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.

Mulligans mobilisation with movement: a review of the tenets and prescription of MWMs
Wayne Hing PhD Associate 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 students at the School of Physiotherapy, Auckland University of Technology

Abstract

Introduction: Mulligans 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 MWMs 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 Introduction response parameters. The treatment of musculoskeletal Introduction joint dysfunction may require a physiotherapist to use Results: Twenty-one studies, which have investigated MWMs at peripheral joints, The treatment of musculoskeletal joint may require a physiotherapist to use were included for analysis. This review highlights that parameters manual therapy. One specific of these manual therapy dysfunction techniquesidentified include mobilization with movement for MWM prescription (tenets, technical and response parameters), are Mulligan variable manual therapy. of these manual therapy techniques mobilization with movement (MWM), a type One of joint mobilisation developed by Brianinclude (Mulligan 2004, Mulligan and in general inconsistently implemented and explained. The efficacy of MWMs (MWM), a type of joint mobilisation developed by Brian Mulligan (Mulligan 2004, Mulligan also referred to as a Mulligan mobilisation (Collins et al 2004, Kochar and Dogra 2002, at peripheral joints is well established for2007); various joints and pathologies with 20 out 2007); also referred tomanipulative as a Mulligan mobilisation (Collinset etal al2003b, 2004, Kochar andet Dogra 2002, of 21 studies (95%) demonstrating positive effects overall. Teys et al 2006) or a technique (Paungmali Vicenzino al 2001). The Conclusions: A proposed algorithm has been formulated for the integration into 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 clinical practice to ensure necessary parameters are considered. It would be which are outlined in MWM consists of many necessary parameters for prescription, Figure technique 1. An accessory glide is applied at a peripheral joint, while a normally advisable that future research has more robust methodology and investigates and/ pain-provoking 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 or implements all necessary established Figure parameters of MWM prescription. Hing W, Bigelow R, Bremner T (2008): Mulligansphysiological mobilisation with movement: a review of 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, the tenets and prescription of MWMs. New Zealand Journal of Physiotherapy 36(3): is that pain should always be reduced Exelby 1996, Mulligan 2004, Wilson and/or 2001). eliminated during the application (Exelby 1995, 144-164. Exelby 1996, Mulligan 2004, Wilson 2001). Keywords: mobilisation with movement, MWM, manual therapy, mulligan mobilisation, manipulative technique.

Introduction

Parameters Parameters

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).

Tenets (Hing 2007, Mulligan 2004) Accessory glide Tenets (Hing 2007, 2004) Mulligan Physiological movement glide Pain-free or pain alteration * Accessory movement effect * Physiological Immediate/instantaneous or pain alteration * Pain-free Overpressure Immediate/instantaneous effect * Technical Parameters (Hing, 2007) Overpressure Repetitions

Note: * = Duplication of parameters as defined by Note: * = clinicians Duplication of different parameters as defined by different clinicians

Technical Parameters (Hing, 2007) Sets Repetitions Frequency Sets Amount of force Frequency Rest periods Amount of force Response Parameters (PILL Acronym) (Hing, 2007) periods Rest Pain-free or pain alteration *

Figure 1: Key parameters of Figure MWM1: Key parameters of prescription MWM prescription

Response Parameters (PILL Acronym) (Hing, 2007) Immediate/instantaneous effect * or pain alteration * Pain-free Long-Lasting Immediate/instantaneous effect * Client specific outcome measure (CSOM) Long-Lasting or comparable sign Client specific outcome measure (CSOM) or comparable sign

Figure 1: Key parameters of MWM prescription

Further gains in pain relief may be attained via the application of pain-free passive overpressure

4 4

144

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

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 Mulligans MWM techniques has been established for improving joint function, with a number of hypotheses for its cause and effect. Mulligans 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 maltracking 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. MWMs 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 MWMs 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 Mulligans 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 NZ Journal of Physiotherapy November 2008, Vol. 36 (3)

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.

Methods

Literature 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 crossreferencing (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 also formed, which included the tenets, pain behaviour analysis, technical parameters, and response parameters (CSOM and the PILL acronym). Each reviewer 145

Figure 2: Flow chart outlining research process

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 B) 56 results C) 1 results 2) Cinahl via Ovid A) 29 results B) 132 results C) 2 results 3) Cochrane via Ovid A) 11 results B) 53 results C) 1 results 4) Cochrane via Wiley A) 84 results B) 1 results C) 4 results Excluded: A) 10 B) 51 C) 0 A) 16 B) 126 C) 1 A) 2 B) 50 C) 0 A) 84 B) 1 C) 0

Excluded:

Excluded:

Excluded:

5) Ebsco Health Databases NB: Adapted search terms: [A) mobilization* with movement OR mobilisation* with movement ] A) 24 results Excluded: B) 89 results C) 1 results 6) Medline via Ebsco NB: Adapted search terms: [A) mobilization* with movement OR mobilisation* with movement ] A) 19 results Excluded: B) 68 results C) 0 results

A) 10 B) 84 C) 1

A) 6 B) 63 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*) ] A) 333 results B) 111 results C) 634 results 8) PEDro A) 3 results B) 22 results C) 3 results Excluded: A) 0 B) 20 C) 0 Excluded: A) 319 B) 110 C) 632

8
146 NZ Journal of Physiotherapy November 2008, Vol. 36 (3)

Figure 2 (continued)

TOTAL TOTAL articles articles identified identified for for analysis analysis in in relation to the exclusion criteria: relation to the exclusion criteria: 117 117 studies studies Cross Cross matching matching of of search search results results for for repeated repeated articles resulted in: 18 studies articles resulted in: 18 studies Cross-referencing Cross-referencing of of all all articles articles resulted resulted in: in: 3 studies 3 studies

Selected Selected Studies Studies Total: Total: 21 21 studies studies to to be be reviewed reviewed 4 True randomised - 4 True randomised control control trials trials (RCTs) (RCTs) 5 Randomised control trials, - 5 Randomised control trials, participants participants as as own own control control - 1 1 Quasi-experimental Quasi-experimental study study (no (no control) control) - 3 3 Non-experimental Non-experimental studies studies (2 (2 pretest/posttest, pretest/posttest, 1 1 repeated repeated measures) measures) 3 Case studies - 3 Case studies - 5 5 Case Case reports reports

Figure Figure 2: 2: Flow Flow chart chart outlining outlining research research process process
analysed all of this data. The content of these tables will be discussed further in the results.

Critiquing Critiquing method: method: - Critiquing Critiquing tool tool selected selected (Downs (Downs & & Black, Black, 1998) 1998) All articles critiqued by both researchers. - All articles critiqued by both researchers. Simultaneously Simultaneously compared compared findings findings

MWM should have on the patient to continue with treatment (Hing, 2007). These are pain-free or pain altering application (reduction + / elimination), instantaneous long-lasting effects, Results Exclusion the included: studies to Exclusion criteria criteria which which was was incorporated incorporated during during the search search and included: studies prior prior to namely the PILL acronym (refer to Tables 2 and 4). During the search, articles were excluded on Lastly Vicenzino & Hing have also discussed the the basis of the strict exclusion criteriastudies previously 1990, written articles, not to peripheral joint manual 1990, non-English non-English written articles, studies not relevant relevant jointsign manual use to of peripheral a comparable to determine treatment mentioned. A total of 117 articles were identified effectiveness, which is also known as a CSOM, also from the stated databases (refer to Figure 2 for therapy/MWM/physiotherapy, spinal manual therapy, chiropractic non-original research, found in Table 4studies, (Hing, 2007). There is a duplication details). Once search results were matched for therapy/MWM/physiotherapy, spinal manual therapy, chiropractic studies, non-original research, of parameters, such as pain-free or pain altering repeated articles between the databases, 18 were application and an use immediate orThe instantaneous included for or analysis. An additional studies cadaver animal and/or if was indication of of aim cadaver or animal studies, studies, and/or three if there there was no no clear clear indication of the the use of MWM. MWM. The aim of of effect, which are both components of tenets and were found by means of further cross-referencing the PILL acronym. This duplication is secondary to by both reviewers (Hetherington 1996, Stephens this review to obtain every study, which has MWM therefore no this review was was study, the which has utilised utilised MWM techniques; techniques; therefore no parameters two different clinicians defining these 1995, Vicenzino et to al obtain 2001), every increasing total of prescription. to 21 studies for analysis - including four true restrictions were on study methodological quality. literature be restrictions were placed placed on (RCTs), study design design or methodological quality. All literature needed to be (Abbott 2001,All Abbott et alneeded 2001, to Altman and randomised controlled trials five or RCTs Burton 1999, Backstrom 2002, Bisset et al 2006, with participants as own control, one quasireviewed to variations in prescription. As were Collins al 2004, DeSantis Hasson 2006, experimental, three non-experimental, three case reviewed accurately accurately to analyse analyse the the possible possible variations in its its et prescription. As papers papersand were Downs and Black 1998, Exelby 1995, Exelby 1996, studies, and five case reports. Further detail of each Folk 2001, Hartling et al 2004, Hetherington 1996, of the studies methodological data variation and both examined, reviewers examined, reference reference lists lists were were cross cross checked checked by by both reviewers for for citations citations of of other other potentially potentially Hignett 2003a, Hignett 2003b, Hing 2007, Hsieh study design are detailed in Appendix 1. et al 2002, Kavanagh 1999, Kochar and Dogra relevant studies, in three were retrieved from process of relevantParameters studies, and and and in total total three studies studies were subsequently subsequently retrieved from this this process of crosscross2002, Lexico Publishing Group Ltd 2007, McLean 1) Specific Rationale Related et al 2002, Monteiro and Victora 2005, Mulligan to MWM Prescription referencing (Hetherington Stephens et 1989, Mulligan 1995, Mulligan 1999, Mulligan Within the prescription of 1996, MWMs, there 1995, are Vicenzino referencing (Hetherington 1996, Stephens 1995, Vicenzino et al al 2001). 2001). 2004, Mulligan 2006, Mulligan 2007, OBrien and different areas that need investigating. Firstly there Vicenzino 1998, Paungmali et al 2003a, Paungmali are the five tenets, described by Mulligan, which et al 2004, Paungmali et al 2003b, Roddy et al 2005, should be considered with all MWMs. These are: Saunders et al 2003, Slater et al 2006, Stephens the accessory glide generated by the Review therapist, the of Review of Study Study Characteristics Characteristics 1995, Teys et al 2006, Vicenzino 2003, Vicenzino physiological movement or action, pain reduction et al 2006, Vicenzino et al 2001, Vicenzino et al or elimination, an immediate effect, and the use Using generic critical appraisal checklist, data was extracted from the 21 2007, Vicenzino Wright 1995, Wilson 2001, of overpressure, which are outlined in Table 1 Using a a generic critical appraisal checklist, data was extractedand from the included included 21 Zhang et al 2005) (Hing, 2007). Pain behaviour is further elaborated in Table 2. The second consideration of MWMs is articles and was Four tables articles and information information was recorded. recorded. Four specific specific tables relating relating to to MWM MWM prescription prescription were were Tenets of MWM the technical parameters of prescription, which Accessory glide are: repetitions, sets, frequency, amount of force, The accessory glide performed should either be and rest periods, which are outlined in Table 3. at a right angle to the joint such as a lateral glide Vicenzino & Hing have devised a new concept of of the elbow, or follow Kaltenborns concave-convex response parameters, which are the effects that the NZ Journal of Physiotherapy November 2008, Vol. 36 (3) 147

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 posterioranterior 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 movement All 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). MWMs for lateral ankle sprains included either dorsiflexion or inversion movements (Collins et al., 2004; Hetherington, 1996; OBrien & 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 MWMs in de Quervains, 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%), 148

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 effect For 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 CSOMs improved post treatment, except temperature pain threshold (TPT), which has not been found to be affected by MWMs 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; OBrien & 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). Overpressure Overpressure 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, OBrien 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 Quervains (Folk 2001), and also for lateral ankle sprains (Hetherington 1996, OBrien 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/sets Although 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 NZ Journal of Physiotherapy November 2008, Vol. 36 (3)

Table 1. Tenets of MWM application

Physiological movement Pain alteration (Reduction +/elimination) NS Yes NS Yes Yes Yes Yes Yes 1) Yes 2) NS Yes Yes Yes Yes Yes Yes Yes Yes NS NA NA NA Overpressure if no pain after active movement NA NA NT NT No Yes NS NS NA NS Immediate effect Overpressure

Author

Accessory glide

Bisset et al., 2006 Kochar & Dogra, 2002 Slater et al., 2006 Teys et al., 2006

Collins et al., 2004 Paungmali et al., 2003a

NS Lateral glide Lateral glide Posterolateral glide to humeral head. At right angle to shoulder elevation PA glide of tibia Lateral glide

Paungmali et al., 2004 Vicenzino et al., 2001 Vicenzino et al., 2006 Gripping a dynamometer Specific combined movement NS. Yes Only states that patient performed the normally pain provoking movement up to 10 times Gripping action, combine with wrist extension or 3rd finger extension Gripping for approx 6 seconds Active inversion NS Yes Yes Yes Yes Yes

NS Wrist extension with weights Gripping Patient actively elevated arm in scapula plane DF in WB Gripping a dynamometer for approx 6 seconds Gripping Gripping Patient actively moving into the onset of pain or end range DF

McLean et al., 2002

Lateral glide Lateral glide 1) PA force applied at the tibia with a belt, therefore a posterior glide of the talus. 2) AP force applied to glide the talus Lateral glide

Abbott, 2001

Lateral glide

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

NS Yes Yes Yes Yes Yes NA Passive overpressure NS NA NS Wrist extension, forearm supination, gripping, radial deviation, thumb opposition Gripping a weight during the MWM Wrist flexion, extension, ulna and Yes radial deviation, and thumb radial or palmer abduction Yes Yes Yes Yes Pain-free passive overpressure Passive overpressure Abduction movement (externally rotated; open can position) MCP extension Yes Yes Yes Yes Passive overpressure NS Patient performed active inversion with and without a belt and then released Thumb flexion

Abbott et al., 2001

Either direct lateral glide of the proximal forearm or 5 posterior, anterior or caudal of lateral

Paungmali et al., 2003b OBrien & Vicenzino, 1998

Lateral glide Posterior glide of distal fibula

Stephens, 1995

Vicenzino & Wright, 1995

Elbow: lateral glide. Wrist: dorsal glide. Thumb: palmar glide Lateral glide

Backstrom, 2002

DeSantis & Hasson, 2006

Radial glide of proximal row of carpal bones. Ulna glide of trapezium and trapezoid for thumb radial abduction. Self MWM: Patient applied ulna glide on forearm with UL WB (i.e. radial glide of carpal bones), shifted BW Right angle to glenohumeral joint

Folk, 2001

Glides at the proximal end of the proximal phalanx: medial, lateral, axial IR and ER. IR proved to be effective in decreasing pain and improving ROM

Hetherington, 1996

Posterior glide of the distal fibula at the lateral malleolus

Hsieh et al., 2002

Supination of the proximal phalanx of the thumb

Note: NS = not stated; NA = Not applicable; NT = not tested; PA = posterior-anterior; DF = dorsiflexion; WB = weight bearing; AP = anterior-posterior; approx = approximately; MWM = mobilisation with movement; UL = upper limb; BW = body weight; IR = internal rotation; ER = external rotation; ROM = range of motion; MCP = metacarpophalangeal.

149

150
Adaptation of MWM in response to pain behaviour Details regarding classification of pain behaviour The elimination of pain was stated, but was unclear whether this was during or after the MWM application Glide was performed whilst a pain-free gripping action was performed. Stated that the pain-free application was fundamental NS. Within the literature review of the case study they state that if the MWM application is painful, an alternative painless angle of mobilization is utilised After the first treatment session causing an exacerbation of pain, the patient was encouraged to perform the gripping action well below their pain threshold during the MWM Continued directional modification of the imposed glide was applied throughout Rx to achieve a pain free Pain-free glides were applied. Chosen MWM resulted in immediate elimination of painful action however was not clear if this was during or after the application The physiological movement performed during the MWM (shoulder NS abduction), must be pain-free The patient was instructed that the MWM with overpressure used Constant repositioning of the joint with alteration of the glide, must be pain-free positioning, force, overpressure, and therapist to patient generated movement, abolished the pain The MWM application was only continued with if the application of NS the glide and the active movement of ankle inversion was pain-free Patient performed self MWMs, and their was an emphasis on pain- NS free application. In the discussion it was stated that pain alleviation is important with MWM application

Table 2. Pain behaviour explanation for application and technique adaptation

Author

Pain alteration (reduction +/- elimination):

Stated (Yes / No)

Bisset et al., 2006

No referred to Vicenzino (2003) Vicenzino (2003) states the gripping action performed during the MWM should be to the onset of pain and no more

Kochar & Dogra, 2002

Slater et al., 2006

Teys et al., 2006 Collins et al., 2004

Paungmali et al., 2003a Paungmali et al., 2004

Vicenzino et al., 2001

Vicenzino et al., 2006

McLean et al., 2002

Abbott, 2001

Abbott et al., 2001

Paungmali et al., 2003b OBrien & Vicenzino, 1998

Vicenzino (2003) states to repeat the MWM several times, only if there is a substantial decrease in pain. If the pain relief has not occurred then glides at different angles should be attempted, up to a maximum of 4 Yes States that MWMs are pain-free with a correct glide, although they NS noted that pain was only diminished during their MWM application No referred to Mulligan (1999), NS (Mulligan 1999) NS Vicenzino & Wright (1995), Abbott et al. (2001), Vicenzino et al. (2001), & Paungmali et al. (2003a) Yes Pain-free arm elevation during the glide The MWM was ceased immediately if any pain was experienced Yes MWM was applied to the end of the pain-free range If pain was experienced during the MWM the treatment was ceased, and the participant was excluded from the study Yes The glide was painlessly applied, and the patient performed a pain- NS. Although no patients reported pain with treatment free gripping action Yes The glide was painlessly applied, and a pain-free gripping action NS was performed Yes The glide was performed whilst the patient performed a pain-free NS. Although no patients reported pain with treatment gripping action Yes It was stated in the text that the essential parameter of an MWM NS is that they do not inflict any pain but rather alleviate pain during normally painful actions Yes Pain-free grip strength test performed while the glide was sustained NS - The force was changed in relation to the study intervention, not the pain response If pain returned, no further repetitions were performed Yes It is stated that the normally pain provoking movement is performed during the MWM (it is unclear whether this was painfree during the treatment) Yes Stated that the aim for the MWM was an elimination of pain with Four attempts of the direction of manual pressure were allowed to the comparable sign (normally pain provoking action) that was determine which eliminated the pain. If there pain was not eliminated or particular to the patient it returned during treatment, no further repetitions were performed Yes The glide was painlessly applied, and a pain-free gripping action NS was performed Yes Stated that MWM success is based on an immediate relief of NS symptoms during its application. MWM, which consisted of inversion to the end of pain free range. It was stated that the MWM reduced pain overall (unclear whether this was during or after the MWM application)

Stephens, 1995

No

Vicenzino & Wright, 1995

Yes

Backstrom, 2002

Yes

DeSantis & Hasson, 2006 Folk, 2001

Yes

Yes

Hetherington, 1996

Yes

Hsieh et al., 2002

Yes

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

Note: MWM = mobilization with movement; NS = not stated. Technical Parameters of MWM

defined. Eighteen out of the 21 articles (86%) stated their repetitions and 11 stated their sets. Majority of studies have followed Mulligans 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. Frequency The 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; OBrien & 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 Mulligans 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 handheld 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 periods There 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., NZ Journal of Physiotherapy November 2008, Vol. 36 (3)

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 Parameters Long-lasting Effective MWMs 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, OBrien 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; OBrien & 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 CSOMs 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; OBrien & 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., 151

152
Frequency Force Rest period 8 sessions. 6 weeks 10 sessions. 3 weeks 1 session 30 secs between sets NS NS NS NS Pain relief due to sensory gating and positional fault correction. Increased tensile strength of tissue To exert rapid pain relieving effects associated with sympathoexcitation mechanisms that would be likely to occur in actual tennis elbow pain NS. Used body weight (belt) NS. Used arm force NS 3 sessions. 24 hours apart 3 sessions. 24 hours apart 1 session NS NS NS. 1) 20 secs. Used a belt and 2) NS bodyweight to produce PA force 2 mins between each Rx NS. Use of body weight NS. Used arm force 3 sessions. 48 hours apart 1 session 1 session 30 secs between Changes to joint or muscle structures and positional fault correction sets 1 min between sets MWM has a mechanical effect rather than a hypoalgesic. After ankle sprain anterior displacement of the talus may occur, and MWM may correct this positional fault 15 secs in between Positional fault correction has been researched, however physiological reps. effects have not been. Hypoalgesic effects of MWM treatment Sets not stated 15 secs between Non-opioid and possible a noradrenergic endogenous pain modulation reps mechanisms 15 secs between Hypoalgesic/physiological mechanisms of pain relief versus mechanical reps joint correction/positional fault mechanism Use of MWM indicated as evidence shows that people with recurrent ankle sprains have common physical impairments being a lack of posterior talar glide and WB dorsiflexion. Based on the arthrokinematic principle of that the talus glides posteriorly during dorsiflexion. To improve the coupling joint motion at the talocrural joint, not just simple posterior talar glide Specific force needs to be applied for sufficient pain relief 1 session Mean % of max force: 100% =113.2N 66% = 74.5N 50% = 55.6N 33% = 36.8N NS NS People with lateral epicondylalgia have reduced shoulder rotation. A change in shoulder ROM with manual therapy at the elbow suggests that the pre intervention limitation was neurophysiologic in nature, not mechanical NS NS NS 6 sessions. 48 hours apart Subject 1: 6 sessions over 2 weeks, and 3 sessions over 1 week (with 1 week between). Subject 2: 6 sessions over 2 weeks NS Correcting the joint malalignment with MWM techniques has an effect on increasing muscle strength and relieving associated pain with normally provoking actions 15 secs in between Pain relief due to descending pain inhibition, not due to endogenous reps. opioid mediators Approx 48 hours between each session NS Positional fault. Post ankle sprain there may be antero-inferior subluxation of the distal fibula and MWM may correct this resulting in increased ROM and decreased pain

Table 3. Technical parameters of the MWM technique and rationale for treatment effectiveness

Author

Reps/Sets Y/N Number Reps Sets

Bisset et al., 2006

Kochar & Dogra, 2002

Slater et al., 2006

Teys et al., 2006 Collins et al., 2004

Referred to Vicenzino (2003) for MWM prescription. Not stated in the study itself Y Y 10 reps. 3 sets. 10 sessions Y Y 6 reps (30 secs). 3 sets. Total duration = 2.5 mins approx Y Y 10 reps. 3 sets Y Y 10 reps. 3 sets

Paungmali et al., 2003a

10 reps applied for approx 6 secs

6 reps

Paungmali et Y al., 2004 Vicenzino et al., Y 2001

6 reps

Vicenzino et al., Y 2006

McLean et al., 2002

1 &2) 4 reps of glides. Each glide maintained for 10 secs at end range or at the onset of pain. 4 sets per Rx. 2 reps each force. 4 force levels (sets)

Abbott, 2001

Abbott et al., 2001

Performed the 1 session provoking movement 10 times. Total time for both sides and measuring = approx 15 mins Up to 10 times 1 session

Paungmali et al., 2003b

10 reps

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

OBrien & Vincenzino, 1998

4 reps

Note: Rx = treatment; Y = yes; N = no; Reps = repetitions; MWM = mobilisation with movement; NS = not stated;; secs = seconds; mins = minutes; approx = approximately; PA = posterior/anterior; max = maximum; N = newtons; ROM = range of motion; WB = weight bearing; UL = upper limb; MCP = metacarpophalangeal.

Use of MWM versus Maitland sustained glides without movement to not only decrease pain but increase ROM and function. To restore normal arthrokinematics by decreasing dysfunctional joint alignment and then in turn allow more uniform tensile stress applied at the tendon during activities MWM was used to reposition the 1st MCP with extension movement and therefore decrease pain and improve ROM. To normalise the arthrokinematics of the 1st MCP joint With a lateral ankle sprain the ligament remains intact and the forces are transmitted to the fibula gliding it anteriorly creating a positional fault. Balance deficits at ankle are commonly associated with mechanoreceptor damage in relation to the malposition of the fibula MWMs used to correct positional fault and therefore decrease pain and improve ROM

Positional fault of carpal bones. MWM realigns bones allowing pain-free movement with correct alignment

Minor positional fault occurring from an injury or strain. Mobilization perpendicular to the dysfunctional plane of motion corrects joints positional fault MWM effect was to decrease pain and increase function during and immediately after its application. Positional fault correction

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 MWMs 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 MWMs 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 ULTTs, 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; OBrien & 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). 153

Table 3 (continued). Technical parameters of the MWM technique and rationale for treatment effectiveness

No longer than 60 secs in between reps NS

NS

NS

NS. Used arm force and WB through the right UL NS Used arm force

NS

NS

NS

NS

NS

12 sessions. 2 months

23 sessions

4 sessions. 2 weeks

5 sessions. 2 weeks

6 reps. Glide sustained for approx 5-10 secs 3 sets of 10 reps for each of the movements

Initially: 10 reps. 2 sets. 5 more sessions: 10x1 only

1 session

2 sets. 10 reps

NS

Stephens, 1995

DeSantis & Hasson, 2006

Vincenzino & Wright, 1995

Hetherington, 1996

Backstrom, 2002

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

Folk, 2001

Hsieh et al., 2002

Self Rx: 6 reps

10 reps. 3 sets

2 hourly during waking hours for 3 weeks

1 session

NS

2 hours between sets

NS

154
Assessment of Long-Lasting Long-lasting affects stated at follow-up assessment NT Yes Assessed at week 6 and 52 post Rx Yes Assessed at 1, 2, 3 & 12 weeks post Rx NT NT NT NT NT NT NT Yes No significant effects Yes significant increases in ROM and pressure pain threshold Yes increase in ROM and pressure pain threshold Yes increase in pain-free grip NT strength and pressure pain threshold. SNS activation Yes increase in pain-free grip NT strength, pressure pain threshold and ULTT Yes increase in PFGS and PPT NT Physiotherapy Rx was superior to wait and see and corticosteroid injections at 6 weeks, however at 52 weeks there was no difference between physio and wait and see Significant reductions in pain, improvements in grip strength and lifting strength in the intervention group NT NT NT NT NT NT NT NT Yes increase in posterior talar glide NT and ROM Yes increase in PFGS (only with 66% NT or 100% force) Yes increase in ROM NT Yes increase in pain-free and maximal grip strength Yes increase in PFGS and PPT Yes Assessed at final (6th) session (48 hours in between sessions) Yes decrease in pain and increase in Yes Assessed 3 times. 1 week ROM (inversion and DF) post Rx phase = phase C Yes decrease in pain with all hand and arm motions Yes increase in PFGS during and after application Hypoalgesic effect of MWM did not reduce with repeated applications. All treatments resulted in increased PFGS (significant) and PPT Reduction in pain, improved inversion and DF ROM, improved functional performance at the ankle. No deterioration. Yes Assessed at each session Elimination of pain would continue for 1-2 days and at the end of 23 treatments however pain would eventually re-occur. Self-MWM would eliminate the pain again. At discharge, MWMs were still effective at decreasing pain if needed Yes Assessed at 6 weeks post Patient had no pain and had returned to full Rx function. Strong correlation between pain reduction and increased function

Table 4. Client specific outcome measure (CSOM) or comparable sign, and PILL acronym

Author

Client specific outcome measure (CSOM) or comparable sign

Pain alteration Instantaneous effect (Reduction +/Elimination)

Bisset et al., 2006

Grip force. Pain VAS scale

NS

Kochar & Dogra, 2002

Yes

NS

Yes

Yes

Yes

Yes

Yes

1) Yes 2) NS Yes

Yes

Yes

PFGS. Pain VAS scale. Ability to lift 0-3 kgs Slater et al., PPT. 2006 Maximal grip and wrist extension force Teys et al., Pain-free ROM in the scapula 2006 plane. PPT Collins et al., WB DF ROM. 2004 PPT. TPT Paungmali et PFGS. al., 2003a PPT. TPT. SNS parameters Paungmali et PFGS. al., 2004 PPT. TPT. ULTT Vicenzino et PFGS. al., 2001 PPT Vicenzino et Posterior talar glide. al., 2006 WB ankle DF ROM McLean et PFGS al., 2002 Abbott, 2001 Passive shoulder internal and external ROM Abbott et al., PFGS. 2001 Maximal grip strength Paungmali et PFGS. al., 2003b PPT

Yes

OBrien & Vicenzino, 1998 Stephens, 1995

VAS. Inversion and WB DF ROM

Yes

Pain scale (VAS) during active NS and resisted wrist extension, forearm supination, and hand grip

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

Vicenzino & PFGS Wright, 1995

Yes

Note: VAS = visual analogue scale; NS = not stated; NT = not tested; Rx = treatment; PFGS = pain free grip strength; kgs = kilograms; PPT = pressure pain threshold; ROM = range of motion; WB = weight bearing; DF = dorsiflexion; TPT = temperature pain threshold; SNS = sympathetic nervous system; ULTT = upper limb tension test; MWM = mobilisation with movement; NPRS = numeric pain rating scale; MCP = metacarpophalangeal; MRI = magnetic resonance imaging.

MWM application reduced pain to 0-1/10 (VAS). All impairments had resolved at 1 year (no evidence of wrist/thumb pain or functional deficits whatsoever) NT

At 1year follow-up assessment, the patient confirmed she had remained symptom free post the MWM Rx NT

MRI examination showed no reduction in the initial positional fault, but she had no pain when flexing her right thumb

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

Discussion

Yes Assessed at 1 month and 52 weeks post Rx

Yes Assessed at 4 months, and 1 year post Rx

Yes Assessed 1 week post Rx

Specific Parameters and Rationale Related to MWM Prescription As previously described, tenets, technical and response parameters, all contribute to the effectiveness of Mulligans 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. Tenets The 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 painfree 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 painfree 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, OBrien and Vicenzino 1998, Stephens 1995). 155

Table 4 (continued). Client specific outcome measure (CSOM) or comparable sign, and PILL acronym

Yes decrease in pain and increase in ROM

Yes decrease in pain and increase in ROM

NT

Yes pain-free end range extension with overpressure

Yes increase in ROM and balance Yes

NT

Pain VAS scale. Yes Strength and ROM at wrist and thumb NPRS during active abduction. Yes Abduction active ROM

Backstrom, 2002

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

DeSantis & Hasson, 2006 Folk, 2001

Pain scale (VAS). End range MCP extension with overpressure Hetherington, Pain on inversion ROM. 1996 Balance single leg standing with eyes closed Hsieh et al., Pain scale (VAS). 2002 ROM

Yes

Yes

Yes immediate decrease of pain following MWM application

Figure 3: Algorithm for the prescription MWM techniques

Key: CRR* = clinical reasoning required

What do I need to employ? Joint mechanics (CRR*)

Figure 3: Algorithm for the prescription

YES

Is an MWM appropriate?
E.g. Decreased ROM, pain present, positional fault evident, decreased strength, reduced function etc (CRR*)

of peripheral joint MWM techniques

CONTINUE ADAPT as necessary (angle, glide, force, etc) Up to 4 times (CRR*)

Pain eliminated or reducing during MWM Pain worsening during the MWM

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:

THEN if NO improvement

STOP

CSOM is same or improved

CONTINUE OR PROGRESS STOP/ STOP/ ADAPT ADAPT as asnecessary necessary (angle, glide, (angle, force,glide, etc) Up to 4 etc) times force, (CRR*) Up to 4 times (CRR*)

CSOM is worse e.g. pain

AFTER APPLICATION OF 1st Set - Re-assess CSOM/s Instantaneous effect?

NB: Consider irritability

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

Further sets - CONSIDER:

Frequency: consider self-MWMs Sets: 3 sets generally Rest period: time for reassessment Constant assessment of CSOM/s

PROGRESSIONS Overpressure Increase force Increase difficulty/level of physiological movement/action Therapist to patient generated Increase frequency/sets (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 156

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

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, OBrien 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 Parameters The 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 Mulligans 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 MWMs 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 NZ Journal of Physiotherapy November 2008, Vol. 36 (3)

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 MWMs, 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 retesting 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 Parameters The 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. 157

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 MWMs can be maintained further via taping and self-MWMs, 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, OBrien 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 Practice Overall, 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 MWMs 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 Research Subsequent 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 MWMs 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, MWMs 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 clinicians 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.

Conclusion

Mulligans 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 MWMs 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 MWMs. 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

158

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

attempt to guide the clinician appropriately, and provide a basis for future research into this area.
Associate Professor Wayne Hing, School of Physiotherapy, Health & Rehabilitation Research Centre, AUT University, Private Bag 92006, Auckland 1142, New Zealand.

Address for Correspondence

References

Abbott 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. Langenbecks Archive of Surgery 384: 432-436. Backstrom KM (2002): Mobilization with movement as an adjunct intervention in a patient with complicated De Quervains 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 Mulligans 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): Mulligans 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, prps 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. OBrien T and Vicenzino B (1998): A study of the effects of Mulligans mobilization with movement treatment of lateral ankle pain using a case study design. Manual Therapy 3: 78-84. Paungmali A, OLeary 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, OLeary 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, OReilly 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 Mulligans 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): Mulligans 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.

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

159

160
Participants Intervention Prescription of MWM/other Rx Times of Ax O/C measures 198 participants. 128 males, 70 females. Mean age: 48 Group 1: 8 sessions of PT. Group 2: corticosteroid injection. Group 3: wait and see PT: 8 sessions for 30 mins over 6 weeks. Included MWM, theraband exercises and stretching. Corticosteriod injection: 1 injection, and a 2nd one if necessary after 2 weeks. Wait and see: advice, education on modifications to ADLs, encourage activity, using analgesic drugs, heat, cold and braces US: 3 MHz, 1.5 W/cm2, pulsed 1:5, 5 mins. MWM: elbow extended, forearm pronated, 10 reps, no pain, glide sustained while participant lifted weight that previously produced pain, for 3 sets, 10 sessions. Progressed MWM by increasing weights by 0.5kg. Exercise: stretching, PRT, concentric/ eccentric exercises 6 weeks and Global improvement. 52 weeks Grip force. Assessors rating of severity. Pain (VAS). Elbow disability (pain-free function questionnaire) Week 1, 2 Pain VAS scale. and 3. Ability to lift 0-3kg Follow-up at weights with no pain, 4 months 24hrs after Rx. Grip Strength. Weight test 66 participants. 36 males, 30 females. Mean age: 41 Group 1: combination of US and MWM on 10 sessions (different Rx on alternate days) completed in 3 weeks and an exercise programme (9 weeks). Group 2: US only on 10 sessions completed in 3 weeks and an exercise programme (9 weeks). Group 3 (control): no treatment Day 0 induced DOMS (eccentric exercises on non-dominant arm). Day 1 injected hypertonic saline (24hrs post exercise) to mimic tennis elbow symptoms (pain duration 10 mins), then applied MWM or placebo Rx Group 1: MWM Rx. Group 2: placebo. Group 3: control Exercises to induce DOMS: repeated eccentric wrist extension contractions 5 sets of 60 reps, with 1 min rest interval between sets. MWM: sustained lateral glide, with PTs hand against participants ulna. Participant supine, shoulder abducted 20, elbow extended and forearm pronated. Placebo: application of a firm constant manual contact around the medial and lateral aspects of the elbow 24 participants. 11 males, 13 females. Mean age: 23 Before exercise, injection and MWM. After Rx. Follow-up at day 7 PPT. McGill pain questionnaire. Muscle force. Maximal grip force (dynamometer). Maximal wrist extension force (force transducer) 24 participants. 11 males, 13 females Mean age: 46 MWM: posterolateral glide with patient seated. Before and AROM (active pain-free PT placed hands over posterior scapula and after Rx, on 3 shoulder elevation). thenar eminence of other hand over anterior sessions PPT aspect of head of humerus. Posterior glide applied to humeral head. Participant actively abducted arm. Placebo: a/a, but hands of PT were anteriorly on the clavicle and sternum, and an anterior glide with minimal force was applied Control: no manual contact of PT MWM: at talocrural joint. Participant WB in Before and stance position with affected leg forward. Belt after Rx around PT pelvis and distal tibia and fibula. Pt leaned back to create PA glide, with talus and forefoot stabilised by PTs hand and other hand over proximal tibia and fibula to maintain leg alignment. Placebo: a/a with belt over calcaneum and minimal force, with stabilising hand over metatarsals. Control: pt in stance position for 5 mins with no manual contact of PT Weight-bearing DF ROM. PPT. TPT 16 participants. Group 1: MWM. 8 males, 8 females. Group 2: placebo. Mean age: 28 Group 3: control

Appendix 1. Characteristics of the included studies

Author

Design

Purpose

Bisset et al., 2006

True RCT

To investigate the efficacy of PT intervention compared with corticosteroid injection and wait and see for lateral epicondylalgia

Kochar & Dogra, 2002

True RCT

To compare the effects of a combination of MWM and US versus US alone, followed by an exercise programme, for lateral epicondylalgia

Slater et al., 2006

True RCT

To examine the effects of a lateral glide MWM in healthy subjects with induced lateral epicondylalgia pain

Teys et al., 2006

True RCT

Examine the effect of MWM of the shoulder in relation to ROM and PPT

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

Collins et al., 2004

RCT with participants as own control (repeated measures, crossover)

Evaluate the effect of MWM for lateral ankle sprains on ROM and hypoalgesia

Appendix 1 (continued). Characteristics of the included studies

24 participants. 17 males, 7 females. Mean age: 49 Each participant completed the 3 randomised Rx groups (Rx, placebo, control), at same time of day. 48 hrs in between each session Rx group: lateral glide MWM with pain-free Before, dynamometer gripping. Participant supine, during and with shoulder internally rotated, elbow after Rx extended, forearm pronation. 10 reps, for 6 secs, 15 sec rest period. Placebo: PT applied a firm manual contact with both hands over the elbow joint whilst the participant gripped the dynamometer pain-free. Control: involved the pain gripping action only (no manual force applied) MWM: participant in supine position. Rx applied immediately after the injection. One hand stabilised the distal humerus on the lateral aspect, and the other hand applied a lateral glide to the proximal radius and ulna MWM: lateral glide of the elbow. One hand gliding the proximal forearm, and other stabilising the distal humerus, while participant performed pain-free gripping. Placebo: firm manual contact over elbow joint. Control: no manual contact of PT Before infection and Rx, and after Rx PFGS. PPT. TPT. Cuteneous blood flux. Skin conductance. Skin temperature. BP. HR

Paungmali et al., 2003a

RCT with participants as own control (repeated measures)

To determine whether an MWM technique at the elbow produces physiological effects such as hypoalgesia and SNS function in patients with lateral epicondylalgia

Paungmali et al., 2004

RCT with participants as own control (repeated measures crossover) 24 participants. Participants received 14 male, 10 female. either MWM Rx, placebo Mean age: 46 or control on affected and un-affected arm. They received all 3 intervention levels on different days Group 1: WB MWM. Group 2: NWB MWM. Group 3: control. All participants experienced 1 of the 3 conditions in a randomised sequence on 3 separate days (at least 48 hours apart)

Evaluate the effect 18 participants. of naloxone on pain 14 male, 4 female. relief from an MWM Mean age: 49 applied to lateral epicondylalgia

All participants received intravenously naloxone, saline or no-substance control on 3 different occasions, then a MWM was applied to the elbow

PFGS. PPT. TPT. Upper limb neural test provocation (radial nerve) Before and after each Rx session. PFGS also measured during Rx PFGS. PPT

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

WB MWM: in standing with therapist Before and Posterior talar glide. manually stabilising the foot on the plinth, after Rx, on 3 WB ankle DF (a WB using belt to apply force and participant sessions lunge measured with a moving into DF. tape measure) NWB MWM: applied with the participant in supine lying, tibia resting on plinth and ankle on the edge. Control group: no manual contact or movement. The participant stood for a similar period of time similar to the treatment time for the other two groups MWM: directed towards the medial aspect of the ulna. Duration of each Rx technique was no more than 10 secs. 3 applications with contraction for baseline measure. 2 applications of the 4 force levels, with 2 min rest intervals Before and after Rx PFGS. Muscle force: measured with a flexible pressure sensing mat between hand and elbow MWM force levels were determined for 33%, 50%, 66% and maximum. All participants received applications of the MWM technique comprising of the 4 force levels in a random order Random assignment of left or right arm to be Ax and Rx (MWM) first MWM: participant in supine, and performed the normally provoking movement on the left and right side Before and after Rx Passive ROM (goniometer): in particular internal and external rotation

Vicenzino et al., 2001

RCT with participants as own control (repeated measures)

Determine whether MWM for lateral epicondylalgia produced hypoalgesia and to compare effects on the affected and non-affected arms

Vicenzino et al., 2006

RCT with participants as own control (repeated measures, crossover)

To explore the 16 participants. deficits in ankle 8 males, 8 females. ROM in patients Mean age: 20 with recurrent ankle sprains, and investigate the effect of a posterior glide MWM applied in NWB and WB on talocrural DF

McLean et al., Quasi2002 experimental repeated measures (randomisa-tion, no control)

To assess different 6 participants. manual forces used 2 males, 4 females. in a MWM technique Mean age: 49 for lateral elbow epicondylalgia and its effects on hypoalgesia

Abbott, 2001

Nonexperimental pre/post test (randomisa-tion)

To investigate the 23 patients. effects of a single 18 male, 5 female. intervention of MWM Mean age: NS at the elbow on shoulder ROM for patients with lateral epicondylalgia

161

162
25 participants. 17 males, 8 females. Mean age: 46 All participants received MWM to unaffected and affected arm (randomised order), in 1 Rx session. If participants pain could not be eliminated Rx was stopped MWM: lateral glide of proximal medial forearm Before and with the distal humerus stabilised, whilst after Rx, on participant performed previously painful each arm movement (fist, gripping, wrist extension, 3rd finger extension). Either of the following glides were performed depending on participants pain response: directly lateral or approx 5 posterior, anterior or caudal of lateral PFGS. Maximal grip strength 24 participants. 19 males, 5 females. Mean age: 50 All participants received lateral glide MWM. Applied on 6 occasions, approx 48 hours apart MWM: patient supine with shoulder in internal rotation, elbow extended and supinated. Therapist stabilised the humerus and applied lateral glide at forearm. Technique performed was pain-free with participants maintaining a grip for approx 6 secs and repeated 10 times with 15 secs rest intervals MWM Rx: posterior glide of distal fibula while participant inverted the ankle. Passive overpressure was applied. Repeated 4 times. Rx1: 6 sessions over 2 weeks. Rx2: 3 sessions over 1 week. No Rx1: 3 sessions over 1 week. No Rx2: 5 measurement sessions over 1 week. Strapping tape was applied to maintain the posterior glide after every Rx session Before and PFGS. after every Rx PPT 2 male participants with recent (2-3 days) lateral ankle sprains. Aged 17 and 18 To determine the effectiveness of MWM applied at the ankle for acute lateral ankle pain Before, during (pain, inversion ROM) and after each Rx Pain: VAS. ROM: inversion and DF (WB). Functional performance (Kaikkonen scale). Function: VAS 43 year old female with left sided chronic lateral epicondylitis Rx: 3 times a week for 1st 4 weeks, then once a week for the following 4 weeks, then once every 2 weeks for the last 6 weeks. Rx: MWMs, ice, US, transverse frictions, exercises began after MWM Rx, massage, stretching, HEP PT for 6 sessions over 5 weeks. Included 2 weeks Ax, 2 weeks Rx (4 sessions), and 6 weeks HEP MWM: lateral mobilisation of the forearm NS at the elbow during active wrist extension, forearm supination and gripping. Dorsal glide of the hand applied at the wrist during radial deviation and the metacarpal of the thumb was mobilised palmerly at the CMC during thumb opposition. Elbow was taped into a lateral glide. Self mobilizations were performed against a doorway to provide pain relief Initial physio Rx: deep and painful massage, ice, laser, some form of sensory stimulation. Exercises stretching and gripping exercises. Experimental Rx: MWM lateral glide applied at the proximal part of the forearm whilst stabilising the lateral aspect of the distal humerus (participant in supine, shoulder internal rotation, elbow extended, forearm pronated). Participant was taught self mobilisation and taping (taping was used to replicate the lateral force applied at the elbow by the MWM) Before Rx, during 2 week Ax phase, and at 6 weeks following Rx Pain: VAS. AROM: shoulder, elbow and thumb. Strength: shoulder, elbow, wrist and grip. Sensation: dermatomes. Special test: resisted wrist ext with elbow at 45. Palpation VAS. PPT. Grip strength. Function VAS. Pain-free function questionnaire

Appendix 1 (continued). Characteristics of the included studies

Abbott et al., 2001

Nonexperimental pre/post test (randomisa-tion)

Determine what proportion of pts respond to MWM for lateral epicondylalgia, whether PGFS and maximum GS increases after 1 Rx of MWM, and determinants of responsiveness

Paungmali et al., 2003b

Non experimental repeated measures

Examine whether initial hypoalgesia effects from MWM applied to lateral epicondylalgia were maintained after repeated applications

OBrien & Vincenzino, 1998

Case study

To determine the effectiveness of MWM applied at the ankle for acute lateral ankle pain

Stephens, 1995

Case study

NS

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

Vincenzino & Wright, 1995

Case study

To investigate effects 39 year old female of a manipulative PT with right tennis technique on pain elbow and dysfunction of a patient with tennis elbow

Appendix 1 (continued). Characteristics of the included studies

61 year old female with de Quervains tenosyno-vitis of the right wrist Rx: Manipulation of capitate on first session only, MWM, elastic splint with horseshoe type insert (introduced on session 6), eccentric and concentric strengthening, AROM, tendon gliding, transverse friction, antiinflammatories and HEP (AROM, strengthening, tendon gliding, frictions, self MWM) MWM: radial glide of proximal row of carpal bones. 3 sets of 10 reps of each of the movements (wrist flexion, extension, ulna and radial deviation, and thumb radial or palmer abduction) (pain-free). Done at all Rx sessions. WB technique participant WB through the hand and the same radial glide was performed as participant progressively WB through the right upper limb. Ulna glide of trapezium and trapezoid for thumb radial abduction. Self-MWM WB of upper limb. Participant applied ulna glide on forearm (therefore radial glide of carpal bones), shifted BW (wrist flexion/extension) with thumb abducted Warm-up: 5 min warm up on cycle ergometer prior to each session. Phase 1: focused on decreasing pain (education on rest, cryotherapy, restoring ROM with MWM) MWM: AP glide with abduction movement (guiding movement of the scapular and humerus with both hands). Phase 2: focused on strengthening rotator cuff, scapular stabilising muscles, improving function, education regarding posture. Each session ended with 10 mins of cryotherapy 2 cortisone injections for de Quervains. OT Rx: splint and gutter use, active ROM exercises. Operation: trigger thumb release. PT Rx: MWM at 1st MCP with sustained painfree internal axial rotation, with overpressure at the end Measurements of pain and AROM at every PT session At each session. Follow-up at 4 months and 12 months post Rx Pain (VAS). Observation. ROM (goniometer). Wrist flexion, extension, radial and ulna deviation. Thumb palmer and radial abduction. Strength isometric and MMT. Accessory motion testing. Palpation. Finklestein test

Backstrom, 2002

Case report

Introduce MWM in the treatment of de Quervains tenosynovitis

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

27 year old male with left shoulder supra-spinatus tendinopathy Physiotherapy 3 times a week for 30 mins with a total of 12 sessions AROM (goniometer) abduction mainly. MMT. Impingement tests (Neer, Hawkins Kennedy, empty can, apprehension). Functional status: shoulder pain and disability index. SF-36 (global self-report questionnaire). Pain (VAS) Measurement taken throughout Rx. Follow-up at 2 months and 1 year post Rx Pain (MCP ext). Swelling. ROM (MCP ext). MMT. Grip strength. Upper limb tension tests. Cervical spine Ax. De Quervains tests (finkelsteins, pincer strength, palpation) MWM: lateral malleous of fibula glided Before, posteriorly with active inversion (with and during and without a belt). after Rx Taping: two strips of 25mm tape approx 15cm in length. Posterior glide applied and then tape applied over the lateral malleolus and travelled around the lower leg (taping changed after 24 hrs) Pain on inversion. ROM. One leg standing test (balance eyes closed). Swelling. Gait Patterns 39 years old female, 4.5 weeks after strain to 1st MCP, with diagnosis of de Quervains of the left hand Received OT (7 sessions in 6 weeks), then referred for trigger thumb release surgery, then back to OT, which then referred to PT. OT evaluation/Rx performed 3 weeks later NS. Patients post ankle sprain with limited and painful ROM Majority of patients were treated only with MWMs and taping. No electro-physical therapies were used

DeSantis & Hasson, 2006

Case report

To describe the effects of an MWM treatment regime for shoulder impingement

Folk, 2001

Case report

To describe the differential diagnosis and treatment techniques for strained 1st MCP joint

Hetherington, 1996

Case report

NS. People with ankle injuries were examined to detect a positional fault and managed using MWM and taping methods

163

164
MWM was applied to the proximal phalanx. MRI was taken before, during MWM, then after a course of MWM Rx. Participant performed self MWMs Self MWM: supinating the proximal phalanx of the thumb using other hands index and thumb, while performing flexion of the thumb undergoing MWM MRI: pre Rx, during 1st Rx, after Rx. Week 1: pain, ROM, distraction/ compression, PROM. Week 2 - a/a. Week 3 - a/a, grip strength MRI. Pain: VAS. AROM: goniometer (flexion of IPJ and MPJ) PROM: thumb radial abduction. Grip strength: hand dynamometer. Compression/ distraction of the MPJ

Appendix 1 (continued). Characteristics of the included studies

Hsieh et al., 2002

Case report

Investigate the use 79 year old female of MRI for positional with right thumb fault and MWM pain effects in the thumb

Note: MWM = mobilization with movement; Rx = treatment; Ax = assessment; O/C = outcome; RCT = randomised controlled trial; PT = physiotherapy; ADLs = activities of daily living; VAS = visual analogue scale; US = ultrasound; MHz = mega hertz; W/cm2 = watts per centimetre squared; mins = minutes; PRT = progressive resistant training; reps = repetitions; kg = kilogram; hrs = hours; DOMS = delayed onset muscle soreness; PPT = pressure pain threshold; AROM = active range of motion; a/a = as above; WB = weight-bearing; pt = patient; PA = posterior-anterior; DF = dorsiflexion, ROM = range of motion; SNS = sympathetic nervous system; TPT = temperature pain threshold; secs = seconds; PFGS = pain-free grip strength; BP = blood pressure; HR = heart rate; NWB = non weight-bearing; NS = not stated; GS = grip strength; approx = approximately; HEP = home exercise programme; CMC = carpometacarpal, BW = body weight; MMT = manual muscle testing; AP = anterior-posterior; SF-36 = short form 36; MCP = metacarpophalangeal; OT = occupational therapy; ext = extension; mm = millimetres; cm = centimetres; MRI = magnetic resonance imaging; IPJ = interphalangeal joint; MPJ = metacarpal phalangeal joint.

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