerance of discomfort with or
without the use of audioanalgesia.
All other patients in the audioanalgesia group
accepted the addition of this procedure very
well. Four patients used only the music, pre­
ferring not to use the white sound. Five pa-
JOURNAL OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION

SHOULDER MOTION
PATIENT H.
r ABDUCTION
EXT. ROTATION
INT. ROTATION
30 45 60 75
FIG. 2. Typical progress chart for one patient from
initiation of treatment to the point where audioanalgesia
was instituted.
tients used the white sound only occasionally,
preferring music most of the time. The re­
mainder of the group used both the music and
white sound regularly (see Table 1). The levels
of white sound used by the subjects in the
audioanalgesia group were in the 85 to 107
decibel range; only one patient used higher
levels. The exposure time to this level was
never more than two minutes without a rest
period.
DISCUSSION
This preliminary study of the use of audio­
analgesia as an adjunct to mobilization of the
shoulder joint with limited range of motion
seems to indicate that the procedure is worthy
of further investigation. Wide use of this tech­
nique would not seem likely at this time since
many factors tend to discourage its use. Among
the factors are:
1. Cost of equipment.
2. Audiometric testing. This has been ad­
vocated for experimental use of audioanalgesia
and some otologists believe it is important in
every case to establish a baseline hearing level
for legal reasons. Other investigators who have
used audioanalgesia have not included audio-
August 1966 • Volume 46 • Number 8
metric tests and have not reported problems as­
sociated with the use of audioanalgesia as long
as the stated precautions are observed.3-5,21
3. Problems of evaluating results when using
audioanalgesia. Many investigators have re­
ported this problem.5'16>17
The results reported here are objective with
respect to range of motion, but many subjective
factors entered the picture. No two patients
were exactly alike either in the nature of the
disease process or in their psychological re­
sponse to their disability. The principal reason
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for matched pairs is for statistical analysis, and
insufficient data were collected here for such
comparison.
Subjectively, patients in the audioanalgesia
group, who were treated with passive mobili­
zation prior to the use of the audioanalgesia,
preferred the addition of audioanalgesia. The
patients were more comfortable and with con­
centration on the music or white sound or both
were distracted from the treatment with re­
sultant decrease in anxiety and more complete
relaxation. The patients were more relaxed,
less apprehensive, and experienced much less
discomfort with the use of audioanalgesia; the
physical therapist, therefore, was able to mobil­
ize the involved shoulder more effectively.
The use of audioanalgesia in dentistry re­
mains a controversial subject. The reason ap­
pears to be because it is not clearly understood
why audioanalgesia has been effective. Since
the proposed physiological mechanisms cannot
be substantiated and the mechanisms may be
more on the basis of distraction and sugges­
tion, dentists today have largely rejected its
use.12-14 Whether this is a valid reason for
rejection has been questioned.5
The results obtained in this study would ap­
pear to justify the use of audioanalgesia as an
adjunct to mobilization of the "frozen" shoul­
der and offers the physical therapist an approach
to mobilization of joints worthy of further in­
vestigation and use.
SUMMARY
Sixteen patients who had diagnoses of chronic
bursitis, bicipital tendinitis, or rotator cuff in­
juries were treated with passive mobilization of
the involved shoulder while receiving audio­
analgesia. These patients were compared with
a matching control group. The results, evalu­
ated by length of time under treatment, rate of
regaining motion, and final improvement in
range of motion, showed that use of audioan-
845

I AUDIOANALGESIA WITH MOBILIZATION
OF THE CHRONIC FROZEN SHOULDER
algesia reduced the time required for mobiliza­
tion, motion was regained more rapidly, and
improvement in range of motion was better.
Patients accepted the technique readily, and
while further study is indicated, it appears that
audioanalgesia might be a useful adjunct to mo­
bilization of the painful shoulder joint with
limited range of motion.
8. Davis, Hallowell, and Aram Glorig, Audio analgesia
(a new problem for otologists). Arch. Otolaryng. (Chi­
cago), 75:498-501, June 1962.
9. Lawrence, Merle, The otologist's responsibility in
audioanalgesia. Arch. Otolaryng. (Chicago), 75:293-
294, April 1962.
10. Davis, H., and A. Glorig, Minimum requirements for
apparatus for audioanalgesia. J. Amer. Dent. Ass.,
63:82-87, October 1961.
11. Davis, Hallowell, J. R. Cox, and A. Glorig. Minimum
requirements for apparatus for audioanalgesia, re­
vised. J. Amer. Dent. Ass., 66:421-434, March 1963.
12. Carlin, S., W. D. Ward, and A. L. Geishon, Effect
of sound stimulation on dental sensation threshold.
Science, 138:1258-1259, December 1962.
13. Carlson, Olof G. A study of the effect of audioanal­

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REFERENCES
1. Gardner, Wallace J., and J. C. R. Licklider, Auditory
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3. Schermer, Robert, Music and "white sound." Milit.
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4. Monsey, Harold L., and Victor Eisner, Effectiveness
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5. Burt, Robert K., and Gerald W. Korn, Audio anal­
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6. Bob, Sidney R., Audioanalgesia in podiatric practice,
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7. Hospital Focus Staff, Sound and music in medicine.
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threshold. Canad. Anaesth. Soc. J., 9:105-108, March
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15. Clutton-Brock, J., Analgesia produced by white sound.
Survey Anesth., 6:312-313, June 1962.
16. Allison, Morgan L., Considerations in the approach to
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