mulligan’s mobilisation with movement a review of the tenets

NZ Journal of Physiotherapy – November 2008, Vol. 36 (3) 144

ML Roberts Prize Winner

This literature review won the annual ML Roberts prize awarded for the best 4th year undergraduate research project at AUT University in 2007. NZJP publishes the resulting paper without internal peer review.

Mulligan’s mobilisation with movement: a review of the tenets and prescription of MWMs

Wayne Hing PhDAssociate Professor, Health & Rehabilitation Research Centre, AUT University

Renee Bigelow BHSc (Physiotherapy)Toni Bremner BHSc (Physiotherapy)

At the time this paper was written, these authors were 4th year studentsat the School of Physiotherapy, Auckland University of Technology

ABSTRACTIntroduction: Mulligan’s manual therapy technique at peripheral joints, namely mobilisation with movement (MWM), has been well documented in research for over a decade. The specific parameters of MWM prescription are relatively variable and generally ill defined. The purpose of this review was to critically evaluate the literature regarding MWM prescription at peripheral joints.Methods: A search was conducted from 1990 to June 2007, to identify all studies pertaining to MWM’s at peripheral joints, using the keywords mobilisation with movement* OR mobilization with movement* OR MWM*; manual therapy AND (mobilisation* OR mobilization); mulligan mobilisation* OR mulligan mobilization* from the following databases: Cinahl, Medline and Amed via Ovid, Pubmed and Medline via Ebsco Health Databases, Cochrane via Wiley and PEDro. Two researchers independently reviewed all papers and cross-examined reference lists for further potential studies. Tables were compiled to determine study content and the specifics regarding MWM prescription; including tenets, technical, and response parameters.Results: Twenty-one studies, which have investigated MWM’s at peripheral joints, were included for analysis. This review highlights that specific parameters identified for MWM prescription (tenets, technical and response parameters), are variable and in general inconsistently implemented and explained. The efficacy of MWM’s at peripheral joints is well established for various joints and pathologies with 20 out of 21 studies (95%) demonstrating positive effects overall.Conclusions: A proposed algorithm has been formulated for the integration into clinical practice to ensure necessary parameters are considered. It would be advisable that future research has more robust methodology and investigates and/or implements all necessary established parameters of MWM prescription. Hing W, Bigelow R, Bremner T (2008): Mulligan’s mobilisation with movement: a review of the tenets and prescription of MWMs. New Zealand Journal of Physiotherapy 36(3): 144-164.Keywords: mobilisation with movement, MWM, manual therapy, mulligan mobilisation, manipulative technique.

InTRODUcTIOnThe treatment of musculoskeletal joint dysfunction may

require a physiotherapist to use manual therapy. One of these manual therapy techniques include mobilization with movement (MWM), a type of joint mobilisation developed by Brian Mulligan (Mulligan 2004, Mulligan 2007); also referred to as a Mulligan mobilisation (Collins et al 2004, Kochar and Dogra 2002, Teys et al 2006) or a manipulative technique (Paungmali et al 2003b, Vicenzino et al 2001). The MWM technique consists of many necessary parameters for prescription, which are outlined in Figure 1. An accessory glide is applied at a peripheral joint, while a normally pain-provoking physiological movement or action is actively or passively performed. A key component to MWM is that pain should always be reduced and/or eliminated during the application (Exelby 1995, Exelby 1996, Mulligan 2004, Wilson 2001). Further gains in pain relief may be attained via

the application of pain-free passive overpressure

Figure 1: Key parameters of MWM prescription

4

Tenets (Hing 2007, Mulligan 2004)

∞ Accessory glide

∞ Physiological movement

∞ Pain-free or pain alteration *

∞ Immediate/instantaneous effect *

∞ Overpressure

Technical Parameters (Hing, 2007)

∞ Repetitions

∞ Sets

∞ Frequency

∞ Amount of force

∞ Rest periods

Response Parameters (‘PILL’ Acronym) (Hing, 2007)



∞ Long-Lasting

∞ Client specific outcome measure (CSOM)

or comparable sign

Note: * = Duplication of

parameters as defined by

different clinicians

Introduction

The treatment of musculoskeletal joint dysfunction may require a physiotherapist to use

manual therapy. One of these manual therapy techniques include mobilization with movement

(MWM), a type of joint mobilisation developed by Brian Mulligan (Mulligan 2004, Mulligan

2007); also referred to as a Mulligan mobilisation (Collins et al 2004, Kochar and Dogra 2002,

Teys et al 2006) or a manipulative technique (Paungmali et al 2003b, Vicenzino et al 2001). The

MWM technique consists of many necessary parameters for prescription, which are outlined in

Figure 1. An accessory glide is applied at a peripheral joint, while a normally pain-provoking

physiological movement or action is actively or passively performed. A key component to MWM

is that pain should always be reduced and/or eliminated during the application (Exelby 1995,

Exelby 1996, Mulligan 2004, Wilson 2001).

Figure 1: Key

parameters of

MWM

prescription

Parameters

4

Tenets (Hing 2007, Mulligan 2004)

∞ Accessory glide

∞ Physiological movement



∞ Overpressure

Technical Parameters (Hing, 2007)

∞ Repetitions

∞ Sets

∞ Frequency

∞ Amount of force

∞ Rest periods

Response Parameters (‘PILL’ Acronym) (Hing, 2007)



∞ Long-Lasting

∞ Client specific outcome measure (CSOM)

or comparable sign

Note: * = Duplication of

parameters as defined by

different clinicians

Introduction

The treatment of musculoskeletal joint dysfunction may require a physiotherapist to use

manual therapy. One of these manual therapy techniques include mobilization with movement

(MWM), a type of joint mobilisation developed by Brian Mulligan (Mulligan 2004, Mulligan

2007); also referred to as a Mulligan mobilisation (Collins et al 2004, Kochar and Dogra 2002,

Teys et al 2006) or a manipulative technique (Paungmali et al 2003b, Vicenzino et al 2001). The

MWM technique consists of many necessary parameters for prescription, which are outlined in

Figure 1. An accessory glide is applied at a peripheral joint, while a normally pain-provoking

physiological movement or action is actively or passively performed. A key component to MWM

is that pain should always be reduced and/or eliminated during the application (Exelby 1995,

Exelby 1996, Mulligan 2004, Wilson 2001).

Figure 1: Key

parameters of

MWM

prescription

Parameters

•••••

•••••

••••


at the end of the available range during the MWM (Mulligan, 2004; Wilson, 2001). Adaptation, or ‘tweakanology’ as described by Mulligan, is essential to perform if the technique does not positively improve pain behaviour (Exelby 1996). Primarily this includes the direction or angle of the accessory glide, and/or the amount of force. The MWM technique also requires a comparable sign or client specific outcome measure (CSOM) as a baseline measure, to evaluate treatment effectiveness (Exelby 1995, Exelby 1996, Wilson 2001).

With respect to the research, the clinical efficacy of Mulligan’s MWM techniques has been established for improving joint function, with a number of hypotheses for its cause and effect. Mulligan’s original theory for the effectiveness of an MWM is based on the concept related to a ‘positional fault’ that occur secondary to injury and lead to mal-tracking of the joint; resulting in symptoms such as pain, stiffness or weakness (Mulligan, 2004). The cause of positional faults has been suggested to be due to changes in the shape of articular surfaces, thickness of cartilage, orientation of fibres of ligaments and capsules, or the direction and pull of muscles and tendons. MWM’s correct this by repositioning the joint causing it to track normally (Mulligan, 2004; Wilson, 2001).

More recent studies have investigated further mechanisms that including the hypoalgesic and sympathetic nervous system (SNS) excitation effects (Abbott 2001, Paungmali et al 2003a, Paungmali et al 2004, Teys et al 2006). Further research has established the effectiveness of MWM’s for increasing joint range of motion (ROM), enhancing muscle function, or more specifically treating particular pathologies (Collins et al 2004, DeSantis and Hasson 2006, Exelby 1996, Mulligan 2004, Paungmali et al 2003b, Teys et al 2006, Vicenzino et al 2006).

Despite the common use of MWM techniques in clinical practice for many musculoskeletal conditions, the prescription is not clearly defined, although there is common reference in the literature to Mulligan’s recommendations as outlined in his text (Mulligan 2004). Prescription refers to many parameters within an MWM, including tenets, technical and response parameters, along with a comparable sign or CSOM (refer to Figure 1). Prescription can be defined as ‘a written direction for the preparation, compounding, and administration of a medicine’ (Lexico Publishing Group Ltd 2007). With respect to MWM prescription, this definition refers to having written guidelines that are clearly defined to draw on for the application of this treatment technique. Tenets represent the principles included in an MWM, which have been outlined by Mulligan (Hing 2007, Mulligan 2004). Both the technical and response parameters are contemporary concepts devised by Vicenzino & Hing (Hing, 2007). To date these aspects of prescription have not yet been reviewed or validated, which

may impact on the clinical application of MWM treatment.

Therefore, the purpose was to undertake a review to critically evaluate the literature regarding MWM prescription at peripheral joints and to determine the specific parameters and rationale related to this prescription thus in attempt to formulate guidelines for clinical practice.

MeTHODsLiterature search strategy

The purpose of this review was to research relevant articles in relation to MWM of peripheral joints only. The electronic databases in the search from 1990 to June 2007, included: CINAHL via Ovid and Ebsco Health Databases, Cochrane via Wiley and Ovid, AMED, Medline via Ebsco and Pubmed, and PEDro. The refined key terms, included mobilisation with movement* OR mobilization with movement* OR MWM*; manual therapy AND (mobilisation* OR mobilization); mulligan mobilisation* OR mulligan mobilization*. These search phrases were adapted for particular databases (Medline via Pubmed and Ebsco, and Ebsco Health Databases), due to the excessive number of results (refer to Figure 2). While performing the search, two independent researchers evaluated all titles and abstracts and were obtained from the various databases or from other sources to determine appropriateness. If this was unclear the full-text article was obtained to confirm whether MWM at peripheral joints was employed. All articles to be included in this review were obtained in hard copy. For more detail on this search strategy see the flow chart below (Figure 2).

Exclusion criteria which was incorporated during the search included: studies prior to 1990, non-English written articles, studies not relevant to peripheral joint manual therapy/MWM/physiotherapy, spinal manual therapy, chiropractic studies, non-original research, cadaver or animal studies, and/or if there was no clear indication of the use of MWM. The aim of this review was to obtain every study, which has utilised MWM techniques; therefore no restrictions were placed on study design or methodological quality. All literature needed to be reviewed accurately to analyse the possible variations in its prescription. As papers were examined, reference lists were cross checked by both reviewers for citations of other potentially relevant studies, and in total three studies were subsequently retrieved from this process of cross-referencing (Hetherington 1996, Stephens 1995, Vicenzino et al 2001).

Review of study characteristicsUsing a generic critical appraisal checklist, data

was extracted from the included 21 articles and information was recorded. Four specific tables relating to MWM prescription were also formed, which included the tenets, pain behaviour analysis, technical parameters, and response parameters (CSOM and the PILL acronym). Each reviewer


Figure 2: Flow chart outlining research process

8

Objective: Two independent researchers to obtain

relevant articles in relation to mobilisation with

movement in peripheral joints only

Global search followed by a refined

search (exclusion criteria implemented)

Generic search terms for the refined search:

KEY:

- A) mobilization* with movement OR mobilisation* with movement OR MWM*

- B) manual therapy AND (mobilization* OR mobilisation*)

- C) mulligan mobilization* OR mulligan mobilisation*

Sources:

1) Amed

A) 22 results Excluded: A) 10

B) 56 results B) 51

C) 1 results C) 0

2) Cinahl via Ovid


B) 132 results B) 126

C) 2 results C) 1

3) Cochrane via Ovid


B) 53 results B) 50

C) 1 results C) 0

4) Cochrane via Wiley


B) 1 results B) 1

C) 4 results C) 0

5) Ebsco Health Databases

NB: Adapted search terms:

[A) mobilization* with movement OR mobilisation* with movement ]


B) 89 results B) 84

C) 1 results C) 1

6) Medline via Ebsco

NB: Adapted search terms:

[A) mobilization* with movement OR mobilisation* with movement ]


B) 68 results B) 63

C) 0 results C) 0

7) Medline via Pubmed

NB: Adapted search terms

mobilization* with movement OR mobilisation* with movement OR MWM* = 71398

mobilization* with movement OR mobilisation* with movement = 71173

i.e. [A) manual therapy AND (mobilization* with movement OR mobilisation* with movement OR MWM*]

manual therapy AND (mobilization* OR mobilisation*) = 2873

i.e. [B) manual physical therapy AND (mobilization* OR mobilisation*) ]


B) 111 results B) 110

C) 634 results C) 632

8) PEDro


B) 22 results B) 20

C) 3 results C) 0


analysed all of this data. The content of these tables will be discussed further in the results.

ResULTsDuring the search, articles were excluded on

the basis of the strict exclusion criteria previously mentioned. A total of 117 articles were identified from the stated databases (refer to Figure 2 for details). Once search results were matched for repeated articles between the databases, 18 were included for analysis. An additional three studies were found by means of further cross-referencing by both reviewers (Hetherington 1996, Stephens 1995, Vicenzino et al 2001), increasing the total to 21 studies for analysis - including four true randomised controlled trials (RCT’s), five RCT’s with participants as own control, one quasi-experimental, three non-experimental, three case studies, and five case reports. Further detail of each of the studies methodological data variation and study design are detailed in Appendix 1.

1) specific parameters and Rationale Related to MWM prescription

Within the prescription of MWM’s, there are different areas that need investigating. Firstly there are the five tenets, described by Mulligan, which should be considered with all MWM’s. These are: the accessory glide generated by the therapist, the physiological movement or action, pain reduction or elimination, an immediate effect, and the use of overpressure, which are outlined in Table 1 (Hing, 2007). Pain behaviour is further elaborated in Table 2. The second consideration of MWM’s is the technical parameters of prescription, which are: repetitions, sets, frequency, amount of force, and rest periods, which are outlined in Table 3. Vicenzino & Hing have devised a new concept of response parameters, which are the effects that the

Figure 2: Flow chart outlining research

process

Exclusion criteria which was incorporated during the search included: studies prior to

1990, non-English written articles, studies not relevant to peripheral joint manual

therapy/MWM/physiotherapy, spinal manual therapy, chiropractic studies, non-original research,

cadaver or animal studies, and/or if there was no clear indication of the use of MWM. The aim of

this review was to obtain every study, which has utilised MWM techniques; therefore no

restrictions were placed on study design or methodological quality. All literature needed to be

reviewed accurately to analyse the possible variations in its prescription. As papers were

examined, reference lists were cross checked by both reviewers for citations of other potentially

relevant studies, and in total three studies were subsequently retrieved from this process of cross-

referencing (Hetherington 1996, Stephens 1995, Vicenzino et al 2001).

Review of Study Characteristics

Using a generic critical appraisal checklist, data was extracted from the included 21

articles and information was recorded. Four specific tables relating to MWM prescription were

TOTAL articles identified for analysis in

relation to the exclusion criteria: 117 studies

Cross matching of search results for repeated

articles resulted in: 18 studies

Cross-referencing of all articles resulted in:

3 studies

Critiquing method:

- Critiquing tool selected (Downs & Black, 1998)

- All articles critiqued by both researchers.

Simultaneously compared findings

Selected Studies

Total: 21 studies to be reviewed

- 4 True randomised control trials (RCTs)

- 5 Randomised control trials, participants as

own control

- 1 Quasi-experimental study (no control)

- 3 Non-experimental studies (2

pretest/posttest, 1 repeated measures)

- 3 Case studies

- 5 Case reports

Figure 2: Flow chart outlining research

process

Exclusion criteria which was incorporated during the search included: studies prior to

1990, non-English written articles, studies not relevant to peripheral joint manual

therapy/MWM/physiotherapy, spinal manual therapy, chiropractic studies, non-original research,

cadaver or animal studies, and/or if there was no clear indication of the use of MWM. The aim of

this review was to obtain every study, which has utilised MWM techniques; therefore no

restrictions were placed on study design or methodological quality. All literature needed to be

reviewed accurately to analyse the possible variations in its prescription. As papers were

examined, reference lists were cross checked by both reviewers for citations of other potentially

relevant studies, and in total three studies were subsequently retrieved from this process of cross-

referencing (Hetherington 1996, Stephens 1995, Vicenzino et al 2001).

Review of Study Characteristics

Using a generic critical appraisal checklist, data was extracted from the included 21

articles and information was recorded. Four specific tables relating to MWM prescription were

TOTAL articles identified for analysis in

relation to the exclusion criteria: 117 studies

Cross matching of search results for repeated

articles resulted in: 18 studies

Cross-referencing of all articles resulted in:

3 studies

Critiquing method:

- Critiquing tool selected (Downs & Black, 1998)

- All articles critiqued by both researchers.

Simultaneously compared findings

Selected Studies

Total: 21 studies to be reviewed

- 4 True randomised control trials (RCTs)

- 5 Randomised control trials, participants as

own control

- 1 Quasi-experimental study (no control)

- 3 Non-experimental studies (2

pretest/posttest, 1 repeated measures)

- 3 Case studies

- 5 Case reports

MWM should have on the patient to continue with treatment (Hing, 2007). These are ‘pain-free’ or pain altering application (reduction + / – elimination), instantaneous and long-lasting effects, namely the ‘PILL’ acronym (refer to Tables 2 and 4). Lastly Vicenzino & Hing have also discussed the use of a comparable sign to determine treatment effectiveness, which is also known as a CSOM, also found in Table 4 (Hing, 2007). There is a duplication of parameters, such as ‘pain-free’ or pain altering application and an immediate or instantaneous effect, which are both components of tenets and the PILL acronym. This duplication is secondary to two different clinicians defining these parameters of prescription.

(Abbott 2001, Abbott et al 2001, Altman and Burton 1999, Backstrom 2002, Bisset et al 2006, Collins et al 2004, DeSantis and Hasson 2006, Downs and Black 1998, Exelby 1995, Exelby 1996, Folk 2001, Hartling et al 2004, Hetherington 1996, Hignett 2003a, Hignett 2003b, Hing 2007, Hsieh et al 2002, Kavanagh 1999, Kochar and Dogra 2002, Lexico Publishing Group Ltd 2007, McLean et al 2002, Monteiro and Victora 2005, Mulligan 1989, Mulligan 1995, Mulligan 1999, Mulligan 2004, Mulligan 2006, Mulligan 2007, O’Brien and Vicenzino 1998, Paungmali et al 2003a, Paungmali et al 2004, Paungmali et al 2003b, Roddy et al 2005, Saunders et al 2003, Slater et al 2006, Stephens 1995, Teys et al 2006, Vicenzino 2003, Vicenzino et al 2006, Vicenzino et al 2001, Vicenzino et al 2007, Vicenzino and Wright 1995, Wilson 2001, Zhang et al 2005)

Tenets of MWMAccessory glide

The accessory glide performed should either be at a right angle to the joint such as a lateral glide of the elbow, or follow Kaltenborn’s concave-convex

Figure 2 (continued)


rule such as an anterior-posterior glide of the ankle (Exelby 1995). All studies, except Bisset et al. (2006) clearly defined the direction of glide, although referred to Vicenzino (2003) for the prescription of their MWM, which clearly outlines that the glide should be a lateral glide of the forearm for treatment of lateral epicondylalgia. All studies at the elbow applied a lateral glide to the ulna. The second most common form of glide was an anterior-posterior mobilisation either directly from mobilising the distal bone of the joint, or mobilising the proximal bone in the opposite direction, such as a posterior-anterior mobilisation (Collins et al., 2004; Vicenzino et al, 2006). The techniques for the wrist and thumb were highly variable (Backstrom, 2002; Folk, 2001; Hsieh et al., 2002).

Physiological movementAll studies involved a secondary movement or

action to be performed by the patient during the MWM. Only two studies did not clearly state the movement performed during the MWM (Abbott, 2001; Bisset et al., 2006). Bisset et al. (2006) once again referred to Vicenzino (2003), which states that the patient should perform a pain-free gripping action. Abbott (2001) stated that the painful movement was performed, although this was not specified. For the treatment of lateral epicondylalgia the movement was either wrist extension or gripping of the hand (Abbott, Patla & Jensen, 2001; Kochar & Dogra, 2002; McLean et al., 2002; Paungmali et al., 2003a; Paungmali et al., 2003b; Paungmali et al., 2004; Slater et al., 2006; Stephens, 1995; Vicenzino & Wright, 1995; Vicenzino et al., 2001). MWM’s for lateral ankle sprains included either dorsiflexion or inversion movements (Collins et al., 2004; Hetherington, 1996; O’Brien & Vicenzino, 1998; Vicenzino et al., 2006). The two studies investigating MWM for treatment of shoulder pain were similar utilising either pure abduction or abduction in the scapula plane (Teys et al., 2006; DeSantis & Hasson, 2006). The movement involved in the treatment of thumb sprains varied between the two studies, either including MCP flexion or extension (Folk, 2001; Hsieh et al., 2002). Only one study to date has investigated the use of MWM’s in de Quervain’s, which employed all wrist movements and thumb abduction (Backstrom, 2002). Overall the rationale for all studies of which physiological movement was performed during the MWM, was based upon utilising a normally pain provoking movement, with which the MWM was to eliminate this pain.

‘Pain-free’ or pain alteration (reduction +/ – elimination)

Mulligan (2004) states that the MWM technique must be pain-free during its application. This tenet of an MWM is questionable, as it is more of an alteration to pain with a reduction and/or elimination, and thus not always ‘pain-free’ as indicated by Mulligan. Majority of studies (86%),

have reported pain-free application, conversely three studies in this review did not state whether their MWM technique reduced or eliminated pain (Bisset et al 2006, Slater et al 2006, Stephens 1995). However the study by Bisset et al (2006) referred to Vicenzino (2003), which states that the application should be ‘pain-free’. It is pertinent to the application and effectiveness of an MWM that a reduction and/or an elimination of pain is achieved throughout the technique, with appropriate adaptation of the technique in relation to pain response. Table 2 summarises the analysis of the concept of pain behaviour and alteration with the MWM technique, and furthermore how the adaptation of the MWM in response to pain behaviour changes have occurred in studies.

Immediate / instantaneous effectFor an MWM to be deemed effective and

progressive, there must be a positive instantaneous or immediate effect during its application. This is determined by the CSOM, which will soon be discussed. All studies that included a CSOM found a positive instantaneous effect, except Slater et al. (2006), which found no significant effects of MWM treatment. Only two studies did not report any immediate/instantaneous effect (Bisset et al 2006, Kochar and Dogra 2002). All the CSOM’s improved post treatment, except temperature pain threshold (TPT), which has not been found to be affected by MWM’s in any studies to date (Abbott, 2001; Abbott et al., 2001; Collins et al., 2004; DeSantis & Hasson, 2006; Folk, 2001; Hetherington, 1996; McLean et al., 2002; O’Brien & Vicenzino, 1998; Paungmali et al., 2003a; Paungmali et al., 2003b; Paungmali et al., 2004; Slater et al., 2006; Stephens, 1995; Teys et al., 2006; Vicenzino et al., 2001; Vicenzino et al., 2006; Vicenzino & Wright, 1995).

OverpressureOverpressure is stated by Mulligan (2004) as

been an essential element of MWM prescription, however it was only utilised in five studies (24%) within this review (DeSantis and Hasson 2006, Folk 2001, Hetherington 1996, O’Brien and Vicenzino 1998, Vicenzino et al 2006). The particular joints and pathologies of which this was applied include the shoulder for supraspinatus tendinopathy (DeSantis and Hasson 2006), the thumb for de Quervain’s (Folk 2001), and also for lateral ankle sprains (Hetherington 1996, O’Brien and Vicenzino 1998, Vicenzino et al 2006). As grip strength was applied, overpressure is indirectly incorporated into any of the studies assessing the effects of MWM at the elbow that focused on lateral epicondylalgia.

Repetitions/setsAlthough Mulligan recommends ten repetitions

and three sets for a typical MWM treatment, there are variations in the literature regarding repetitions and sets of its application. Mulligan (1995) states this prescription in the text, but the rationale is ill


Tab

le 1

. Te

nets

of M

WM

ap

plic

atio

n

Auth

or

Acc

esso

ry g

lide

ph

ysi

olo

gica

l m

ovem

ent

pai

n a

lter

atio

n(R

educt

ion

+/-

elim

inat

ion

)

Imm

edia

te e

ffec

tO

ver

pre

ssure

Bis

set

et a

l., 2006

NS

NS

NS

NT

NS

Koc

har

& D

ogra

, 2002

Late

ral gl

ide

Wri

st e

xten

sion

wit

h w

eigh

tsYes

NT

NS

Sla

ter

et a

l., 2006

Late

ral gl

ide

Gri

ppin

gN

SN

oN

ATey

s et

al., 2006

Pos

tero

late

ral gl

ide

to h

um

eral h

ead. A

t ri

ght

an

gle

to s

hou

lder

ele

vati

onPati

ent

act

ivel

y el

evate

d a

rm in

sc

apu

la p

lan

eYes

Yes

NS

Col

lin

s et

al., 2004

PA

glide

of t

ibia

DF in

WB

Yes

Yes

NS

Pau

ngm

ali e

t al., 2003a

Late

ral gl

ide

Gri

ppin

g a d

ynam

omet

er for

appro

x 6 s

econ

ds

Yes

Yes

NA

Pau

ngm

ali e

t al., 2004

Late

ral gl

ide

Gri

ppin

gYes

Yes

NA

Vic

enzi

no

et a

l., 2001

Late

ral gl

ide

Gri

ppin

gYes

Yes

NA

Vic

enzi

no

et a

l., 2006

1) PA

for

ce a

pplied

at

the

tibia

wit

h a

bel

t,

ther

efor

e a p

oste

rior

glide

of t

he

talu

s.2) A

P for

ce a

pplied

to

glid

e th

e ta

lus

Pati

ent

act

ivel

y m

ovin

g in

to t

he

onse

t of

pain

or

end r

an

ge D

F1) Yes

2) N

SYes

Ove

rpre

ssu

re if n

o pain

aft

er

act

ive

mov

emen

t

McL

ean

et

al., 2002

Late

ral gl

ide

Gri

ppin

g a d

ynam

omet

erYes

Yes

NA

Abbot

t, 2

001

Late

ral gl

ide

Spec

ific

com

bin

ed m

ovem

ent

NS

.O

nly

sta

tes

that

pati

ent

per

form

ed

the

nor

mally

pain

pro

vokin

g m

ovem

ent

up t

o 10 t

imes

Yes

Yes

NA

Abbot

t et

al., 2001

Eit

her

dir

ect

late

ral gl

ide

of t

he

pro

xim

al

fore

arm

or

5°

pos

teri

or, an

teri

or o

r ca

udal

of late

ral

Gri

ppin

g act

ion

, co

mbin

e w

ith

w

rist

ext

ensi

on o

r 3

rd fi

nge

r ex

ten

sion

Yes

Yes

NS

Pau

ngm

ali e

t al., 2003b

Late

ral gl

ide

Gri

ppin

g fo

r appro

x 6 s

econ

ds

Yes

Yes

NA

O’B

rien

& V

icen

zin

o, 1

998

Pos

teri

or g

lide

of d

ista

l fibu

laA

ctiv

e in

vers

ion

Yes

Yes

Pass

ive

over

pre

ssu

re

Ste

ph

ens,

1995

Elb

ow: la

tera

l gl

ide.

Wri

st: dor

sal gl

ide.

Th

um

b: palm

ar

glid

e

Wri

st e

xten

sion

, fo

rearm

su

pin

ati

on, gr

ippin

g, r

adia

l dev

iati

on, th

um

b o

ppos

itio

n

NS

Yes

NS

Vic

enzi

no

& W

righ

t, 1

995

Late

ral gl

ide

Gri

ppin

g a w

eigh

t du

rin

g th

e M

WM

Yes

Yes

NA

Back

stro

m, 2002

Radia

l gl

ide

of p

roxi

mal ro

w o

f ca

rpal bon

es.

Uln

a g

lide

of t

rapez

ium

an

d t

rapez

oid for

th

um

b r

adia

l abdu

ctio

n.

Sel

f M

WM

: Pati

ent

applied

uln

a g

lide

on

fore

arm

wit

h U

L W

B (i.e.

radia

l gl

ide

of

carp

al bon

es), s

hifte

d B

W

Wri

st fl

exio

n, ex

ten

sion

, u

lna a

nd

radia

l dev

iati

on, an

d t

hu

mb r

adia

l or

palm

er a

bdu

ctio

n

Yes

Yes

NS

DeS

an

tis

& H

ass

on, 2006

Rig

ht

an

gle

to g

len

ohu

mer

al jo

int

Abdu

ctio

n m

ovem

ent

(ext

ern

ally

rota

ted; op

en c

an

pos

itio

n)

Yes

Yes

Pain

-fre

e pass

ive

over

pre

ssu

re

Fol

k, 2001

Glides

at

the

pro

xim

al en

d o

f th

e pro

xim

al

ph

ala

nx:

med

ial, late

ral, a

xial IR

an

d E

R.

IR p

rove

d t

o be

effe

ctiv

e in

dec

reasi

ng

pain

an

d im

pro

vin

g R

OM

MC

P e

xten

sion

Yes

Yes

Pass

ive

over

pre

ssu

re

Het

her

ingt

on, 1996

Pos

teri

or g

lide

of t

he

dis

tal fibu

la a

t th

e la

tera

l m

alleo

lus

Pati

ent

per

form

ed a

ctiv

e in

vers

ion

w

ith

an

d w

ith

out

a b

elt

an

d t

hen

re

lease

d

Yes

Yes

Pass

ive

over

pre

ssu

re

Hsi

eh e

t al., 2002

Su

pin

ati

on o

f th

e pro

xim

al ph

ala

nx

of t

he

thu

mb

Th

um

b fl

exio

nYes

Yes

NS

Not

e: N

S =

not

sta

ted

; N

A =

Not

ap

plic

ab

le; N

T =

not

tes

ted

; PA

= p

oste

rior

-an

teri

or; D

F =

dor

sifl

exio

n; W

B =

wei

ght

bea

rin

g; A

P =

an

teri

or-p

oste

rior

; a

ppro

x = a

ppro

xim

ate

ly; M

WM

= m

obili

sati

on

wit

h m

ovem

ent;

UL =

up

per

lim

b; B

W =

bod

y w

eigh

t; I

R =

in

tern

al ro

tati

on; E

R =

ext

ern

al ro

tati

on; R

OM

= r

an

ge o

f m

otio

n;

MC

P =

met

aca

rpop

ha

lan

gea

l.


Auth

or

pai

n a

lter

atio

n (re

duct

ion

+/-

elim

inat

ion

):A

dap

tati

on o

f M

WM

in r

esponse

to p

ain b

ehav

iour

sta

ted (yes

/ n

o)

Det

ails

reg

ardin

g cl

assi

fica

tion

of

pai

n b

ehav

iour

Bis

set

et a

l.,

2006

No

– re

ferr

ed t

o V

icen

zin

o (2

003)

Vic

enzi

no

(2003) st

ate

s th

e gr

ippin

g act

ion

per

form

ed d

uri

ng

the

MW

M s

hou

ld b

e to

th

e on

set

of p

ain

an

d n

o m

ore

Vic

enzi

no

(2003) st

ate

s to

rep

eat

the

MW

M s

ever

al ti

mes

, on

ly if

ther

e is

a s

ubst

an

tial dec

rease

in

pain

. If

th

e pain

rel

ief

has

not

occ

urr

ed t

hen

gl

ides

at

dif

fere

nt

an

gles

sh

ould

be

att

empte

d,

up t

o a m

axi

mu

m o

f 4

Koc

har

& D

ogra

, 2002

Yes

Sta

tes

that

MW

M’s

are

pain

-fre

e w

ith

a c

orre

ct g

lide,

alt

hou

gh t

hey

n

oted

th

at

pain

was

only

dim

inis

hed

du

rin

g th

eir

MW

M a

pplica

tion

NS

Sla

ter

et a

l.,

2006

No

– re

ferr

ed t

o M

ullig

an

(1999),

Vic

enzi

no

& W

righ

t (1

995),

Abbot

t et

al. (2001), V

icen

zin

o et

al. (2001), &

Pau

ngm

ali e

t al.

(2003a)

NS

(M

ullig

an

1999)

NS

Tey

s et

al.,

2006

Yes

Pain

-fre

e arm

ele

vati

on d

uri

ng

the

glid

eTh

e M

WM

was

cease

d im

med

iate

ly if

an

y pain

was

exper

ien

ced

Col

lin

s et

al.,

2004

Yes

MW

M w

as

applied

to

the

end o

f th

e pain

-fre

e ra

nge

If p

ain

was

exper

ien

ced d

uri

ng

the

MW

M t

he

trea

tmen

t w

as

cease

d,

an

d

the

part

icip

an

t w

as

excl

uded

fro

m t

he

stu

dy

Pau

ngm

ali e

t al.,

2003a

Yes

Th

e gl

ide

was

pain

less

ly a

pplied

, an

d t

he

pati

ent

per

form

ed a

pain

-fr

ee g

rippin

g act

ion

NS

. A

lth

ough

no

pati

ents

rep

orte

d p

ain

wit

h t

reatm

ent

Pau

ngm

ali e

t al.,

2004

Yes

Th

e gl

ide

was

pain

less

ly a

pplied

, an

d a

pain

-fre

e gr

ippin

g act

ion

w

as

per

form

edN

S

Vic

enzi

no

et a

l.,

2001

Yes

Th

e gl

ide

was

per

form

ed w

hilst

th

e pati

ent

per

form

ed a

pain

-fre

e gr

ippin

g act

ion

NS

. A

lth

ough

no

pati

ents

rep

orte

d p

ain

wit

h t

reatm

ent

Vic

enzi

no

et a

l.,

2006

Yes

It w

as

state

d in

th

e te

xt t

hat

the

esse

nti

al para

met

er o

f an

MW

M

is t

hat

they

do

not

in

flic

t an

y pain

bu

t ra

ther

allev

iate

pain

du

rin

g n

orm

ally

pain

ful act

ion

s

NS

McL

ean

et

al.,

2002

Yes

Pain

-fre

e gr

ip s

tren

gth

tes

t per

form

ed w

hile

the

glid

e w

as

sust

ain

edN

S -

Th

e fo

rce

was

chan

ged in

rel

ati

on t

o th

e st

udy

inte

rven

tion

, n

ot t

he

pain

res

pon

seA

bbot

t, 2

001

Yes

It is

state

d t

hat

the

nor

mally

pain

pro

vokin

g m

ovem

ent

is

per

form

ed d

uri

ng

the

MW

M (it

is

un

clea

r w

het

her

th

is w

as

pain

-fr

ee d

uri

ng

the

trea

tmen

t)

If p

ain

ret

urn

ed,

no

furt

her

rep

etit

ion

s w

ere

per

form

ed

Abbot

t et

al.,

2001

Yes

Sta

ted t

hat

the

aim

for

th

e M

WM

was

an

elim

inati

on o

f pain

wit

h

the

com

para

ble

sig

n (n

orm

ally

pain

pro

vokin

g act

ion

) th

at

was

part

icu

lar

to t

he

pati

ent

Fou

r att

empts

of

the

dir

ecti

on o

f m

an

ual pre

ssu

re w

ere

allow

ed t

o det

erm

ine

wh

ich

elim

inate

d t

he

pain

. If

th

ere

pain

was

not

elim

inate

d o

r it

ret

urn

ed d

uri

ng

trea

tmen

t, n

o fu

rth

er r

epet

itio

ns

wer

e per

form

edPau

ngm

ali e

t al.,

2003b

Yes

Th

e gl

ide

was

pain

less

ly a

pplied

, an

d a

pain

-fre

e gr

ippin

g act

ion

w

as

per

form

edN

S

O’B

rien

& V

icen

zin

o,

1998

Yes

Sta

ted t

hat

MW

M s

ucc

ess

is b

ase

d o

n a

n im

med

iate

rel

ief of

sy

mpto

ms

du

rin

g it

s applica

tion

. M

WM

, w

hic

h c

onsi

sted

of

inve

rsio

n t

o th

e en

d o

f pain

fre

e ra

nge

. It

was

state

d t

hat

the

MW

M

redu

ced p

ain

ove

rall (u

ncl

ear

wh

eth

er t

his

was

du

rin

g or

aft

er t

he

MW

M a

pplica

tion

)

NS

Ste

ph

ens,

1995

No

Th

e el

imin

ati

on o

f pain

was

state

d, bu

t w

as

un

clea

r w

het

her

th

is

was

du

rin

g or

aft

er t

he

MW

M a

pplica

tion

NS

. W

ith

in t

he

lite

ratu

re r

evie

w o

f th

e ca

se s

tudy

they

sta

te t

hat

if t

he

MW

M a

pplica

tion

is

pain

ful, a

n a

lter

nati

ve p

ain

less

an

gle

of

mob

iliz

ati

on is

uti

lise

d

Vic

enzi

no

& W

righ

t,

1995

Yes

Glide

was

per

form

ed w

hilst

a p

ain

-fre

e gr

ippin

g act

ion

was

per

form

ed. S

tate

d t

hat

the

pain

-fre

e applica

tion

was

fun

dam

enta

lA

fter

th

e firs

t tr

eatm

ent

sess

ion

cau

sin

g an

exa

cerb

ati

on o

f pain

, th

e pati

ent

was

enco

ura

ged t

o per

form

th

e gr

ippin

g act

ion

wel

l bel

ow t

hei

r pain

th

resh

old d

uri

ng

the

MW

MB

ack

stro

m,

2002

Yes

Pain

-fre

e gl

ides

wer

e applied

. C

hos

en M

WM

res

ult

ed in

im

med

iate

el

imin

ati

on o

f pain

ful act

ion

how

ever

was

not

cle

ar

if t

his

was

du

rin

g or

aft

er t

he

applica

tion

Con

tin

ued

dir

ecti

onal m

odifi

cati

on o

f th

e im

pos

ed g

lide

was

applied

th

rou

ghou

t R

x to

ach

ieve

a p

ain

fre

e

DeS

an

tis

& H

ass

on,

2006

Yes

Th

e ph

ysio

logi

cal m

ovem

ent

per

form

ed d

uri

ng

the

MW

M (sh

ould

er

abdu

ctio

n), m

ust

be

pain

-fre

eN

S

Fol

k,

2001

Yes

Th

e pati

ent

was

inst

ruct

ed t

hat

the

MW

M w

ith

ove

rpre

ssu

re u

sed

mu

st b

e pain

-fre

eC

onst

an

t re

pos

itio

nin

g of

th

e jo

int

wit

h a

lter

ati

on o

f th

e gl

ide,

pos

itio

nin

g, f

orce

, ov

erpre

ssu

re,

an

d t

her

apis

t to

pati

ent

gen

erate

d

mov

emen

t, a

bol

ish

ed t

he

pain

H

eth

erin

gton

, 1996

Yes

Th

e M

WM

applica

tion

was

only

con

tin

ued

wit

h if th

e applica

tion

of

the

glid

e an

d t

he

act

ive

mov

emen

t of

an

kle

in

vers

ion

was

pain

-fre

eN

S

Hsi

eh e

t al.,

2002

Yes

Pati

ent

per

form

ed s

elf M

WM

’s, an

d t

hei

r w

as

an

em

ph

asi

s on

pain

-fr

ee a

pplica

tion

. In

th

e dis

cuss

ion

it

was

state

d t

hat

pain

allev

iati

on

is im

por

tan

t w

ith

MW

M a

pplica

tion

NS

Tab

le 2

. Pa

in b

eha

vio

ur e

xpla

natio

n fo

r ap

plic

atio

n a

nd te

chn

ique

ad

ap

tatio

n

Not

e: M

WM

= m

obiliz

ati

on w

ith

mov

emen

t; N

S =

not

sta

ted.

Tec

hn

ical Para

met

ers

of M

WM


defined. Eighteen out of the 21 articles (86%) stated their repetitions and 11 stated their sets. Majority of studies have followed Mulligan’s recommendations and prescribed three sets of ten repetitions. It is evident that this is the only rationale for MWM prescription, in combination with its use in previous studies. Variations of this prescription were utilised, ranging from two to ten repetitions, with one to four sets.

FrequencyThe frequency of treatment varied from one to 19,

with one session most commonly utilised (Abbott, 2001; Abbott et al., 2001; Folk, 2001; Hetherington, 1996; McLean et al., 2002; Paungmali et al., 2003a; Slater et al., 2006; Stephens, 1995; Vicenzino et al., 2001; Vicenzino et al., 2006). The other two most common frequencies were three or six sessions, which commonly implemented an interval between treatment sessions, varying from 24 to 48 hours (Collins et al., 2004; DeSantis & Hasson, 2006; Kochar & Dogra, 2002; O’Brien & Vicenzino, 1998; Paungmali et al., 2003b; Paungmali et al., 2004; Teys et al., 2006; Vicenzino & Wright, 1995). The most frequent treatment carried out two hourly during waking hours, for three weeks (Hsieh et al., 2002), and the less frequent was approximately one treatment every five days (Backstrom, 2002; Bisset et al., 2006).

Amount of force.The amount of force recommended for an MWM

is not stated in Mulligan’s text (2004), nor was it stated in majority of studies. McLean et al. (2002) is the only study to state the amount of force used, as this was the aim of their study. Using a hand-held dynamometer, therapists applied a lateral glide to elbows with lateral epicondylalgia at 33%, 50%, 66% or 100% of maximal force. The outcome measure was pain-free grip strength (PFGS), and the results showed that 66% or 100% of force resulted in significant gains. The remainder of the studies either did not state the force used (13/21, 62%), or distinguished between using body weight or therapist arm force (7/21, 33%). Therefore the application of force is an important variable in MWM prescription, for determining treatment effectiveness, and this should be investigated further (Backstrom 2002, Collins et al 2004, DeSantis and Hasson 2006, Kochar and Dogra 2002, Paungmali et al 2003a, Slater et al 2006, Vicenzino et al 2006).

Rest periodsThere is large variation in rest periods among the

studies reviewed and it has only been stated in 11 studies (52%) ranging from 30 seconds to two hours between sets (Collins et al 2004, Hsieh et al 2002, McLean et al 2002, Slater et al 2006, Teys et al 2006, Vicenzino et al 2006), and 15 to 60 seconds between repetitions (Paungmali et al., 2003a; Paungmali et al. 2003b; Paungmali et al., 2004; Vicenzino et al.,

2001; Vicenzino & Wright, 1995). Most commonly the rest period was 15 seconds between repetitions with these four studies investigating the hypoalgesic effects of a lateral glide performed at the elbow in patients with lateral epicondylalgia (Paungmali et al., 2003a; Paungmali et al. 2003b; Paungmali et al., 2004; Vicenzino et al., 2001). These studies found positive results with increases in PFGS and pressure pain threshold (PPT).

Response parametersLong-lasting

Effective MWM’s should have a long-lasting effect in order for permanent change to occur. This is a further response parameter, as proposed by Vicenzino & Hing (Hing, 2007). Unfortunately this was only investigated in nine of the studies (43%) via follow-up assessments to establish deterioration or improvement from treatment (Backstrom 2002, Bisset et al 2006, Folk 2001, Hsieh et al 2002, Kochar and Dogra 2002, O’Brien and Vicenzino 1998, Paungmali et al 2003b, Stephens 1995, Vicenzino and Wright 1995). Interestingly, five were case studies/reports, which highlights the fact that other research designs have not incorporated follow-up assessment (Backstrom, 2002; Folk, 2001; Hsieh et al., 2002; O’Brien & Vicenzino, 1998; Stephens, 1995). The follow-up period varied from one to 52 weeks. The results included reduction in pain levels, increase in participant assessment scores, increase in pain-free strength, function and ROM. No studies that investigated this parameter found any negative long-term effects of MWM treatment when compared to placebo or control.

Client specific outcome measure (CSOM) or comparable sign

The CSOM or comparable sign is the outcome measure utilised during and immediately after MWM treatment, to determine its effectiveness, and whether the treatment should be continued with. Vicenzino & Hing have established that this should be carried out after all MWM applications, and only continued with if the CSOM has improved (Hing, 2007). It determines whether adaptation in relation to pain response needs to be applied. All studies incorporated a CSOM in their MWM application, which varied in relation to the joint, main problem or deficit, and purpose of research. The number of specific CSOM’s also varied between studies, but all included either pain levels, strength, ROM or PPT (Abbott, 2001; Abbott et al., 2001; Collins et al., 2004; DeSantis & Hasson, 2006; Folk, 2001; Hetherington, 1996; McLean et al., 2002; O’Brien & Vicenzino, 1998; Paungmali et al., 2003a; Paungmali et al., 2003b; Paungmali et al., 2004; Slater et al., 2006; Stephens, 1995; Teys et al., 2006; Vicenzino et al., 2001; Vicenzino et al., 2006; Vicenzino & Wright, 1995). Others that were included were TPT, upper limb tension tests (ULTT), sympathetic SNS, joint glides or balance (Collins et al., 2004; Hetherington, 1996; Paungmali et al.,


Auth

or

Rep

s/set

sf

requen

cyf

orc

eR

est

per

iod

y

/n

num

ber

Rep

sset

s

Bis

set

et a

l.,

2006

Ref

erre

d t

o V

icen

zin

o (2

003) fo

r M

WM

pre

scri

pti

on.

Not

sta

ted in

th

e st

udy

itse

lf

8 s

essi

ons.

6 w

eeks

NS

NS

NS

Koc

har

&

Dog

ra, 2002

YY

10 r

eps.

3 s

ets.

10 s

essi

ons

10 s

essi

ons.

3 w

eeks

NS

.U

sed b

ody

wei

ght

(bel

t)

NS

Pain

rel

ief du

e to

sen

sory

gati

ng

an

d p

osit

ion

al fa

ult

cor

rect

ion

. In

crea

sed

ten

sile

str

engt

h o

f ti

ssu

e

Sla

ter

et a

l.,

2006

YY

6 r

eps

(30 s

ecs)

.3 s

ets.

Tot

al du

rati

on =

2.5

m

ins

appro

x

1 s

essi

onN

S.

Use

d a

rm for

ce30 s

ecs

bet

wee

n

sets

To

exer

t ra

pid

pain

rel

ievi

ng

effe

cts

ass

ocia

ted w

ith

sym

path

oexc

itati

on

mec

han

ism

s th

at

wou

ld b

e likel

y to

occ

ur

in a

ctu

al te

nn

is e

lbow

pain

Tey

s et

al.,

2006

YY

10 r

eps.

3 s

ets

3 s

essi

ons.

24 h

ours

apart

NS

30 s

ecs

bet

wee

n

sets

Ch

an

ges

to joi

nt

or m

usc

le s

tru

ctu

res

an

d p

osit

ion

al fa

ult

cor

rect

ion

Col

lin

s et

al.,

2004

YY

10 r

eps.

3 s

ets

3 s

essi

ons.

24 h

ours

apart

NS

.U

se o

f bod

y w

eigh

t

1 m

in b

etw

een

set

sM

WM

has

a m

ech

an

ical ef

fect

rath

er t

han

a h

ypoa

lges

ic. A

fter

an

kle

sp

rain

an

teri

or d

ispla

cem

ent

of t

he

talu

s m

ay

occu

r, a

nd M

WM

may

corr

ect

this

pos

itio

nal fa

ult

Pau

ngm

ali e

t al., 2003a

YN

10 r

eps

applied

for

appro

x 6 s

ecs

1 s

essi

onN

S.

Use

d a

rm for

ce15 s

ecs

in b

etw

een

re

ps.

Set

s n

ot s

tate

d

Pos

itio

nal fa

ult

cor

rect

ion

has

bee

n r

esea

rch

ed, h

owev

er p

hys

iolo

gica

l ef

fect

s h

ave

not

bee

n. H

ypoa

lges

ic e

ffec

ts o

f M

WM

tre

atm

ent

Pau

ngm

ali e

t al., 2004

YN

6 r

eps

3 s

essi

ons.

48 h

ours

apart

NS

15 s

ecs

bet

wee

n

reps

Non

-opio

id a

nd p

ossi

ble

a n

oradre

ner

gic

endog

enou

s pain

mod

ula

tion

m

ech

an

ism

sV

icen

zin

o et

al.,

2001

YN

6 r

eps

1 s

essi

onN

S15 s

ecs

bet

wee

n

reps

Hyp

oalg

esic

/ph

ysio

logi

cal m

ech

an

ism

s of

pain

rel

ief ve

rsu

s m

ech

an

ical

join

t co

rrec

tion

/pos

itio

nal fa

ult

mec

han

ism

Vic

enzi

no

et a

l.,

2006

YY

1 &

2) 4 r

eps

of

glid

es. E

ach

glide

main

tain

ed for

10

secs

at

end r

an

ge o

r at

the

onse

t of

pain

. 4 s

ets

per

Rx.

1 s

essi

onN

S.

Use

d a

bel

t an

d

bod

ywei

ght

to

pro

du

ce P

A for

ce

1) 20 s

ecs.

2) N

SU

se o

f M

WM

in

dic

ate

d a

s ev

iden

ce s

how

s th

at

peo

ple

wit

h r

ecu

rren

t an

kle

sp

rain

s h

ave

com

mon

ph

ysic

al im

pair

men

ts b

ein

g a lack

of pos

teri

or t

ala

r gl

ide

an

d W

B d

orsi

flex

ion

. B

ase

d o

n t

he

art

hro

kin

emati

c pri

nci

ple

of th

at

the

talu

s gl

ides

pos

teri

orly

du

rin

g dor

siflex

ion

. To

impro

ve t

he

cou

plin

g jo

int

mot

ion

at

the

talo

cru

ral jo

int,

not

ju

st s

imple

pos

teri

or t

ala

r gl

ide

McL

ean

et

al.,

2002

YY

2 r

eps

each

for

ce.

4 for

ce lev

els

(set

s)1 s

essi

onM

ean

% o

f m

ax

forc

e:

100%

=113.2

N66%

= 7

4.5

N50%

= 5

5.6

N33%

= 3

6.8

N

2 m

ins

bet

wee

n

each

Rx

Spec

ific

forc

e n

eeds

to b

e applied

for

su

ffici

ent

pain

rel

ief

Abbot

t, 2

001

NN

Per

form

ed t

he

pro

vokin

g m

ovem

ent

10 t

imes

.Tot

al ti

me

for

bot

h

sides

an

d m

easu

rin

g = a

ppro

x 15 m

ins

1 s

essi

onN

SN

SPeo

ple

wit

h late

ral ep

icon

dyl

alg

ia h

ave

red

uce

d s

hou

lder

rot

ati

on. A

ch

an

ge in

sh

ould

er R

OM

wit

h m

an

ual th

erapy

at

the

elbow

su

gges

ts

that

the

pre

in

terv

enti

on lim

itati

on w

as

neu

roph

ysio

logi

c in

natu

re, n

ot

mec

han

ical

Abbot

t et

al.,

2001

YN

Up t

o 10 t

imes

1 s

essi

onN

SN

SC

orre

ctin

g th

e jo

int

mala

lign

men

t w

ith

MW

M t

ech

niq

ues

has

an

eff

ect

on

incr

easi

ng

mu

scle

str

engt

h a

nd r

elie

vin

g ass

ocia

ted p

ain

wit

h n

orm

ally

pro

vokin

g act

ion

sPau

ngm

ali e

t al., 2003b

YN

10 r

eps

6 s

essi

ons.

48 h

ours

apart

NS

15 s

ecs

in b

etw

een

re

ps.

Appro

x 48 h

ours

bet

wee

n e

ach

se

ssio

n

Pain

rel

ief du

e to

des

cen

din

g pain

in

hib

itio

n, n

ot d

ue

to e

ndog

enou

s op

ioid

med

iato

rs

O’B

rien

&

Vin

cen

zin

o,

1998

YN

4 r

eps

Su

bje

ct 1

: 6

sess

ion

s ov

er

2 w

eeks,

an

d 3

se

ssio

ns

over

1 w

eek (w

ith

1

wee

k b

etw

een

).S

ubje

ct 2

: 6

sess

ion

s ov

er 2

w

eeks

NS

NS

Pos

itio

nal fa

ult

. Pos

t an

kle

spra

in t

her

e m

ay

be

an

tero

-in

feri

or

sublu

xati

on o

f th

e dis

tal fibu

la a

nd M

WM

may

corr

ect

this

res

ult

ing

in

incr

ease

d R

OM

an

d d

ecre

ase

d p

ain

Tab

le 3

. Te

chn

ica

l pa

ram

ete

rs o

f the

MW

M te

chn

ique

and

ratio

nale

for t

rea

tme

nt e

ffec

tive

ness


Ste

ph

ens,

1995

NN

NS

23 s

essi

ons

NS

NS

Min

or p

osit

ion

al fa

ult

occ

urr

ing

from

an

in

jury

or

stra

in. M

obiliz

ati

on

per

pen

dic

ula

r to

th

e dys

fun

ctio

nal pla

ne

of m

otio

n c

orre

cts

join

ts

pos

itio

nal fa

ult

Vin

cen

zin

o &

W

righ

t, 1

995

YY

6 r

eps.

Glide

sust

ain

ed for

appro

x 5-1

0 s

ecs

4 s

essi

ons.

2 w

eeks

NS

No

lon

ger

than

60

secs

in

bet

wee

n

reps

MW

M e

ffec

t w

as

to d

ecre

ase

pain

an

d in

crea

se fu

nct

ion

du

rin

g an

d

imm

edia

tely

aft

er its

applica

tion

. Pos

itio

nal fa

ult

cor

rect

ion

Back

stro

m,

2002

YY

3 s

ets

of 1

0 r

eps

for

each

of th

e m

ovem

ents

12 s

essi

ons.

2 m

onth

sN

S.

Use

d a

rm for

ce

an

d W

B t

hro

ugh

th

e ri

ght

UL

NS

Pos

itio

nal fa

ult

of ca

rpal bon

es. M

WM

rea

lign

s bon

es a

llow

ing

pain

-fre

e m

ovem

ent

wit

h c

orre

ct a

lign

men

t

DeS

an

tis

&

Hass

on, 2006

YY

Init

ially:

10 r

eps.

2 s

ets.

5 m

ore

sess

ion

s:

10x1

on

ly

5 s

essi

ons.

2 w

eeks

NS

Use

d a

rm for

ceN

SU

se o

f M

WM

ver

sus

Mait

lan

d s

ust

ain

ed g

lides

wit

hou

t m

ovem

ent

to n

ot

only

dec

rease

pain

bu

t in

crea

se R

OM

an

d fu

nct

ion

. To

rest

ore

nor

mal

art

hro

kin

emati

cs b

y dec

reasi

ng

dys

fun

ctio

nal jo

int

align

men

t an

d t

hen

in

tu

rn a

llow

mor

e u

nifor

m t

ensi

le s

tres

s applied

at

the

ten

don

du

rin

g act

ivit

ies

Fol

k, 2001

YY

2 s

ets.

10 r

eps

1 s

essi

onN

SN

SM

WM

was

use

d t

o re

pos

itio

n t

he

1st M

CP w

ith

ext

ensi

on m

ovem

ent

an

d t

her

efor

e dec

rease

pain

an

d im

pro

ve R

OM

. To

nor

malise

th

e art

hro

kin

emati

cs o

f th

e 1

st M

CP joi

nt

Het

her

ingt

on,

1996

YY

10 r

eps.

3 s

ets

1 s

essi

onN

SN

SW

ith

a late

ral an

kle

spra

in t

he

liga

men

t re

main

s in

tact

an

d t

he

forc

es a

re

tran

smit

ted t

o th

e fibu

la g

lidin

g it

an

teri

orly

cre

ati

ng

a p

osit

ion

al fa

ult

. B

ala

nce

defi

cits

at

an

kle

are

com

mon

ly a

ssoc

iate

d w

ith

mec

han

orec

epto

r dam

age

in

rel

ati

on t

o th

e m

alp

osit

ion

of th

e fibu

laH

sieh

et

al.,

2002

YN

Sel

f R

x: 6

rep

s2 h

ourl

y du

rin

g w

akin

g h

ours

fo

r 3 w

eeks

NS

2 h

ours

bet

wee

n

sets

MW

M’s

use

d t

o co

rrec

t pos

itio

nal fa

ult

an

d t

her

efor

e dec

rease

pain

an

d

impro

ve R

OM

Not

e: R

x =

tre

atm

ent;

Y =

yes

; N

= n

o; R

eps

= r

epet

itio

ns;

MW

M =

mob

ilisa

tion

wit

h m

ovem

ent;

NS

= n

ot s

tate

d;; s

ecs

= s

econ

ds;

min

s = m

inu

tes;

appro

x = a

ppro

xim

ate

ly;

PA

= p

oste

rior

/a

nte

rior

; m

ax

= m

axi

mu

m;

N =

new

ton

s; R

OM

= r

an

ge o

f m

otio

n; W

B =

wei

ght

bea

rin

g; U

L =

upper

lim

b; M

CP =

met

aca

rpop

ha

lan

gea

l.

2003a; Paungmali et al., 2004; Vicenzino et al., 2006). However specific studies did not use the CSOM immediately after the first set to test for an instantaneous/immediate effect (Bisset et al 2006, Kochar and Dogra 2002).

2) Overall efficacy of MWM’s All studies included in this review found

significant positive results with MWM applications, when compared to placebo or control groups. The only study in which no significant results were found with PPT or strength was by Slater et al. (2006), which is also the only study, which investigated the efficacy of MWM’s on an induced condition. All other studies utilised patients with genuine pathologies, whereas this study induced lateral epicondylalgia pain via delayed onset of muscle soreness and hypertonic saline.

The most common significant results found were increase in strength, reduction in pain levels, increase in PPT, improved ULTT’s, and overall function improvements when compared with placebo or control, mainly in lateral epicondylalgia (Abbott et al., 2001; Bisset et al., 2006; Kochar & Dogra, 2002; McLean et al., 2002; Paungmali et al., 2003a; Paungmali et al., 2003b; Paungmali et al., 2004; Stephens, 1995; Vicenzino et al., 2001;Vicenzino & Wright, 1995). No change in TPT has been found at the elbow (Paungmali et al., 2004). Other interesting findings were that repeated applications of MWM, or MWM with naloxone did not have an inhibitory effect on the pain relieving effects, therefore suggests that a non-opioid mechanism occurs for the analgesic response (Paungmali et al., 2003a; Paungmali et al., 2004). The only study investigating the required force for optimal effects, demonstrated that best results are gained when an MWM is applied at either 66% or 100% of maximal force (McLean et al., 2002). MWM treatment was also found to be superior in the long-term when compared to corticosteroid injection (Bisset et al., 2006). Alterations in SNS function following an MWM were demonstrated, showing an increase in heart rate, blood pressure, skin conductance, blood flux and skin temperature. These are similar to the effects of spinal manipulation (Paungmali et al., 2003b). MWM applied at the elbow has shown to have beneficial effects on shoulder rotation ROM (Abbott, 2001).

At the shoulder, wrist, thumb and ankle, similar results were found. These were decrease in pain, increase in ROM, PPT, strength and joint glides, and improved function (Backstrom, 2002; Collins et al., 2004; DeSantis & Hasson, 2006; Folk, 2001; Hetherington, 1996; Hsieh et al., 2002; O’Brien & Vicenzino, 1998; Teys et al., 2006; Vicenzino et al., 2006). Again no change in TPT was found at the ankle (Collins et al., 2004). One study investigated MWM under magnetic resonance imaging and found MWM to correct a position fault at the thumb, although this was not maintained post MWM, although the positive effects were long-lasting (Hsieh et al., 2002).Ta

ble

3 (

co

ntin

ued

). T

ec

hnic

al p

ara

me

ters

of t

he M

WM

tec

hniq

ue a

nd ra

tiona

le fo

r tre

atm

ent

effe

ctiv

ene

ss


Auth

or

cli

ent

spec

ific

outc

om

e m

easu

re (c

sO

M) or

com

par

able

sig

n

pai

n a

lter

atio

n(R

educt

ion

+/-

eli

min

atio

n)

Inst

anta

neo

us

effe

ctA

sses

smen

t of

‘Lon

g-Las

tin

g’Lon

g-la

stin

g af

fect

s st

ated

at

follow

-up

asse

ssm

ent

Bis

set

et a

l.,

2006

Gri

p for

ce.

Pain

VA

S s

cale

NS

NT

Yes

– A

sses

sed a

t w

eek 6

an

d

52 p

ost

Rx

Ph

ysio

ther

apy

Rx

was

super

ior

to w

ait

an

d s

ee a

nd

cort

icos

tero

id in

ject

ion

s at

6 w

eeks,

how

ever

at

52

wee

ks

ther

e w

as

no

dif

fere

nce

bet

wee

n p

hys

io a

nd

wait

an

d s

eeK

och

ar

&

Dog

ra, 2002

PF

GS

.Pain

VA

S s

cale

.A

bilit

y to

lift

0-3

kgs

Yes

NT

Yes

– A

sses

sed a

t 1, 2, 3 &

12

wee

ks

pos

t R

xS

ign

ifica

nt

redu

ctio

ns

in p

ain

, im

pro

vem

ents

in

gr

ip s

tren

gth

an

d lifti

ng

stre

ngt

h in

th

e in

terv

enti

on

grou

pS

late

r et

al.,

2006

PPT.

Maxi

mal gr

ip a

nd w

rist

ex

ten

sion

for

ce

NS

Yes

– N

o si

gnifi

can

t ef

fect

sN

TN

T

Tey

s et

al.,

2006

Pain

-fre

e R

OM

in

th

e sc

apu

la

pla

ne.

PPT

Yes

Yes

– s

ign

ifica

nt

incr

ease

s in

RO

M

an

d p

ress

ure

pain

th

resh

old

NT

NT

Col

lin

s et

al.,

2004

WB

DF R

OM

.PPT.

TPT

Yes

Yes

– in

crea

se in

RO

M a

nd p

ress

ure

pain

th

resh

old

NT

NT

Pau

ngm

ali e

t al., 2003a

PF

GS

.PPT.

TPT.

SN

S p

ara

met

ers

Yes

Yes

– in

crea

se in

pain

-fre

e gr

ip

stre

ngt

h a

nd p

ress

ure

pain

th

resh

old.

SN

S a

ctiv

ati

on

NT

NT

Pau

ngm

ali e

t al., 2004

PF

GS

.PPT.

TPT.

ULTT

Yes

Yes

– in

crea

se in

pain

-fre

e gr

ip

stre

ngt

h, pre

ssu

re p

ain

th

resh

old a

nd

ULTT

NT

NT

Vic

enzi

no

et

al., 2001

PF

GS

.PPT

Yes

Yes

– in

crea

se in

PFG

S a

nd P

PT

NT

NT

Vic

enzi

no

et

al., 2006

Pos

teri

or t

ala

r gl

ide.

WB

an

kle

DF R

OM

1) Yes

2) N

SYes

– in

crea

se in

pos

teri

or t

ala

r gl

ide

an

d R

OM

NT

NT

McL

ean

et

al., 2002

PF

GS

Yes

Yes

– in

crea

se in

PFG

S (on

ly w

ith

66%

or

100%

for

ce)

NT

NT

Abbot

t, 2

001

Pass

ive

shou

lder

in

tern

al an

d

exte

rnal R

OM

Yes

Yes

– in

crea

se in

RO

MN

TN

T

Abbot

t et

al.,

2001

PF

GS

.M

axi

mal gr

ip s

tren

gth

Yes

Yes

– in

crea

se in

pain

-fre

e an

d

maxi

mal gr

ip s

tren

gth

NT

NT

Pau

ngm

ali e

t al., 2003b

PF

GS

.PPT

Yes

Yes

– in

crea

se in

PFG

S a

nd P

PT

Yes

– A

sses

sed a

t fin

al (6

th)

sess

ion

(48 h

ours

in

bet

wee

n s

essi

ons)

Hyp

oalg

esic

eff

ect

of M

WM

did

not

red

uce

wit

h

repea

ted a

pplica

tion

s. A

ll t

reatm

ents

res

ult

ed in

in

crea

sed P

FG

S (si

gnifi

can

t) a

nd P

PT

O’B

rien

&

Vic

enzi

no,

1998

VA

S.

Inve

rsio

n a

nd W

B D

F R

OM

Yes

Yes

– d

ecre

ase

in

pain

an

d in

crea

se in

R

OM

(in

vers

ion

an

d D

F)

Yes

– A

sses

sed 3

tim

es. 1 w

eek

pos

t R

x ph

ase

= p

hase

CR

edu

ctio

n in

pain

, im

pro

ved in

vers

ion

an

d D

F R

OM

, im

pro

ved fu

nct

ion

al per

form

an

ce a

t th

e an

kle

. N

o det

erio

rati

on.

Ste

ph

ens,

1995

Pain

sca

le (VA

S) du

rin

g act

ive

an

d r

esis

ted w

rist

ext

ensi

on,

fore

arm

su

pin

ati

on, an

d h

an

d

grip

NS

Yes

– d

ecre

ase

in

pain

wit

h a

ll h

an

d

an

d a

rm m

otio

ns

Yes

– A

sses

sed a

t ea

ch s

essi

on

an

d a

t th

e en

d o

f 23 t

reatm

ents

Elim

inati

on o

f pain

wou

ld c

onti

nu

e fo

r 1-2

days

h

owev

er p

ain

wou

ld e

ven

tually

re-o

ccu

r. S

elf-

MW

M

wou

ld e

lim

inate

th

e pain

aga

in. A

t dis

charg

e,

MW

Ms

wer

e st

ill ef

fect

ive

at

dec

reasi

ng

pain

if

nee

ded

Vic

enzi

no

&

Wri

ght,

1995

PF

GS

Yes

Yes

– in

crea

se in

PFG

S d

uri

ng

an

d

aft

er a

pplica

tion

Yes

– A

sses

sed a

t 6 w

eeks

pos

t R

xPati

ent

had n

o pain

an

d h

ad r

etu

rned

to

full

fun

ctio

n. S

tron

g co

rrel

ati

on b

etw

een

pain

red

uct

ion

an

d in

crea

sed fu

nct

ion

Tab

le 4

. Clie

nt s

pe

cifi

c o

utc

om

e m

ea

sure

(C

SOM

) o

r co

mp

ara

ble

sig

n, a

nd P

ILL

ac

rony

m


The overall efficacy of MWM’s has largely proven to be effective in both reducing pain and improving function in conditions such as lateral epicondylalgia, shoulder pain, de Quervain’s, thumb and ankle sprains. The long-term results are discussed above, within ‘long-lasting’ effects.

DIscUssIOnspecific parameters and Rationale Related to MWM prescription

As previously described, tenets, technical and response parameters, all contribute to the effectiveness of Mulligan’s manual therapy technique. However, a key finding from this review is that prescription of MWM has been poorly explained or not adequately applied in the literature. This is interesting considering that specific aspects of MWM application have been stated as being necessary components - such as ‘pain-free’, specific reps and sets, and overpressure. Variations exist in the prescription of MWM not only between studies, but also within individual studies.

TenetsThe tenets of MWM prescription, as described

by Mulligan, were generally well incorporated, with the exception of overpressure. All studies clearly defined the accessory glide together with the direction, with the exception of Bisset et al. (2006) who did not state it within the study treatment method, however did refer to Vicenzino (2003). The secondary physiological movement or action performed by the patient is important to ensure a normally pain provoking movement can be altered with the MWM technique. All studies involved this tenet, with only two not clearly stating the movement or action performed (Abbott 2001, Bisset et al 2006), however Bisset et al. (2006) referred to Vicenzino (2003) for its prescription.

The secondary physiological movement closely relates to pain behaviour and how the pain associated with this movement or action should be reduced or eliminated with an MWM. However the concept of terminology surrounding the term ‘pain-free’ as initially stated by Mulligan is controversial. As explained in the results and outlined in Table 2 the alteration of pain that occurs during and after MWM is not always an elimination of pain or otherwise known as ‘pain-free’. Majority of studies (86%) documented pain-free application was utilised, with a minimal number discussing a reduction of pain as also being accepted. This raises the question of why is there is a chosen belief that MWM must be pain-free to continue with treatment? Thus should the term ‘pain-free’ be changed to pain alteration (reduction + / – elimination)? Several studies referred to the fundamental concept of pain-free application, yet it was not employed in the methods, or if stated it was not clear if pain was altered during or after the MWM (Abbott 2001, Backstrom 2002, Hsieh et al 2002, O’Brien and Vicenzino 1998, Stephens 1995). N

ote:

VA

S =

vis

ual an

alo

gue

scale

; N

S =

not

sta

ted;

NT =

not

tes

ted;

Rx

= t

reatm

ent;

PFG

S =

pain

fre

e gr

ip s

tren

gth

; kgs

= k

ilog

ram

s; P

PT =

pre

ssu

re p

ain

th

resh

old;

RO

M =

ran

ge o

f m

otio

n;

WB

= w

eigh

t bea

rin

g; D

F =

dor

siflex

ion

; TPT =

tem

per

atu

re p

ain

th

resh

old; S

NS

= s

ympath

etic

ner

vou

s sy

stem

; U

LTT =

upper

lim

b t

ensi

on t

est;

MW

M =

mob

ilis

ati

on w

ith

mov

emen

t; N

PR

S =

nu

mer

ic p

ain

rati

ng

scale

; M

CP =

met

aca

rpop

hala

nge

al; M

RI

= m

agn

etic

res

onan

ce im

agi

ng.

Back

stro

m,

2002

Pain

VA

S s

cale

.S

tren

gth

an

d R

OM

at

wri

st

an

d t

hu

mb

Yes

Yes

– d

ecre

ase

in

pain

an

d in

crea

se

in R

OM

Yes

– A

sses

sed a

t 4 m

onth

s,

an

d 1

yea

r pos

t R

xM

WM

applica

tion

red

uce

d p

ain

to

0-1

/10 (VA

S). A

ll

impair

men

ts h

ad r

esol

ved a

t 1 y

ear

(no

evid

ence

of

wri

st/th

um

b p

ain

or

fun

ctio

nal defi

cits

wh

ats

oeve

r)D

eSan

tis

& H

ass

on,

2006

NPR

S d

uri

ng

act

ive

abdu

ctio

n.

Abdu

ctio

n a

ctiv

e R

OM

Yes

Yes

– d

ecre

ase

in

pain

an

d in

crea

se

in R

OM

NT

NT

Fol

k, 2001

Pain

sca

le (VA

S).

En

d r

an

ge M

CP e

xten

sion

w

ith

ove

rpre

ssu

re

Yes

Yes

– p

ain

-fre

e en

d r

an

ge e

xten

sion

w

ith

ove

rpre

ssu

reYes

– A

sses

sed a

t 1 m

onth

an

d

52 w

eeks

pos

t R

xA

t 1ye

ar

follow

-up a

sses

smen

t, t

he

pati

ent

con

firm

ed s

he

had r

emain

ed s

ympto

m fre

e pos

t th

e M

WM

Rx

Het

her

ingt

on,

1996

Pain

on

in

vers

ion

RO

M.

Bala

nce

– s

ingl

e le

g st

an

din

g w

ith

eye

s cl

osed

Yes

Yes

– in

crea

se in

RO

M a

nd b

ala

nce

NT

NT

Hsi

eh e

t al.,

2002

Pain

sca

le (VA

S).

RO

M

Yes

Yes

– im

med

iate

dec

rease

of pain

fo

llow

ing

MW

M a

pplica

tion

Yes

– A

sses

sed 1

wee

k p

ost

Rx

MR

I ex

am

inati

on s

how

ed n

o re

du

ctio

n in

th

e in

itia

l pos

itio

nal fa

ult

, bu

t sh

e h

ad n

o pain

wh

en fl

exin

g h

er r

igh

t th

um

b

Tab

le 4

(c

ont

inue

d).

Clie

nt s

pe

cifi

c o

utc

om

e m

ea

sure

(C

SOM

) o

r co

mp

ara

ble

sig

n, a

nd P

ILL

ac

rony

m


Figure 3: Algorithm for the prescription MWM techniques

Figure 3:

Algorithm for the

prescription

of peripheral

joint MWM

techniques

Is an MWM appropriate?

E.g. Decreased ROM, pain

present, positional fault

evident, decreased strength,

reduced function etc

(CRR*)

YES

What do I need to employ?

∞ Joint mechanics (CRR*) ∞ Accessory glide direction

(e.g. lateral/medial, AP/PA)

∞ Physiological movement OR

action (a normally pain provoking

movement e.g. CSOM)

∞ Manual contact / belt use

∞ Client specific outcome

measure/s (relate to presenting

problem/s e.g. weakness, pain)

∞ Aim for pain alteration

(reduction +/– elimination)

∞ Number of initial reps

(generally 6-10)

∞ Force (Note: Irritability)

Either 66% or 100%

∞ Rest period after 1st set

First application of

MWM:

Pain eliminated or

reducing during

MWM

Pain worsening during

the MWM

ADAPT

as necessary

(angle, glide,

force, etc)

Up to 4 times

(CRR*)

CONTINUE

THEN if NO

improvement

STOP

AFTER APPLICATION

OF 1st Set

- Re-assess CSOM/s

Instantaneous effect?

CSOM is worse

e.g. pain

CSOM is same or

improved

NB: Consider irritability

ADAPT

(angle, glide,

as necessary

force, etc)

Up to 4 times (CRR*)

CONTINUE

OR

PROGRESS

Further sets

- CONSIDER:

∞ Frequency: consider self-MWMs

∞ Sets: 3 sets generally

∞ Rest period: time for re-

assessment

∞ Constant assessment of CSOM/s

PROGRESSIONS

∞ Overpressure

∞ Increase force

∞ Increase difficulty/level of

physiological movement/action

∞ Therapist to patient generated

∞ Increase frequency/sets

(CRR*)

Key:

CRR* = clinical reasoning

required

FINAL COMMENTS:

! Aim to positively alter pain

! Overpressure is essential to gain

maximum benefit from an MWM

! Lasting effect with further reps

! Continuous assessment to assess for

long-lasting effects

! Encourage self-MWMs

! Consider taping to maintain joint

positions

! Consider muscle strengthening to work

concurrently with MWMs

STOP/

••

•

••

•

•

•

•

•

•••

••

STOP/ADAPT

as necessary(angle, glide,

force, etc)Up to 4 times

(CRR*)

This also raises the importance of adaptation in response to pain behaviour during the MWM. Only eight studies explained their particular method of adapting the MWM application to alter pain (Abbott

2001, Abbott et al 2001, Backstrom 2002, Bisset et al 2006, Collins et al 2004, Folk 2001, Teys et al 2006, Vicenzino and Wright 1995). For example Bisset et al (2006) referred to Vicenzino (2003)


for MWM prescription, who recommends that an MWM is repeated several times, only if there is a substantial decrease in pain, and if the pain relief has not occurred then glides at different angles should be attempted; up to a maximum of four times. Abbott et al. (2001) also states that four attempts of the glide direction are permitted, in order to determine which best eliminates the pain. If the pain was not eliminated or it returned during treatment, no further repetitions were performed.

Another tenet or response parameter associated with an MWM is the immediate or instantaneous effect, which occurs during and/or after the application and is determined by the related CSOM/s. Only two studies did not report any immediate or instantaneous effect (Bisset et al 2006, Kochar and Dogra 2002). This aspect of prescription is a necessity in relation to the effectiveness of the MWM, and also adaptation with regards to pain behaviour.

Overpressure is considered to be a key component in MWM techniques to produce effective pain relief, either as a progression and/or an adaptation if the patient remains symptomatic after initial application (Mulligan 2004, Wilson 2001). The literature however does not significantly reflect this, with only five studies (24%) incorporating this parameter (DeSantis and Hasson 2006, Folk 2001, Hetherington 1996, O’Brien and Vicenzino 1998, Vicenzino et al 2006). Several reviews have discussed the use of overpressure, to further alter pain behaviour and acquire pain-free end range (Exelby, 1996; Wilson, 2001).

Technical parametersThe documentation of technical parameters was

variable throughout the studies. Within this review 18 out of 21 studies (86%) stated the number of repetitions and sets employed. Majority of these studies referred to Mulligan’s recommendations of three sets of ten repetitions, although no specific research has been undertaken to investigate the efficacy of these parameters (Mulligan 1995). While the rationale for prescription of repetitions and sets is generally ill defined and based on experimentation in clinical practice, Mulligan (2004) does state the importance of performing an adequate number of repetitions to result in a more lasting effect.

In regards to frequency of MWM treatment one session was most commonly utilised, which is unlikely in a clinical setting but is often carried out in research, especially with MWM’s displaying immediate benefits (Abbott, 2001; Abbott et al., 2001; Folk, 2001; Hetherington, 1996; McLean et al., 2002; Paungmali et al., 2003a; Slater et al., 2006; Vicenzino et al., 2001; Vicenzino et al., 2006). A case study by Stephens (1995) utilised the most frequent treatment sessions (n = 19), which may reflect the chronicity of lateral epicondylalgia, and may represent the need for intense and regular physiotherapy intervention for effective treatment outcomes. This is a clear example of how case

studies can be more clinically relevant with greater generalisability of results.

The amount of force applied during an MWM is a parameter of limited research and documentation within studies. McLean et al. (2002) is the only study to date, which has investigated the effects of MWM in relation to varied amounts of force applied for the accessory glide. The results illustrated that 66% or 100% of maximal force is superior over less amounts, indicating the amount of force is pertinent to consider with MWM effectiveness. It is therefore interesting that no other studies to date have detailed this parameter, apart from seven out of 21 (33%) distinguishing between the use of body weight or therapist arm force (Backstrom 2002, Collins et al 2004, DeSantis and Hasson 2006, Kochar and Dogra 2002, Paungmali et al 2003a, Slater et al 2006, Vicenzino et al 2006).

The rest period between sets of MWM’s, has not been stated by Mulligan (1995), nor is it clearly outlined in any review articles (Exelby, 1995; Exelby, 1996; Vicenzino, 2003; Wilson, 2001), although re-testing between each set for treatment effectiveness is advocated (Exelby, 1996; Wilson, 2001). This area was poorly defined with approximately half of studies (52%) stating the rest periods, with large variations evident. Most commonly employed was a 15 second rest period between repetitions, which was unique to a research purpose of investigating hypoalgesic effects of a lateral glide performed at the elbow in patients with lateral epicondylalgia (Paungmali et al., 2003a; Paungmali et al. 2003b; Paungmali et al., 2004; Vicenzino et al., 2001). To date there are no consistencies within the literature to guide the rest periods between sets (Collins et al 2004, Hsieh et al 2002, McLean et al 2002, Slater et al 2006, Teys et al 2006, Vicenzino et al 2006). In the clinical setting it is probably most appropriate to have a rest period between sets, of a time that allows re-testing of the CSOM to determine treatment effectiveness, and therefore determine whether the MWM application is to be continued with.

Response parametersThe response parameters as recently defined

by Vicenzino & Hing includes the PILL acronym and the CSOM (Hing, 2007). As previously stated the PILL acronym consists of pain alteration, an instantaneous/immediate effect which have both been discussed earlier in tenets, along with long-lasting and the CSOM. Long-lasting effects have been investigated via follow-up assessments in nine studies (43%), all concluding with significant positive results. Paungmali et al. (2003b) established that hypoalgesic effects did not reduce with repeated treatments, therefore is probable that a non-opioid form of analgesia is the cause of pain relief. Also, the case report by Hsieh et al. (2002), determined at follow-up that pain was eliminated via the intervention, however the final magnetic resonance imaging (MRI) illustrated no change in the initial positional fault of the thumb.


The authors therefore suggested that the correction of positional faults during the MWM, as shown by MRI, resulted in immediate effects. The long-term effects, including, pain relief, was hypothesised to be due to changes in nociceptive and motor system dysfunction, possibly implying the role of hypoalgesia. Mulligan (2004) also states that the effects of MWM’s can be maintained further via taping and self-MWM’s, which may further enhance the possible long-lasting effects. This was included in several studies within this review (Backstrom 2002, Hetherington 1996, Hsieh et al 2002, O’Brien and Vicenzino 1998, Stephens 1995, Vicenzino and Wright 1995).

All studies in this review have incorporated the use of CSOM or a comparable sign to be utilised during and/or immediately after an MWM as a response parameter. The development of the CSOM by Vicenzino & Hing is a new concept, which is related to the requirements of what must occur in order to continue with MWM treatment (Hing, 2007). In general, the choice of the CSOM within the literature was variable but very consistent in relation to employing a normally provoking movement or action, with which the MWM is aimed to improve.

proposed Guidelines for clinical practiceOverall, it is apparent that certain parameters

of MWM prescription are ill defined, although the efficacy for particular joints is well established. It may be that experimentation or adaptation of the technique is necessary and common in daily practice, however, a review of its necessary components of prescription was timely. The key components of prescribing an MWM technique need to be defined. Thus it is proposed that the following algorithm is utilised for the prescription of MWM’s at peripheral joints in clinical practice (refer to Figure 3). This algorithm is based on the findings of this systematic review and incorporates all necessary components of MWM prescription.

The algorithm encompasses all parameters that have been reviewed in this research and is based upon integration of results. This includes tenets (accessory glide, physiological movement or action, pain alteration (reduction + / – elimination), immediate/instantaneous effect, overpressure), technical parameters (repetitions, sets, frequency, amount of force, rest periods) and response parameters (long-lasting, CSOM). The content of the algorithm aims to allow the practitioner to easily follow it through in order to apply appropriate MWM prescription. Aspects of the algorithm require clinical reasoning in regards to prescription specifics and consideration of irritability.

future ResearchSubsequent to the extensive research and

analysis undertaken for this review, there are particular areas within MWM prescription that

require further investigation. This could include research into the efficacy and prescription of MWM’s at joints that have not yet been examined such as the hip and knee. This could also incorporate the consideration of various pathologies as in the clinical setting, MWM’s are utilised for many conditions and in all peripheral joints. It is clear that the specific prescription parameters of the MWM technique have not been consistently employed, nor evaluated. For example the use of overpressure was rarely implemented although it is considered a key component of MWM application, therefore investigation into its additional benefits may be necessary. Further parameters of MWM prescription, which were analysed in this review such as the accessory glide, repetitions, sets, frequency, rest periods, also warrant specific comparative research regarding the effects. Once the efficacies of the discussed parameters are further defined, they need to be prescribed appropriately and more clearly explained in future research. An example is with the amount of force used, which has been validated by McLean et al. (2002) although not implemented appropriately in subsequent research to date.

The efficacy of the proposed algorithm could be investigated via the comparison of its implementation versus the common clinician’s MWM application. Perhaps common MWM application could be initially identified through a survey with case examples, which will determine a representative norm for everyday clinical practice and MWM prescription. This will overall establish the efficacy of the algorithm and the incorporation of all necessary MWM prescription components, with regards to treatment outcomes.

cOncLUsIOnMulligan’s peripheral MWM techniques are

commonly utilised within musculoskeletal physiotherapy. This review of the MWM prescription at peripheral joints highlighted that this area of research has strengths, limitations and inconsistencies.

The specific parameters identified for MWM prescription in the literature, is variable and in general inconsistently implemented and explained. The efficacy of MWM’s appears to be well established for various joints and pathologies, as shown by previous reviews, however due to the methodological quality of studies, and gaps in particular areas of both prescription and application, it is apparent that further research is warranted into the specific parameters of MWM’s. The proposed algorithm may be integrated into clinical practice, to aid in the inclusion of all necessary components established from this review.

To conclude, this manual therapy technique is widely used and advocated for many aspects of peripheral joint dysfunction. This review has presented an evaluation of MWM prescription, in


attempt to guide the clinician appropriately, and provide a basis for future research into this area.

ADDRess fOR cORRespOnDenceAssociate Professor Wayne Hing, School of Physiotherapy,

Health & Rehabilitation Research Centre, AUT University, Private Bag 92006, Auckland 1142, New Zealand.

RefeRencesAbbott JH (2001): Mobilization with movement applied to the

elbow affects shoulder range of movement in subjects with lateral epcondylalgia. Manual Therapy 6: 170-177.

Abbott JH, Patla CE and Jensen RH (2001): The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral epicondylalgia. Manual Therapy 6: 163-169.

Altman DG and Burton MJ (1999): The cochrane collaboration. Langenbeck’s Archive of Surgery 384: 432-436.

Backstrom KM (2002): Mobilization with movement as an adjunct intervention in a patient with complicated De Quervain’s tenosynovitis: a case report. Journal of Orthopaedic & Sports Physical Therapy 32: 86-97.

Bisset L, Beller E, Jull G, Brooks P, Darnell R and Vicenzino B (2006): Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial. British Medical Journal 333: 939-944.

Collins N, Teys P and Vicenzino B (2004): The inital effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains. Manual Therapy 9: 77-82.

DeSantis L and Hasson SM (2006): Use of mobilization with movement in the treatment of a patient with subacromial impingement: a case report. Journal of Manipulative and Manual Therapy 14: 77-87.

Downs SH and Black N (1998): The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Journal of Epidemiology and Community Health 52: 377-384.

Exelby L (1995): Mobilisations with movement: a personal view. Physiotherapy 81: 724-729.

Exelby L (1996): Peripheral mobilisations with movement. Manual Therapy 1: 118-126.

Folk B (2001): Traumatic thumb injury management using mobilization with movement. Manual Therapy 6: 178-182.

Hartling L, Brison RJ, Crumley ET, Klassen TP and Picket W (2004): A systematic review of interventions to prevent childhood farm injuries. Pediatrics 114: 483-496.

Hetherington B (1996): Lateral ligament strains of the ankle, do they exist? Manual Therapy 1: 274-275.

Hignett S (2003a): Intervention strategies to reduce musculoskeletal injuries associated with handling patients: a systematic review. Occupation and Environmental Medicine 60: 1-8.

Hignett S (2003b): Systematic review of patient handling activities starting in lying, sitting and starting positions. Journal of Advanced Nursing 41: 545-552.

Hing W (2007). Personal communication surrounding the concepts of MWM prescription. Vicenzino B. Auckland University of Technology.

Hsieh CY, Vicenzino B, Yang CH, Hu MH and Yang C (2002): Mulligan’s mobilization with movement for the thumb: a single case report using magnetic resonance imaging to evaluate the positional fault hypothesis. Manual Therapy 7: 44-49.

Kavanagh J (1999): Is there a positional fault at the inferior tibiofibular joint in patients with acute or chronic ankle sprains compared to normals? Manual Therapy 4: 19-24.

Kochar M and Dogra A (2002): Effectiveness of a specific physiotherapy regimen on patients with tennis elbow. Physiotherapy 88: 333-341.

Lexico Publishing Group Ltd (2007). Dictionary.com. 2007.McLean S, Naish R, Reed L, Urry S and Vicenzino B (2002): A

pilot study of the manual force levels required to produce manipulation induced hypoalgesia. Clinical Biomechanics 17: 304-308.

Monteiro POA and Victora CG (2005): Rapid growth in infancy and childhood and obesity in later life - a systematic review. Obesity Reviews 6: 143-154.

Mulligan B (1989): Manual therapy: “nags”, “snags”, “prp’s” etc. (1st ed. ed.) Wellington: Plane View Services Ltd.

Mulligan B (1995): Manual therapy: “NAGS”, “SNAGS”, “MWMS” etc. (3rd ed. ed.) Wellington: Plane View Services Ltd.

Mulligan B (1999): Manual therapy: “NAGS”, “SNAGS”, “MWMs” etc. (4th ed. ed.) Wellington: Plane View Services Ltd.

Mulligan B (2004): Manual therapy: “NAGS”, “SNAGS”, “MWMS” etc. (5th ed. ed.) Wellington: Plane View Services Ltd.

Mulligan B (2006): Manual therapy: “NAGS”, “SNAGS”, “MWMS” etc. (6th ed. ed.) Wellington: Plane View Services Ltd.

Mulligan B (2007). The Mulligan Concept. 2007.O’Brien T and Vicenzino B (1998): A study of the effects of

Mulligan’s mobilization with movement treatment of lateral ankle pain using a case study design. Manual Therapy 3: 78-84.

Paungmali A, O’Leary S, Souvlis T and Vicenzino B (2003a): Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Physical Therapy 83: 374-383.

Paungmali A, O’Leary S, Souvlis T and Vicenzino B (2004): Naloxone fails to antagonize initial hypoalgesic effect of a manual therapy treatment for lateral epicondylalgia. Journal of Manipulative and Manual Therapy 27: 180-185.

Paungmali A, Vicenzino B and Smith M (2003b): Hypoalgesia by elbow manipulation in lateral epicondylalgia does not exhibit tolerance. Journal of Pain 4: 448-454.

Roddy E, Zhang W, Doherty M, Arden NK, Barlow J, Birrell F, Carr A, Chakravarty K, Dickson J, Hay E, Hoise G, Hurley M, Jordan K, McCarthy C, McMurdo M, Mockett S, O’Reilly S, Peat G, Pendleton A and Richards S (2005): Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee - the MOVE consensus. Rheumatology 44: 67-73.

Saunders LD, Soomro GM, Buckingham J, Jamtvedt G and Raina P (2003): Assessing the methodological quality of nonrandomized intervention studies. Western Journal of Nursing Research 25: 223-237.

Slater H, Arendt-Nielson L, Wright A and Graven N (2006): Effects of a manual therapy technique in experimental lateral epicondylalgia. Manual Therapy 11: 107-117.

Stephens G (1995): Lateral epicondylitis. Journal of Manipulative and Manual Therapy 3: 50-58.

Teys P, Bisset L and Vicenzino B (2006): The initial effects of a Mulligan’s mobilization with movement technique on range of movement and pressure pain threshold in pain-limited shoulders. Manual Therapy 11: 1-6.

Vicenzino B (2003): Lateral epicondylalgia: a musculoskeletal physiotherapy perspective. Manual Therapy 8: 66-79.

Vicenzino B, Branjerdporn M, Teys P and Jordan K (2006): Initial changes in posterior talar glide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent ankle sprain. Journal of Orthopaedic & Sports Physical Therapy 36: 464-471.

Vicenzino B, Paungmali A, Buratowski S and Wright A (2001): Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypolgesia. Manual Therapy 6: 205-212.

Vicenzino B, Paungmali A and Teys P (2007): Mulligan’s mobilization-with-movement, positional faults, and pain relief: Current concepts from a critical review of literature. Manual Therapy 12: 98-108.

Vicenzino B and Wright A (1995): Effects of a novel manipulative physiotherapy technique on tennis elbow: a single case study. Manual Therapy 1: 30-35.

Wilson E (2001): The Mulligan concept: NAGS, SNAGS and mobilizations with movement. Journal of Bodywork and Movement Therapies 5: 81-89.

Zhang W, Roddy E, Doherty M, Arden NK, Barlow J, Birrell F, Carr A, Chakravarty K, Dickson J, Hay E, Hoise G and Hurley M (2005): Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee - the MOVE consensus.


Auth

or

Des

ign

purp

ose

par

tici

pan

tsIn

terv

enti

on

pre

scri

pti

on

of

MW

M/oth

er R

xT

imes

of

Ax

O/c

mea

sure

s

Bis

set

et a

l.,

2006

Tru

e R

CT

To

inve

stig

ate

th

e ef

fica

cy o

f PT in

terv

enti

on

com

pare

d w

ith

co

rtic

oste

roid

in

ject

ion

an

d w

ait

an

d s

ee for

late

ral

epic

ondyl

alg

ia

198 p

art

icip

an

ts.

128 m

ale

s, 7

0

fem

ale

s.M

ean

age

: 48

Gro

up 1

: 8 s

essi

ons

of P

T.

Gro

up 2

: co

rtic

oste

roid

in

ject

ion

.G

rou

p 3

: w

ait

an

d s

ee

PT: 8 s

essi

ons

for

30 m

ins

over

6 w

eeks.

In

clu

ded

MW

M, th

eraban

d e

xerc

ises

an

d

stre

tch

ing.

Cor

tico

ster

iod in

ject

ion

: 1 in

ject

ion

, an

d a

2n

d o

ne

if n

eces

sary

aft

er 2

wee

ks.

Wait

an

d s

ee:

advi

ce, ed

uca

tion

on

m

odifi

cati

ons

to A

DL’s

, en

cou

rage

act

ivit

y,

usi

ng

an

alg

esic

dru

gs, h

eat,

col

d a

nd b

race

s

6 w

eeks

an

d

52 w

eeks

Glo

bal im

pro

vem

ent.

Gri

p for

ce.

Ass

esso

rs r

ati

ng

of

seve

rity

.Pain

(VA

S).

Elb

ow d

isabilit

y (p

ain

-fre

e fu

nct

ion

qu

esti

onn

air

e)

Koc

har

&

Dog

ra, 2002

Tru

e R

CT

To

com

pare

th

e ef

fect

s of

a

com

bin

ati

on o

f M

WM

an

d U

S

vers

us

US

alo

ne,

fo

llow

ed b

y an

ex

erci

se p

rogr

am

me,

fo

r la

tera

l ep

icon

dyl

alg

ia

66 p

art

icip

an

ts.

36 m

ale

s, 3

0

fem

ale

s.M

ean

age

: 41

Gro

up 1

: co

mbin

ati

on

of U

S a

nd M

WM

on

10

sess

ion

s (d

iffe

ren

t R

x on

alt

ern

ate

days

) co

mple

ted

in 3

wee

ks

an

d a

n

exer

cise

pro

gram

me

(9

wee

ks)

.G

rou

p 2

: U

S o

nly

on

10

sess

ion

s co

mple

ted in

3

wee

ks

an

d a

n e

xerc

ise

pro

gram

me

(9 w

eeks)

.G

rou

p 3

(co

ntr

ol): n

o tr

eatm

ent

US

: 3 M

Hz,

1.5

W/cm

2, pu

lsed

1:5

, 5 m

ins.

MW

M: el

bow

ext

ended

, fo

rearm

pro

nate

d,

10 r

eps,

no

pain

, gl

ide

sust

ain

ed w

hile

part

icip

an

t lift

ed w

eigh

t th

at

pre

viou

sly

pro

du

ced p

ain

, fo

r 3 s

ets,

10 s

essi

ons.

Pro

gres

sed M

WM

by

incr

easi

ng

wei

ghts

by

0.5

kg.

Exe

rcis

e: s

tret

chin

g, P

RT, co

nce

ntr

ic/

ecce

ntr

ic e

xerc

ises

Wee

k 1

, 2

an

d 3

.Fol

low

-up a

t 4 m

onth

s

Pain

– V

AS

sca

le.

Abilit

y to

lift

0-3

kg

wei

ghts

wit

h n

o pain

, 24h

rs a

fter

Rx.

Gri

p S

tren

gth

.W

eigh

t te

st

Sla

ter

et a

l.,

2006

Tru

e R

CT

To

exam

ine

the

effe

cts

of a

late

ral

glid

e M

WM

in

h

ealt

hy

subje

cts

wit

h in

du

ced late

ral

epic

ondyl

alg

ia p

ain

24 p

art

icip

an

ts.

11 m

ale

s, 1

3

fem

ale

s.M

ean

age

: 23

Day

0 –

in

du

ced D

OM

S

(ecc

entr

ic e

xerc

ises

on

n

on-d

omin

an

t arm

).D

ay

1 –

in

ject

ed

hyp

erto

nic

salin

e (2

4h

rs

pos

t ex

erci

se) to

mim

ic

ten

nis

elb

ow s

ympto

ms

(pain

du

rati

on 1

0 m

ins)

, th

en a

pplied

MW

M o

r pla

cebo

Rx

Exe

rcis

es t

o in

du

ce D

OM

S: re

pea

ted e

ccen

tric

w

rist

ext

ensi

on c

ontr

act

ion

s –

5 s

ets

of 6

0

reps,

wit

h 1

min

res

t in

terv

al bet

wee

n s

ets.

MW

M: su

stain

ed late

ral gl

ide,

wit

h P

T’s

han

d

aga

inst

part

icip

an

ts u

lna. Part

icip

an

t su

pin

e,

shou

lder

abdu

cted

20°,

elb

ow e

xten

ded

an

d

fore

arm

pro

nate

d.

Pla

cebo:

applica

tion

of a fi

rm c

onst

an

t m

an

ual co

nta

ct a

rou

nd t

he

med

ial an

d late

ral

asp

ects

of th

e el

bow

Bef

ore

exer

cise

, in

ject

ion

an

d

MW

M.

Aft

er R

x.Fol

low

-up a

t day

7

PPT.

McG

ill pain

qu

esti

onn

air

e.M

usc

le for

ce.

Maxi

mal gr

ip for

ce

(dyn

am

omet

er).

Maxi

mal w

rist

ext

ensi

on

forc

e (for

ce t

ran

sdu

cer)

Tey

s et

al.,

2006

Tru

e R

CT

Exa

min

e th

e ef

fect

of

MW

M o

f th

e sh

ould

er in

rel

ati

on

to R

OM

an

d P

PT

24 p

art

icip

an

ts.

11 m

ale

s, 1

3

fem

ale

sM

ean

age

: 46

Gro

up 1

: M

WM

Rx.

Gro

up 2

: pla

cebo.

Gro

up 3

: co

ntr

ol

MW

M: pos

tero

late

ral gl

ide

wit

h p

ati

ent

seate

d.

PT p

lace

d h

an

ds

over

pos

teri

or s

capu

la a

nd

then

ar

emin

ence

of ot

her

han

d o

ver

an

teri

or

asp

ect

of h

ead o

f h

um

eru

s. P

oste

rior

glide

applied

to

hu

mer

al h

ead. Part

icip

an

t act

ivel

y abdu

cted

arm

.Pla

cebo:

a/a, bu

t h

an

ds

of P

T w

ere

an

teri

orly

on

th

e cl

avi

cle

an

d s

tern

um

, an

d a

n a

nte

rior

gl

ide

wit

h m

inim

al fo

rce

was

applied

Con

trol

: n

o m

an

ual co

nta

ct o

f PT

Bef

ore

an

d

aft

er R

x, o

n 3

se

ssio

ns

AR

OM

(act

ive

pain

-fre

e sh

ould

er e

leva

tion

).PPT

Col

lin

s et

al.,

2004

RC

T w

ith

part

icip

an

ts

as

own

con

trol

(r

epea

ted

mea

sure

s,

cros

sove

r)

Eva

luate

th

e ef

fect

of

MW

M for

late

ral

an

kle

spra

ins

on R

OM

an

d

hyp

oalg

esia

16 p

art

icip

an

ts.

8 m

ale

s, 8

fem

ale

s.M

ean

age

: 28

Gro

up 1

: M

WM

.G

rou

p 2

: pla

cebo.

Gro

up 3

: co

ntr

ol

MW

M: at

talo

cru

ral jo

int.

Part

icip

an

t W

B in

st

an

ce p

osit

ion

wit

h a

ffec

ted leg

for

ward

. B

elt

aro

un

d P

T p

elvi

s an

d d

ista

l ti

bia

an

d fi

bu

la.

Pt

lean

ed b

ack

to

crea

te P

A g

lide,

wit

h t

alu

s an

d for

efoo

t st

abilis

ed b

y PT’s

han

d a

nd

oth

er h

an

d o

ver

pro

xim

al ti

bia

an

d fi

bu

la t

o m

ain

tain

leg

align

men

t.Pla

cebo:

a/a w

ith

bel

t ov

er c

alc

an

eum

an

d

min

imal fo

rce,

wit

h s

tabilis

ing

han

d o

ver

met

ata

rsals

.C

ontr

ol: pt

in s

tan

ce p

osit

ion

for

5 m

ins

wit

h

no

man

ual co

nta

ct o

f PT

Bef

ore

an

d

aft

er R

xW

eigh

t-bea

rin

g D

F R

OM

.PPT.

TPT

Ap

pe

ndix

1. C

hara

cte

ristic

s o

f the

inc

lud

ed

stu

die

s


Auth

or

Des

ign

purp

ose

par

tici

pan

tsIn

terv

enti

on

pre

scri

pti

on

of

MW

M/oth

er R

xT

imes

of

Ax

O/c

mea

sure

s

Bis

set

et a

l.,

2006

Tru

e R

CT

To

inve

stig

ate

th

e ef

fica

cy o

f PT in

terv

enti

on

com

pare

d w

ith

co

rtic

oste

roid

in

ject

ion

an

d w

ait

an

d s

ee for

late

ral

epic

ondyl

alg

ia

198 p

art

icip

an

ts.

128 m

ale

s, 7

0

fem

ale

s.M

ean

age

: 48

Gro

up 1

: 8 s

essi

ons

of P

T.

Gro

up 2

: co

rtic

oste

roid

in

ject

ion

.G

rou

p 3

: w

ait

an

d s

ee

PT: 8 s

essi

ons

for

30 m

ins

over

6 w

eeks.

In

clu

ded

MW

M, th

eraban

d e

xerc

ises

an

d

stre

tch

ing.

Cor

tico

ster

iod in

ject

ion

: 1 in

ject

ion

, an

d a

2n

d o

ne

if n

eces

sary

aft

er 2

wee

ks.

Wait

an

d s

ee:

advi

ce, ed

uca

tion

on

m

odifi

cati

ons

to A

DL’s

, en

cou

rage

act

ivit

y,

usi

ng

an

alg

esic

dru

gs, h

eat,

col

d a

nd b

race

s

6 w

eeks

an

d

52 w

eeks

Glo

bal im

pro

vem

ent.

Gri

p for

ce.

Ass

esso

rs r

ati

ng

of

seve

rity

.Pain

(VA

S).

Elb

ow d

isabilit

y (p

ain

-fre

e fu

nct

ion

qu

esti

onn

air

e)

Koc

har

&

Dog

ra, 2002

Tru

e R

CT

To

com

pare

th

e ef

fect

s of

a

com

bin

ati

on o

f M

WM

an

d U

S

vers

us

US

alo

ne,

fo

llow

ed b

y an

ex

erci

se p

rogr

am

me,

fo

r la

tera

l ep

icon

dyl

alg

ia

66 p

art

icip

an

ts.

36 m

ale

s, 3

0

fem

ale

s.M

ean

age

: 41

Gro

up 1

: co

mbin

ati

on

of U

S a

nd M

WM

on

10

sess

ion

s (d

iffe

ren

t R

x on

alt

ern

ate

days

) co

mple

ted

in 3

wee

ks

an

d a

n

exer

cise

pro

gram

me

(9

wee

ks)

.G

rou

p 2

: U

S o

nly

on

10

sess

ion

s co

mple

ted in

3

wee

ks

an

d a

n e

xerc

ise

pro

gram

me

(9 w

eeks)

.G

rou

p 3

(co

ntr

ol): n

o tr

eatm

ent

US

: 3 M

Hz,

1.5

W/cm

2, pu

lsed

1:5

, 5 m

ins.

MW

M: el

bow

ext

ended

, fo

rearm

pro

nate

d,

10 r

eps,

no

pain

, gl

ide

sust

ain

ed w

hile

part

icip

an

t lift

ed w

eigh

t th

at

pre

viou

sly

pro

du

ced p

ain

, fo

r 3 s

ets,

10 s

essi

ons.

Pro

gres

sed M

WM

by

incr

easi

ng

wei

ghts

by

0.5

kg.

Exe

rcis

e: s

tret

chin

g, P

RT, co

nce

ntr

ic/

ecce

ntr

ic e

xerc

ises

Wee

k 1

, 2

an

d 3

.Fol

low

-up a

t 4 m

onth

s

Pain

– V

AS

sca

le.

Abilit

y to

lift

0-3

kg

wei

ghts

wit

h n

o pain

, 24h

rs a

fter

Rx.

Gri

p S

tren

gth

.W

eigh

t te

st

Sla

ter

et a

l.,

2006

Tru

e R

CT

To

exam

ine

the

effe

cts

of a

late

ral

glid

e M

WM

in

h

ealt

hy

subje

cts

wit

h in

du

ced late

ral

epic

ondyl

alg

ia p

ain

24 p

art

icip

an

ts.

11 m

ale

s, 1

3

fem

ale

s.M

ean

age

: 23

Day

0 –

in

du

ced D

OM

S

(ecc

entr

ic e

xerc

ises

on

n

on-d

omin

an

t arm

).D

ay

1 –

in

ject

ed

hyp

erto

nic

salin

e (2

4h

rs

pos

t ex

erci

se) to

mim

ic

ten

nis

elb

ow s

ympto

ms

(pain

du

rati

on 1

0 m

ins)

, th

en a

pplied

MW

M o

r pla

cebo

Rx

Exe

rcis

es t

o in

du

ce D

OM

S: re

pea

ted e

ccen

tric

w

rist

ext

ensi

on c

ontr

act

ion

s –

5 s

ets

of 6

0

reps,

wit

h 1

min

res

t in

terv

al bet

wee

n s

ets.

MW

M: su

stain

ed late

ral gl

ide,

wit

h P

T’s

han

d

aga

inst

part

icip

an

ts u

lna. Part

icip

an

t su

pin

e,

shou

lder

abdu

cted

20°,

elb

ow e

xten

ded

an

d

fore

arm

pro

nate

d.

Pla

cebo:

applica

tion

of a fi

rm c

onst

an

t m

an

ual co

nta

ct a

rou

nd t

he

med

ial an

d late

ral

asp

ects

of th

e el

bow

Bef

ore

exer

cise

, in

ject

ion

an

d

MW

M.

Aft

er R

x.Fol

low

-up a

t day

7

PPT.

McG

ill pain

qu

esti

onn

air

e.M

usc

le for

ce.

Maxi

mal gr

ip for

ce

(dyn

am

omet

er).

Maxi

mal w

rist

ext

ensi

on

forc

e (for

ce t

ran

sdu

cer)

Tey

s et

al.,

2006

Tru

e R

CT

Exa

min

e th

e ef

fect

of

MW

M o

f th

e sh

ould

er in

rel

ati

on

to R

OM

an

d P

PT

24 p

art

icip

an

ts.

11 m

ale

s, 1

3

fem

ale

sM

ean

age

: 46

Gro

up 1

: M

WM

Rx.

Gro

up 2

: pla

cebo.

Gro

up 3

: co

ntr

ol

MW

M: pos

tero

late

ral gl

ide

wit

h p

ati

ent

seate

d.

PT p

lace

d h

an

ds

over

pos

teri

or s

capu

la a

nd

then

ar

emin

ence

of ot

her

han

d o

ver

an

teri

or

asp

ect

of h

ead o

f h

um

eru

s. P

oste

rior

glide

applied

to

hu

mer

al h

ead. Part

icip

an

t act

ivel

y abdu

cted

arm

.Pla

cebo:

a/a, bu

t h

an

ds

of P

T w

ere

an

teri

orly

on

th

e cl

avi

cle

an

d s

tern

um

, an

d a

n a

nte

rior

gl

ide

wit

h m

inim

al fo

rce

was

applied

Con

trol

: n

o m

an

ual co

nta

ct o

f PT

Bef

ore

an

d

aft

er R

x, o

n 3

se

ssio

ns

AR

OM

(act

ive

pain

-fre

e sh

ould

er e

leva

tion

).PPT

Col

lin

s et

al.,

2004

RC

T w

ith

part

icip

an

ts

as

own

con

trol

(r

epea

ted

mea

sure

s,

cros

sove

r)

Eva

luate

th

e ef

fect

of

MW

M for

late

ral

an

kle

spra

ins

on R

OM

an

d

hyp

oalg

esia

16 p

art

icip

an

ts.

8 m

ale

s, 8

fem

ale

s.M

ean

age

: 28

Gro

up 1

: M

WM

.G

rou

p 2

: pla

cebo.

Gro

up 3

: co

ntr

ol

MW

M: at

talo

cru

ral jo

int.

Part

icip

an

t W

B in

st

an

ce p

osit

ion

wit

h a

ffec

ted leg

for

ward

. B

elt

aro

un

d P

T p

elvi

s an

d d

ista

l ti

bia

an

d fi

bu

la.

Pt

lean

ed b

ack

to

crea

te P

A g

lide,

wit

h t

alu

s an

d for

efoo

t st

abilis

ed b

y PT’s

han

d a

nd

oth

er h

an

d o

ver

pro

xim

al ti

bia

an

d fi

bu

la t

o m

ain

tain

leg

align

men

t.Pla

cebo:

a/a w

ith

bel

t ov

er c

alc

an

eum

an

d

min

imal fo

rce,

wit

h s

tabilis

ing

han

d o

ver

met

ata

rsals

.C

ontr

ol: pt

in s

tan

ce p

osit

ion

for

5 m

ins

wit

h

no

man

ual co

nta

ct o

f PT

Bef

ore

an

d

aft

er R

xW

eigh

t-bea

rin

g D

F R

OM

.PPT.

TPT

Pau

ngm

ali e

t al., 2003a

RC

T w

ith

part

icip

an

ts

as

own

con

trol

(r

epea

ted

mea

sure

s)

To

det

erm

ine

wh

eth

er a

n M

WM

te

chn

iqu

e at

the

elbow

pro

du

ces

ph

ysio

logi

cal ef

fect

s su

ch a

s h

ypoa

lges

ia

an

d S

NS

fu

nct

ion

in

pati

ents

wit

h late

ral

epic

ondyl

alg

ia

24 p

art

icip

an

ts.

17 m

ale

s, 7

fe

male

s.M

ean

age

: 49

Each

part

icip

an

t co

mple

ted t

he

3

ran

dom

ised

Rx

grou

ps

(Rx,

pla

cebo,

con

trol

), a

t sa

me

tim

e of

day.

48 h

rs

in b

etw

een

each

ses

sion

Rx

grou

p: la

tera

l gl

ide

MW

M w

ith

pain

-fre

e dyn

am

omet

er g

rippin

g. P

art

icip

an

t su

pin

e,

wit

h s

hou

lder

in

tern

ally

rota

ted, el

bow

ex

ten

ded

, fo

rearm

pro

nati

on. 10 r

eps,

for

6

secs

, 15 s

ec r

est

per

iod.

Pla

cebo:

PT a

pplied

a fi

rm m

an

ual co

nta

ct

wit

h b

oth

han

ds

over

th

e el

bow

joi

nt

wh

ilst

th

e part

icip

an

t gr

ipped

th

e dyn

am

omet

er

pain

-fre

e.C

ontr

ol: in

volv

ed t

he

pain

gri

ppin

g act

ion

on

ly

(no

man

ual fo

rce

applied

)

Bef

ore,

du

rin

g an

d

aft

er R

x

PFG

S.

PPT.

TPT.

Cu

ten

eou

s blo

od fl

ux.

Skin

con

du

ctan

ce.

Skin

tem

per

atu

re.

BP.

HR

Pau

ngm

ali e

t al., 2004

RC

T w

ith

part

icip

an

ts

as

own

con

trol

(r

epea

ted

mea

sure

s cr

osso

ver)

Eva

luate

th

e ef

fect

of

nalo

xon

e on

pain

re

lief

fro

m a

n M

WM

applied

to

late

ral

epic

ondyl

alg

ia

18 p

art

icip

an

ts.

14 m

ale

, 4 fem

ale

.M

ean

age

: 49

All p

art

icip

an

ts r

ecei

ved

intr

ave

nou

sly

nalo

xon

e,

salin

e or

no-

subst

an

ce

con

trol

on

3 d

iffe

ren

t oc

casi

ons,

th

en a

MW

M

was

applied

to

the

elbow

MW

M: part

icip

an

t in

su

pin

e pos

itio

n. R

x applied

im

med

iate

ly a

fter

th

e in

ject

ion

. O

ne

han

d s

tabilis

ed t

he

dis

tal h

um

eru

s on

th

e la

tera

l asp

ect,

an

d t

he

oth

er h

an

d a

pplied

a

late

ral gl

ide

to t

he

pro

xim

al ra

diu

s an

d u

lna

Bef

ore

infe

ctio

n a

nd

Rx,

an

d a

fter

R

x

PFG

S.

PPT.

TPT.

Upper

lim

b n

eura

l te

st

pro

voca

tion

(ra

dia

l n

erve

)

Vic

enzi

no

et

al., 2001

RC

T w

ith

part

icip

an

ts

as

own

con

trol

(r

epea

ted

mea

sure

s)

Det

erm

ine

wh

eth

er

MW

M for

late

ral

epic

ondyl

alg

ia

pro

du

ced

hyp

oalg

esia

an

d t

o co

mpare

eff

ects

on

th

e aff

ecte

d a

nd

non

-aff

ecte

d a

rms

24 p

art

icip

an

ts.

14 m

ale

, 10 fem

ale

.M

ean

age

: 46

Part

icip

an

ts r

ecei

ved

eith

er M

WM

Rx,

pla

cebo

or c

ontr

ol o

n a

ffec

ted a

nd

un

-aff

ecte

d a

rm.

Th

ey r

ecei

ved a

ll 3

in

terv

enti

on lev

els

on

dif

fere

nt

days

MW

M: la

tera

l gl

ide

of t

he

elbow

. O

ne

han

d g

lidin

g th

e pro

xim

al fo

rearm

, an

d

oth

er s

tabilis

ing

the

dis

tal h

um

eru

s, w

hile

part

icip

an

t per

form

ed p

ain

-fre

e gr

ippin

g.Pla

cebo:

firm

man

ual co

nta

ct o

ver

elbow

joi

nt.

Con

trol

: n

o m

an

ual co

nta

ct o

f PT

Bef

ore

an

d

aft

er e

ach

R

x se

ssio

n.

PFG

S a

lso

mea

sure

d

du

rin

g R

x

PFG

S.

PPT

Vic

enzi

no

et

al., 2006

RC

T w

ith

part

icip

an

ts

as

own

con

trol

(r

epea

ted

mea

sure

s,

cros

sove

r)

To

explo

re t

he

defi

cits

in

an

kle

R

OM

in

pati

ents

w

ith

rec

urr

ent

an

kle

spra

ins,

an

d

inve

stig

ate

th

e ef

fect

of

a p

oste

rior

glide

MW

M a

pplied

in

N

WB

an

d W

B o

n

talo

cru

ral D

F

16 p

art

icip

an

ts.

8 m

ale

s, 8

fem

ale

s.M

ean

age

: 20

Gro

up 1

: W

B M

WM

.G

rou

p 2

: N

WB

MW

M.

Gro

up 3

: co

ntr

ol.

All p

art

icip

an

ts

exper

ien

ced 1

of th

e 3 c

ondit

ion

s in

a

ran

dom

ised

seq

uen

ce o

n

3 s

epara

te d

ays

(at

least

48 h

ours

apart

)

WB

MW

M: in

sta

ndin

g w

ith

th

erapis

t m

an

ually

stabilis

ing

the

foot

on

th

e plin

th,

usi

ng

bel

t to

apply

for

ce a

nd p

art

icip

an

t m

ovin

g in

to D

F.

NW

B M

WM

: applied

wit

h t

he

part

icip

an

t in

su

pin

e ly

ing,

tib

ia r

esti

ng

on p

lin

th a

nd a

nkle

on

th

e ed

ge.

Con

trol

gro

up: n

o m

an

ual co

nta

ct o

r m

ovem

ent.

Th

e part

icip

an

t st

ood for

a s

imilar

per

iod o

f ti

me

sim

ilar

to t

he

trea

tmen

t ti

me

for

the

oth

er t

wo

grou

ps

Bef

ore

an

d

aft

er R

x, o

n 3

se

ssio

ns

Pos

teri

or t

ala

r gl

ide.

WB

an

kle

DF (a W

B

lun

ge m

easu

red w

ith

a

tape

mea

sure

)

McL

ean

et

al.,

2002

Qu

asi

-ex

per

imen

tal

– re

pea

ted

mea

sure

s (r

an

dom

isa-t

ion

, n

o co

ntr

ol)

To

ass

ess

dif

fere

nt

man

ual fo

rces

use

d

in a

MW

M t

ech

niq

ue

for

late

ral el

bow

ep

icon

dyl

alg

ia

an

d its

eff

ects

on

h

ypoa

lges

ia

6 p

art

icip

an

ts.

2 m

ale

s, 4

fem

ale

s.M

ean

age

: 49

MW

M for

ce lev

els

wer

e det

erm

ined

for

33%

, 50%

, 66%

an

d m

axi

mu

m.

All p

art

icip

an

ts r

ecei

ved

applica

tion

s of

th

e M

WM

te

chn

iqu

e co

mpri

sin

g of

th

e 4 for

ce lev

els

in a

ra

ndom

ord

er

MW

M: dir

ecte

d t

oward

s th

e m

edia

l asp

ect

of t

he

uln

a. D

ura

tion

of ea

ch R

x te

chn

iqu

e w

as

no

mor

e th

an

10 s

ecs.

3 a

pplica

tion

s w

ith

con

tract

ion

for

base

lin

e m

easu

re. 2

applica

tion

s of

th

e 4 for

ce lev

els,

wit

h 2

min

re

st in

terv

als

Bef

ore

an

d

aft

er R

xPFG

S.

Mu

scle

for

ce: m

easu

red

wit

h a

flex

ible

pre

ssu

re

sen

sin

g m

at

bet

wee

n

han

d a

nd e

lbow

Abbot

t, 2

001

Non

-ex

per

imen

tal

– pre

/pos

t te

st

(ran

dom

isa-t

ion

)

To

inve

stig

ate

th

e ef

fect

s of

a s

ingl

e in

terv

enti

on o

f M

WM

at

the

elbow

on

sh

ould

er R

OM

for

pati

ents

wit

h late

ral

epic

ondyl

alg

ia

23 p

ati

ents

.18 m

ale

, 5 fem

ale

.M

ean

age

: N

S

Ran

dom

ass

ign

men

t of

le

ft o

r ri

ght

arm

to

be

Ax

an

d R

x (M

WM

) firs

t

MW

M: part

icip

an

t in

su

pin

e, a

nd p

erfo

rmed

th

e n

orm

ally

pro

vokin

g m

ovem

ent

on t

he

left

an

d r

igh

t si

de

Bef

ore

an

d

aft

er R

xPass

ive

RO

M

(gon

iom

eter

): in

part

icu

lar

inte

rnal an

d

exte

rnal ro

tati

on

Ap

pe

ndix

1 (

co

ntin

ued

). C

hara

cte

ristic

s o

f the

inc

lud

ed

stu

die

s


Abbot

t et

al.,

2001

Non

-ex

per

imen

tal

– pre

/pos

t te

st

(ran

dom

isa-t

ion

)

Det

erm

ine

wh

at

pro

por

tion

of

pts

res

pon

d t

o M

WM

for

late

ral

epic

ondyl

alg

ia,

wh

eth

er P

GFS

an

d m

axi

mu

m G

S

incr

ease

s aft

er 1

R

x of

MW

M, an

d

det

erm

inan

ts o

f re

spon

sive

nes

s

25 p

art

icip

an

ts.

17 m

ale

s, 8

fe

male

s.M

ean

age

: 46

All p

art

icip

an

ts r

ecei

ved

MW

M t

o u

naff

ecte

d a

nd

aff

ecte

d a

rm (ra

ndom

ised

or

der

), in

1 R

x se

ssio

n.

If p

art

icip

an

ts p

ain

cou

ld

not

be

elim

inate

d R

x w

as

stop

ped

MW

M: la

tera

l gl

ide

of p

roxi

mal m

edia

l fo

rearm

w

ith

th

e dis

tal h

um

eru

s st

abilis

ed, w

hilst

part

icip

an

t per

form

ed p

revi

ousl

y pain

ful

mov

emen

t (fi

st, gr

ippin

g, w

rist

ext

ensi

on, 3rd

fin

ger

exte

nsi

on).

Eit

her

of th

e fo

llow

ing

glid

es w

ere

per

form

ed

dep

endin

g on

part

icip

an

ts p

ain

res

pon

se:

dir

ectl

y la

tera

l or

appro

x 5°

pos

teri

or, an

teri

or

or c

au

dal of

late

ral

Bef

ore

an

d

aft

er R

x, o

n

each

arm

PFG

S.

Maxi

mal gr

ip s

tren

gth

Pau

ngm

ali e

t al., 2003b

Non

ex

per

imen

tal

– re

pea

ted

mea

sure

s

Exa

min

e w

het

her

in

itia

l h

ypoa

lges

ia

effe

cts

from

MW

M

applied

to

late

ral

epic

ondyl

alg

ia

wer

e m

ain

tain

ed

aft

er r

epea

ted

applica

tion

s

24 p

art

icip

an

ts.

19 m

ale

s, 5

fe

male

s.M

ean

age

: 50

All p

art

icip

an

ts r

ecei

ved

late

ral gl

ide

MW

M.

Applied

on

6 o

ccasi

ons,

appro

x 48 h

ours

apart

MW

M: pati

ent

supin

e w

ith

sh

ould

er in

in

tern

al ro

tati

on, el

bow

ext

ended

an

d

supin

ate

d. Th

erapis

t st

abilis

ed t

he

hu

mer

us

an

d a

pplied

late

ral gl

ide

at

fore

arm

. Tec

hn

iqu

e per

form

ed w

as

pain

-fre

e w

ith

part

icip

an

ts m

ain

tain

ing

a g

rip for

appro

x 6

secs

an

d r

epea

ted 1

0 t

imes

wit

h 1

5 s

ecs

rest

in

terv

als

Bef

ore

an

d

aft

er e

very

Rx

PFG

S.

PPT

O’B

rien

&

Vin

cen

zin

o,

1998

Case

stu

dy

To

det

erm

ine

the

effe

ctiv

enes

s of

M

WM

applied

at

the

an

kle

for

acu

te

late

ral an

kle

pain

2 m

ale

part

icip

an

ts

wit

h r

ecen

t (2

-3

days

) la

tera

l an

kle

sp

rain

s. A

ged 1

7

an

d 1

8

To

det

erm

ine

the

effe

ctiv

enes

s of

MW

M

applied

at

the

an

kle

for

acu

te late

ral an

kle

pain

MW

M R

x: p

oste

rior

glide

of d

ista

l fibu

la

wh

ile

part

icip

an

t in

vert

ed t

he

an

kle

. Pass

ive

over

pre

ssu

re w

as

applied

. R

epea

ted 4

tim

es.

Rx1

: 6 s

essi

ons

over

2 w

eeks.

Rx2

: 3 s

essi

ons

over

1 w

eek.

No

Rx1

: 3 s

essi

ons

over

1 w

eek.

No

Rx2

: 5 m

easu

rem

ent

sess

ion

s ov

er 1

wee

k.

Str

appin

g ta

pe

was

applied

to

main

tain

th

e pos

teri

or g

lide

aft

er e

very

Rx

sess

ion

Bef

ore,

du

rin

g (p

ain

, in

vers

ion

R

OM

) an

d

aft

er e

ach

Rx

Pain

: VA

S.

RO

M: in

vers

ion

an

d D

F

(WB

).Fu

nct

ion

al per

form

an

ce

(Kaik

kon

en s

cale

).Fu

nct

ion

: VA

S

Ste

ph

ens,

1995

Case

stu

dy

NS

43 y

ear

old fem

ale

w

ith

lef

t si

ded

ch

ron

ic late

ral

epic

ondyl

itis

Rx:

3 t

imes

a w

eek for

1st

4 w

eeks,

th

en o

nce

a

wee

k for

th

e fo

llow

ing

4

wee

ks,

th

en o

nce

eve

ry

2 w

eeks

for

the

last

6

wee

ks.

Rx:

MW

M’s

, ic

e, U

S,

tran

sver

se fri

ctio

ns,

ex

erci

ses

beg

an

aft

er

MW

M R

x, m

ass

age

, st

retc

hin

g, H

EP

MW

M: la

tera

l m

obilis

ati

on o

f th

e fo

rearm

at

the

elbow

du

rin

g act

ive

wri

st e

xten

sion

, fo

rearm

su

pin

ati

on a

nd g

rippin

g. D

orsa

l gl

ide

of t

he

han

d a

pplied

at

the

wri

st d

uri

ng

radia

l dev

iati

on a

nd t

he

met

aca

rpal of

th

e th

um

b

was

mob

ilis

ed p

alm

erly

at

the

CM

C d

uri

ng

thu

mb o

ppos

itio

n.

Elb

ow w

as

taped

in

to a

late

ral gl

ide.

Sel

f m

obiliz

ati

ons

wer

e per

form

ed a

gain

st a

doo

rway

to p

rovi

de

pain

rel

ief

NS

Pain

: VA

S.

AR

OM

: sh

ould

er, el

bow

an

d t

hu

mb.

Str

engt

h: sh

ould

er,

elbow

, w

rist

an

d g

rip.

Sen

sati

on: der

mato

mes

.S

pec

ial te

st: re

sist

ed

wri

st e

xt w

ith

elb

ow a

t 45°.

Palp

ati

on

Vin

cen

zin

o &

W

righ

t, 1

995

Case

stu

dy

To

inve

stig

ate

eff

ects

of

a m

an

ipu

lati

ve P

T

tech

niq

ue

on p

ain

an

d d

ysfu

nct

ion

of a

pati

ent

wit

h t

enn

is

elbow

39 y

ear

old fem

ale

w

ith

rig

ht

ten

nis

el

bow

PT for

6 s

essi

ons

over

5 w

eeks.

In

clu

ded

2

wee

ks

Ax,

2 w

eeks

Rx

(4

sess

ion

s), an

d 6

wee

ks

HE

P

Init

ial ph

ysio

Rx:

dee

p a

nd p

ain

ful m

ass

age

, ic

e, lase

r, s

ome

form

of se

nso

ry s

tim

ula

tion

. E

xerc

ises

– s

tret

chin

g an

d g

rippin

g ex

erci

ses.

Exp

erim

enta

l R

x: M

WM

– late

ral gl

ide

applied

at

the

pro

xim

al part

of th

e fo

rearm

wh

ilst

st

abilis

ing

the

late

ral asp

ect

of t

he

dis

tal

hu

mer

us

(part

icip

an

t in

su

pin

e, s

hou

lder

in

tern

al ro

tati

on, el

bow

ext

ended

, fo

rearm

pro

nate

d). P

art

icip

an

t w

as

tau

ght

self

mob

ilis

ati

on a

nd t

apin

g (t

apin

g w

as

use

d t

o re

plica

te t

he

late

ral fo

rce

applied

at

the

elbow

by

the

MW

M)

Bef

ore

Rx,

du

rin

g 2

wee

k A

x ph

ase

, an

d

at

6 w

eeks

follow

ing

Rx

VA

S.

PPT.

Gri

p s

tren

gth

.Fu

nct

ion

VA

S.

Pain

-fre

e fu

nct

ion

qu

esti

onn

air

e

Ap

pe

ndix

1 (

co

ntin

ued

). C

hara

cte

ristic

s o

f the

inc

lud

ed

stu

die

s


Back

stro

m,

2002

Case

rep

ort

Intr

odu

ce M

WM

in

th

e tr

eatm

ent

of d

e Q

uer

vain

’s

ten

osyn

ovit

is

61 y

ear

old fem

ale

w

ith

de

Qu

erva

in’s

te

nos

yno-

viti

s of

th

e ri

ght

wri

st

Rx:

Man

ipu

lati

on o

f ca

pit

ate

on

firs

t se

ssio

n

only

, M

WM

, el

ast

ic s

plin

t w

ith

hor

sesh

oe t

ype

inse

rt (in

trod

uce

d o

n

sess

ion

6), e

ccen

tric

an

d

con

cen

tric

str

engt

hen

ing,

A

RO

M, te

ndon

glidin

g,

tran

sver

se fri

ctio

n, an

ti-

inflam

mato

ries

an

d H

EP

(AR

OM

, st

ren

gth

enin

g,

ten

don

glidin

g, fri

ctio

ns,

se

lf M

WM

)

MW

M: ra

dia

l gl

ide

of p

roxi

mal ro

w o

f ca

rpal

bon

es. 3 s

ets

of 1

0 r

eps

of e

ach

of th

e m

ovem

ents

(w

rist

flex

ion

, ex

ten

sion

, u

lna

an

d r

adia

l dev

iati

on, an

d t

hu

mb r

adia

l or

palm

er a

bdu

ctio

n) (p

ain

-fre

e). D

one

at

all R

x se

ssio

ns.

WB

tec

hn

iqu

e –

part

icip

an

t W

B t

hro

ugh

th

e h

an

d a

nd t

he

sam

e ra

dia

l gl

ide

was

per

form

ed a

s part

icip

an

t pro

gres

sive

ly W

B

thro

ugh

th

e ri

ght

upper

lim

b.

Uln

a g

lide

of t

rapez

ium

an

d t

rapez

oid for

th

um

b r

adia

l abdu

ctio

n.

Sel

f-M

WM

– W

B o

f u

pper

lim

b. Part

icip

an

t applied

uln

a g

lide

on for

earm

(th

eref

ore

radia

l gl

ide

of c

arp

al bon

es), s

hifte

d B

W (w

rist

flex

ion

/ex

ten

sion

) w

ith

th

um

b a

bdu

cted

At

each

se

ssio

n.

Fol

low

-up

at

4 m

onth

s an

d 1

2

mon

ths

pos

t R

x

Pain

(VA

S).

Obse

rvati

on.

RO

M (go

nio

met

er). W

rist

flex

ion

, ex

ten

sion

, ra

dia

l an

d u

lna d

evia

tion

. Th

um

b p

alm

er a

nd r

adia

l abdu

ctio

n.

Str

engt

h –

iso

met

ric

an

d

MM

T.

Acc

esso

ry m

otio

n t

esti

ng.

Palp

ati

on.

Fin

kle

stei

n t

est

DeS

an

tis

&

Hass

on, 2006

Case

rep

ort

To

des

crib

e th

e ef

fect

s of

an

MW

M

trea

tmen

t re

gim

e fo

r sh

ould

er

impin

gem

ent

27 y

ear

old m

ale

w

ith

lef

t sh

ould

er

supra

-spin

atu

s te

ndin

opath

y

Ph

ysio

ther

apy

3 t

imes

a

wee

k for

30 m

ins

wit

h a

to

tal of

12 s

essi

ons

Warm

-up: 5 m

in w

arm

up o

n c

ycle

erg

omet

er

pri

or t

o ea

ch s

essi

on.

Ph

ase

1: fo

cuse

d o

n d

ecre

asi

ng

pain

(e

du

cati

on o

n r

est,

cry

oth

erapy,

res

tori

ng

RO

M w

ith

MW

M)

MW

M: A

P g

lide

wit

h a

bdu

ctio

n m

ovem

ent

(gu

idin

g m

ovem

ent

of t

he

scapu

lar

an

d

hu

mer

us

wit

h b

oth

han

ds)

.Ph

ase

2: fo

cuse

d o

n s

tren

gth

enin

g ro

tato

r cu

ff, sc

apu

lar

stabilis

ing

mu

scle

s, im

pro

vin

g fu

nct

ion

, ed

uca

tion

reg

ard

ing

pos

ture

.E

ach

ses

sion

en

ded

wit

h 1

0 m

ins

of

cryo

ther

apy

Mea

sure

-m

ents

of pain

an

d A

RO

M

at

ever

y PT

sess

ion

AR

OM

(go

nio

met

er) –

abdu

ctio

n m

ain

ly.

MM

T.

Impin

gem

ent

test

s (N

eer,

H

aw

kin

s K

enn

edy,

em

pty

ca

n, appre

hen

sion

).Fu

nct

ion

al st

atu

s:

shou

lder

pain

an

d

dis

abilit

y in

dex

.S

F-3

6 (gl

obal se

lf-r

epor

t qu

esti

onn

air

e).

Pain

(VA

S)

Fol

k, 2001

Case

rep

ort

To

des

crib

e th

e dif

fere

nti

al dia

gnos

is

an

d t

reatm

ent

tech

niq

ues

for

st

rain

ed 1

st M

CP

join

t

39 y

ears

old

fe

male

, 4.5

wee

ks

aft

er s

train

to

1st

MC

P, w

ith

dia

gnos

is o

f de

Qu

erva

in’s

of th

e le

ft h

an

d

Rec

eive

d O

T (7 s

essi

ons

in 6

wee

ks)

, th

en r

efer

red

for

trig

ger

thu

mb r

elea

se

surg

ery,

th

en b

ack

to

OT,

wh

ich

th

en r

efer

red t

o PT.

OT e

valu

ati

on/R

x per

form

ed 3

wee

ks

late

r

2 c

orti

son

e in

ject

ion

s fo

r de

Qu

erva

in’s

.O

T R

x: s

plin

t an

d g

utt

er u

se, act

ive

RO

M

exer

cise

s.O

per

ati

on: t

rigg

er t

hu

mb r

elea

se.

PT R

x: M

WM

at

1st

MC

P w

ith

su

stain

ed p

ain

-fr

ee in

tern

al axi

al ro

tati

on, w

ith

ove

rpre

ssu

re

at

the

end

Mea

sure

-m

ent

taken

th

rou

ghou

t R

x.Fol

low

-up

at

2 m

onth

s an

d 1

yea

r pos

t R

x

Pain

(M

CP e

xt).

Sw

ellin

g.R

OM

(M

CP e

xt).

MM

T.

Gri

p s

tren

gth

.U

pper

lim

b t

ensi

on t

ests

.C

ervi

cal sp

ine

Ax.

De

Qu

erva

in’s

tes

ts

(fin

kel

stei

ns,

pin

cer

stre

ngt

h, palp

ati

on)

Het

her

ingt

on,

1996

Case

rep

ort

NS

.Peo

ple

wit

h a

nkle

in

juri

es w

ere

exam

ined

to

det

ect

a p

osit

ion

al fa

ult

an

d m

an

age

d u

sin

g M

WM

an

d t

apin

g m

eth

ods

NS

.Pati

ents

pos

t an

kle

sp

rain

wit

h lim

ited

an

d p

ain

ful R

OM

Majo

rity

of pati

ents

wer

e tr

eate

d o

nly

wit

h M

WM

’s

an

d t

apin

g.N

o el

ectr

o-ph

ysic

al

ther

apie

s w

ere

use

d

MW

M: la

tera

l m

alleo

us

of fi

bu

la g

lided

pos

teri

orly

wit

h a

ctiv

e in

vers

ion

(w

ith

an

d

wit

hou

t a b

elt)

.Tapin

g: t

wo

stri

ps

of 2

5m

m t

ape

appro

x 15cm

in

len

gth

. Pos

teri

or g

lide

applied

an

d t

hen

ta

pe

applied

ove

r th

e la

tera

l m

alleo

lus

an

d

trave

lled

aro

un

d t

he

low

er leg

(ta

pin

g ch

an

ged

aft

er 2

4 h

rs)

Bef

ore,

du

rin

g an

d

aft

er R

x

Pain

on

in

vers

ion

.R

OM

.O

ne

leg

stan

din

g te

st

(bala

nce

– e

yes

clos

ed).

Sw

ellin

g.G

ait

Patt

ern

s

Ap

pe

ndix

1 (

co

ntin

ued

). C

hara

cte

ristic

s o

f the

inc

lud

ed

stu

die

s


Hsi

eh e

t al.,

2002

Case

rep

ort

Inve

stig

ate

th

e u

se

of M

RI

for

pos

itio

nal

fau

lt a

nd M

WM

ef

fect

s in

th

e th

um

b

79 y

ear

old fem

ale

w

ith

rig

ht

thu

mb

pain

MW

M w

as

applied

to

the

pro

xim

al ph

ala

nx.

MR

I w

as

taken

bef

ore,

du

rin

g M

WM

, th

en a

fter

a c

ours

e of

MW

M R

x.Part

icip

an

t per

form

ed s

elf

MW

M’s

Sel

f M

WM

: su

pin

ati

ng

the

pro

xim

al ph

ala

nx

of t

he

thu

mb u

sin

g ot

her

han

ds

index

an

d

thu

mb, w

hile

per

form

ing

flex

ion

of th

e th

um

b

un

der

goin

g M

WM

MR

I: p

re R

x,

du

rin

g 1st

R

x, a

fter

Rx.

Wee

k 1

: pain

, R

OM

, dis

tract

ion

/co

mpre

ssio

n,

PR

OM

.W

eek 2

- a

/a.

Wee

k 3

- a

/a,

grip

str

engt

h

MR

I.Pain

: VA

S.

AR

OM

: go

nio

met

er

(flex

ion

of IP

J a

nd M

PJ)

PR

OM

: th

um

b r

adia

l abdu

ctio

n.

Gri

p s

tren

gth

: h

an

d

dyn

am

omet

er.

Com

pre

ssio

n/

dis

tract

ion

of th

e M

PJ

Not

e: M

WM

= m

obili

zati

on w

ith

mov

emen

t; R

x =

tre

atm

ent;

Ax

= a

sses

smen

t; O

/C

= o

utc

ome;

RC

T =

ra

nd

omis

ed c

ontr

olle

d t

ria

l; P

T =

ph

ysi

oth

era

py; A

DL’s

= a

ctiv

itie

s of

da

ily liv

ing;

VA

S =

vis

ua

l a

na

logu

e sc

ale

; U

S =

ult

raso

un

d;

MH

z =

meg

a h

ertz

; W

/cm

2 =

wa

tts

per

cen

tim

etre

squ

are

d;

min

s = m

inu

tes;

PR

T =

pro

gres

sive

res

ista

nt

tra

inin

g; r

eps

= r

epet

itio

ns;

kg

= k

ilogr

am

; h

rs =

hou

rs;

DO

MS

= d

ela

yed

on

set m

usc

le s

oren

ess;

PP

T =

pre

ssu

re p

ain

th

resh

old

; AR

OM

= a

ctiv

e ra

nge

of m

otio

n; a

/a

= a

s a

bov

e; W

B =

wei

ght-

bea

rin

g; p

t = p

ati

ent;

PA

= p

oste

rior

-an

teri

or; D

F =

dor

sifl

exio

n,

RO

M =

ra

nge

of

mot

ion

; S

NS

= s

ym

pa

thet

ic n

ervo

us

syst

em;

TPT =

tem

per

atu

re p

ain

th

resh

old

; se

cs =

sec

ond

s; P

FG

S =

pa

in-f

ree

grip

str

engt

h;

BP =

blo

od p

ress

ure

; H

R =

hea

rt r

ate

; N

WB

= n

on

wei

ght-

bea

rin

g; N

S =

not

sta

ted

; G

S =

gri

p s

tren

gth

; a

ppro

x = a

ppro

xim

ate

ly;

HE

P =

hom

e ex

erci

se p

rogr

am

me;

CM

C =

ca

rpom

eta

carp

al, B

W =

bod

y w

eigh

t; M

MT =

ma

nu

al

mu

scle

tes

tin

g; A

P =

a

nte

rior

-pos

teri

or;

SF

-36

= s

hor

t fo

rm 3

6;

MC

P =

met

aca

rpop

ha

lan

gea

l; O

T =

occ

upa

tion

al th

era

py;

ext

= e

xten

sion

; m

m =

mill

imet

res;

cm

= c

enti

met

res;

MR

I = m

agn

etic

res

ona

nce

im

agi

ng;

IPJ

=

inte

rph

ala

nge

al jo

int;

MP

J =

met

aca

rpa

l p

ha

lan

gea

l jo

int.

Ap

pe

ndix

1 (

co

ntin

ued

). C

hara

cte

ristic

s o

f the

inc

lud

ed

stu

die

s

mulligan’s mobilisation with movement a review of the tenets

Documents