Mulligan’s Mobilization with Movement: A Systematic...
Transcript of Mulligan’s Mobilization with Movement: A Systematic...
The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e39]
The treatment of musculoskeletal joint dysfunction may require a physiotherapist to use a number of
modalities. Developed manual therapy techniques include that of Brian Mulli-gan’s widely used mobilization with movement (MWM) for peripheral joint
pain1,2, also referred to as a Mulligan mobilization3-5 or a manipulative tech - nique6,7.
With respect to the research, the clinical efficacy of Mulligan’s MWM techniques has been established for im-proving joint function, with a number of
hypotheses for its cause and effect. Mul-ligan’s original theory for the effective-ness of an MWM is based on a mechani-cal model documented in his first teaching text8. This concept is related to minor positional faults that occur sec-ondary to injury and that lead to mal-tracking of the joint, resulting in symp-toms such as pain, stiffness, or weakness1. This theory in conjunction with the pre-scription of MWMs is still advocated in Mulligan’s latest edition and remains un-changed9. The cause of positional faults has been suggested as changes in the shape of articular surfaces, thickness of cartilage, orientation of fibers of liga-ments and capsules, or the direction and pull of muscles and tendons. MWMs cor-rect this by repositioning the joint, caus-ing it to track normally1,10. Subsequent research to date also suggests that the mechanisms behind the effectiveness of MWMs are based on mechanical dys-function and therefore positional fault correction1,3,11,12.
More recent studies have investi-gated further mechanisms and effects that may underpin MWM techniques, including hypoalgesic and sympathetic nervous system (SNS) excitation ef-fects5,13-15. Further research has estab-lished the effectiveness of MWMs for increasing joint range of motion (ROM),
ABSTRACT: Mulligan’s manual therapy technique at peripheral joints, namely mobiliza-tion with movement (MWM), has been well documented in research. The efficacy of MWM has been established in the treatment of joint dysfunction and various pathologies. The purpose of this systematic review was to critically evaluate the literature regarding MWM at peripheral joints and determine the overall efficacy related to MWM prescription. Elec-tronic databases (Cinahl, Medline and Amed via Ovid, Pubmed and Medline via Ebsco Health Databases, Cochrane via Wiley and PEDro) were searched up to August 2008 with no date restriction to identify all studies pertaining to MWM at peripheral joints. The key-words used were mobilisation with movement* OR mobilization with movement* OR MWM*; manual therapy AND (mobilisation* OR mobilization); mulligan mobilisation* OR mulligan mobilization*. Two researchers independently reviewed all papers and cross-examined reference lists for further potential studies. Methodological quality was assessed using the Downs and Black checklist, and tables were compiled to determine study charac-teristics. Twenty-one studies, which have investigated MWM at peripheral joints, were in-cluded for analysis. This review highlights that there is an overall moderate level of method-ological quality (mean = 15 (/28), SD ± 4.54, range = 4—23 /28). The efficacy of MWM at peripheral joints is well established for various joints and pathologies with 24 out of 25 stud-ies (96%) demonstrating positive effects. It would be advisable that future research have more robust methodology and investigate and/or implement all necessary established pa-rameters of MWM prescription.
KEYWORDS: Manipulative Technique, Manual Therapy, Mobilization with Movement (MWM), Mulligan Mobilization
1Associate Professor, Health and Rehabilitation Research Centre, AUT University, Auckland, New Zealand2Staff Physiotherapist, IRM Physiotherapy, Auckland, New Zealand3Staff Physiotherapist, Waikato Hospital, Waikato, New ZealandAddress all correspondence and requests for reprints to: Dr. Wayne Hing, [email protected]
Mulligan’s Mobilization with Movement: A Systematic Review
Wayne Hing, PhD1; Renee BigeloW, BHSc2; Toni BRemneR, BHSc3
[e40] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
enhancing muscle function, or more specifically treating particular patholo-gies1,3,5,6,16-18.
The purpose of this review initially originated from a global search that was undertaken to explore the literature re-garding Mulligan’s manual therapy tech-niques. From this search, it became evi-dent that there has been no review or consensus regarding the prescription of MWMs in peripheral joints. Therefore, the purpose was to undertake a system-atic review to critically evaluate the lit-erature regarding the overall efficacy of MWM prescription and use at periph-eral joints in an attempt to formulate guidelines for clinical practice.
Methods
Search Strategy
Electronic databases (Cinahl, Medline and Amed via Ovid, Pubmed and Med-line via EBSCO Health Databases, Co-chrane via Wiley and PEDro) were searched to August 2008 with no date restriction to identify all studies pertain-ing to MWM at peripheral joints. The refined key terms were mobilisation with movement* OR mobilization with movement* OR MWM*; manual ther-apy AND (mobilisation* OR mobiliza-tion); mulligan mobilisation* OR mul-ligan mobilization*. These search phrases were adapted for particular da-tabases (Medline via Pubmed and EB-SCO, and EBSCO Health Databases), due to the excessive number of results (Figure 1). While performing the search, two independent researchers evaluated all titles and abstracts that were obtained from the various databases or from other sources to determine appropriate-ness. If this was unclear, the full-text ar-ticle was obtained to confirm whether MWM at peripheral joints was em-ployed. All articles to be included in this review were obtained in hard copy.
Exclusion criteria that were incor-porated during the search included studies prior to 1990, non-English writ-ten articles, studies not relevant to pe-ripheral joint manual therapy/MWM/physiotherapy, spinal manual therapy, chiropractic studies, non-original re-search, cadaver or animal studies, and/
or if there was no clear indication of the use of MWM. Due to the aim of this sys-tematic review, to obtain every study that had used MWM techniques, no re-strictions were placed on study design or methodological quality, as all literature needed to be reviewed to accurately ana-lyze the possible variations in its pre-scription. As papers were read, reference lists were cross-examined by both re-viewers for citations of other potentially relevant studies, and in total three stud-ies were subsequently retrieved from this process of cross-referencing7,19,20.
Review of Methodological Quality
The critical appraisal tool employed for this research was the Downs and Black checklist for the assessment of method-ological quality21. This tool has been stated to be valid and reliable for criti-cally evaluating experimental and non-experimental studies22,23, and it has pre-viously been used in many systematic reviews24-29. The Downs and Black tool consists of four categories: reporting (/11), external validity and power (/4), internal validity (bias) (/7), and internal validity (confounding or selection bias) (/6) totalling 28. The last item in this tool, regarding the power of a study, was modified due to its complexity and to ensure consistency with the scoring. The item was changed from a score out of five to a score out of one, and it was placed with the external validity cate-gory in the table. An example of a study in which this tool was previously modi-fied is Monteiro and Victora27.
Each article was assessed with this scoring system, independently by the two researchers, to decrease bias. The scores and content of each article were meticulously discussed throughout. If any disagreements arose, they were de-liberated between the two researchers and resolved. After critiquing each study, it was categorized as being of a strong, moderate, limited, or poor quality depending on its score (Table 1). This method of score categorization was adapted from previous systematic re-views that have used the Downs and Black checklist and have further classi-fied the resulting values24,26. No studies were excluded on the basis of limited
quality, due to the purpose of the review and its aim to assess all studies that have incorporated MWMs in peripheral joints.
Review of Study Characteristics
Using a generic critical appraisal check-list, data was extracted from the in-cluded 25 articles and information was recorded into tables under the following headings: design, purpose, participants, interventions, MWM prescription or other treatment, outcome measures and timing of assessment, statistical analysis, results, and strengths and limitations.
Results
During the search, articles were ex-cluded on the basis of the strict exclu-sion criteria previously mentioned. A total of 121 articles were identified from the stated databases (Figure 1). Once search results were matched for repeated articles between the databases, 22 were included for analysis. An additional 3 studies were found by means of further cross-referencing by both reviewers7,19,20, increasing the total to 25 studies for critical analysis—including 4 true ran-domized controlled trials (RCTs), 6 RCTs with participants as own control, 3 quasi-experimental, 3 non-experi-mental, 4 case studies, and 5 case re-ports. Both researchers performed the statistical calculations independently, to ensure correct results.
Methodological Scoring and Categorization (critical evaluation of the literature regarding MWM prescription at peripheral joints)
The included 25 articles were analyzed using the Downs and Black tool result-ing in a variation of data in relation to the particular study design (mean = 15/28; SD ± 4.54; range = 4—23/28). Table 2 reflects the reporting analyses of items 1 through 10. Table 3 reflects the reporting analyses of the external valid-ity items of 11 through 14. Table 4 out-lines the scoring for the internal validity items of 15 through 21. Table 5 also in-cludes internal validity items but focuses on confounding or selection biases of
The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e41]
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
51
Initial global search followed by a refined
search (exclusion criteria implemented)
Articles retrieved by Amed (79), Cinahl via
Ovid (163), Cochrane via Ovid (65),
Cochrane via Wiley (89), and Pedro (28)
with normal search terms: 424
Articles retrieved by EBSCO Health
Databases (114), Medline via EBSCO (87),
and Medline via Pubmed (1078) with
adapted key terms due to excessive number
of results: 1279
Excluded: 360
NB: Includes databases
with repeated articles
Excluded: 1222
NB: Includes databases
with repeated articles
Cross-referencing of all articles for further
studies results: 3
Total articles identified for analysis in
relation to the final exclusion criteria: 121
Cross-matching of search results for repeated
articles results: 22
Final studies selected for the systematic
review of Mulligan’s Mobilization with
Movement: 25
items 22 through 27. In general, the studies were of a moderate level of meth-odological quality. Categorization of the methodological scores, as detailed in Table 1, was adapted from systematic
reviews that had previously used the Downs and Black critiquing tool for as-sessing quality of studies24,26.
As illustrated in Table 6, RCTs with participants as their own control
achieved the highest mean score (mean = 18.5) with the least variability (±1.71), meaning overall they were of moderate methodological quality. This is closely followed by true RCTs (mean = 17.5) and then non-experimental studies (mean = 17.33), both ranking at a mod-erate level of quality. Interestingly, the non-experimental group of studies had less variability (±3.68) compared to the true RCTs (±5.12). This suggests that there is greater variability (range = 11–23) in the methodological quality of true RCTs in this area of research, even though it includes the highest scoring study to date30. Quality of studies was
FiguRe 1. Flow chart outlining search results
TABLE 1. Categorization of total methodological scores
Quality Index: Percentage: Methodological Quality Score:
Strong 75% + 21 +Moderate 50–74% 14–20Limited 25–49% 7–13Poor < 25% < 7
Adapted from Hartling et al24 and Hignett26
[e42] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
TABLE 2. reporting analysis via the Downs and black checklist for methodological quality
Author 1 2 3 4 5 6 7 8 9 10
Bisset et al30 1 1 1 0 2 1 1 1 1 0Kochar & Dogra4 1 1 1 1 1 1 1 0 0 0Slater et al42 1 1 1 1 0 1 1 0 0 0Teys et al5 1 1 1 1 1 1 1 1 1 1Collins et al3 1 1 1 1 0 1 1 0 1 1Paungmali et al14 1 1 1 1 1 1 1 1 1 0Paungmali et al15 1 1 0 1 1 0 1 1 1 0Teys et al40 1 1 1 1 0 1 1 1 1 1Vicenzino et al7 1 1 1 1 1 1 0 1 1 1Vicenzino et al18 1 1 1 1 0 1 1 1 1 1McLean et al31 1 1 1 1 0 1 1 0 0 1Reid et al32 1 1 1 1 2 1 1 0 1 1Yang et al33 1 1 1 1 2 1 1 0 1 0Abbot13 1 1 1 1 0 1 1 0 0 1Abbottet al41 1 1 1 1 0 1 1 0 1 0Paungmali et al6 1 1 1 1 2 1 1 1 1 1O’Brien & Vincenzino38 1 1 1 1 0 0 0 0 1 1Penso39 1 1 1 1 1 1 0 0 1 0Stephens20 0 0 1 0 0 0 0 0 1 0Vincenzino & Wright34 1 1 1 1 0 1 0 1 1 0Backstrom35 1 1 1 1 0 0 0 0 1 0DeSantis & Hasson16 1 1 1 1 0 1 0 0 1 0Folk36 1 0 1 1 0 1 0 0 1 0Hetherington19 0 1 0 1 0 0 0 0 0 0Hsieh et al37 1 0 1 1 0 1 0 0 1 0
1. Is the hypothesis/aim/objective of the study clearly described? 2. Are the main outcomes to be measured clearly described in the introduction or methods section? 3. Are the characteristics of the patients included in the study clearly described? 4. Are the interventions of interest clearly described? 5. Are the distributions of principle confounders in each group of subjects to be compared clearly described? 6. Are the main findings of the study clearly described? 7. Does the study provide estimates of the random variability in the data for the main outcomes? 8. Have all important adverse events that may be a consequence of the intervention been reported? 9. Have the characteristics of patients lost to follow-up been described? 10. Have the actual probability values been reported?1 = yes, 0 = no
more consistent in the group of RCTs with participants as their own control. The quasi-experimental studies31-33 had a mean score of 17.33 (±3.68), ranking them as moderate quality. Case studies and case reports had the lowest mean scores, 12.75 (±2.95) and 10.4 (±3.38) respectively, categorizing them as being of limited methodological quality. The range of case studies (range = 8–16) and reports (range = 4–14), however, was large, and two studies had a moderate level of quality16,34, which is in general equivalent to the quality of several true
RCTs, RCTs with participants as own control, quasi-experimental, and non-experimental studies.
When comparing the 4 categories from the Downs and Black tool, in re-gards to the mean, standard deviation, and range, it is evident that the different categories display either a low or moder-ate level of quality (Table 6). The catego-ries of external validity/power (/4) and internal validity (confounding and se-lection bias) (/6) generally scored low, which is indicated by their means, stan-dard deviations, and ranges, calculated
across all studies: 0.84 (±0.78) (range = 0–4/4) and 2.84 (±1.22) (range = 1–6/6), respectively. Reporting (/11) and inter-nal validity (bias) (/7) generally scored with a moderate level of quality, with scores of 7.16 (±2.22) (range = 2–11/11) and 4.64 (±1.87) (range = 0–7/7), re-spectively. Two studies in particular19,20 had the lowest total scores, resulting in an overall reduction of the mean values and increasing the variability of the data. The study that displayed the highest overall score (by Bisset et al30) of 23 out of 27 also illustrated consistency in all 4
The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e43]
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
categories, which differs from the other studies, which only excelled in particu-lar categories.
Characteristics of Studies
Data extracted from the 25 studies for the generic critical appraisal checklist il-lustrate trends and variations in the overall characteristics of each study. De-signs of studies have been previously mentioned and are outlined in Table 6. The characteristics of the studies can be found in Table 7, and the results, along with summaries of strengths and limita-tions of the studies, are found in Table 8. Nearly half of the studies (12/25; 48%) investigated MWM effects on lateral
epicondylalgia. The next most common condition investigated was lateral ankle sprains (6/25; 24%). Following this, an equal number of studies have assessed the effects at the shoulder (4/25; 16%) and thumb (2/25; 8%), with pathologies including anterior shoulder pain and subacromial impingement for the shoul-der joint, and metacarpophalangeal (MCP) strains of the thumb. Only one study has investigated MWM at the wrist for de Quervain’s (4%).
All studies have examined the ef-fects of MWMs on genuine pathologies, where the participants presented with the condition, except for the study by Slater et al37, which induced lateral epi-condylalgia. It is important to highlight
also that this was the only study that did not conclude with any significant be-tween-group differences in response to the intervention of MWM versus pla-cebo. The genders of the participants varied between studies, although there was approximately equal male and fe-male representation across all the in-cluded studies. There was a large varia-tion in the average age of the participants, ranging from 17 to 79 years, which may reflect the six different pathologies in-vestigated, each with their own epide-miological data. MWM treatment dura-tions varied from one day to two months. Only 8 of the 25 studies included some form of follow-up, with all demonstrat-ing significant positive results from MWM use4,20,30,34-39.
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 pain pressure threshold (PPT) or strength was by Slater et al37, which is also the only study that investigated the efficacy of MWMs on an induced condi-tion. All other studies used patients with genuine pathologies, whereas this study induced lateral epicondylalgia pain via delayed onset of muscle soreness and hypertonic saline.
The most common significant re-sults found were increase in strength, reduction in pain levels, increase in PPT, improved upper limb tension tests, and overall function improve-ments when compared with placebo or control, mainly in lateral epicond-ylalgia4,6,7,13-15,20,30,31,34. No change in tem-perature pain threshold (TPT) has been found at the elbow15. 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 suggesting that a non-opioid mechanism occurs for the analgesic response6,15. The only study investigating the required force for opti-mal effects demonstrated that best re-sults are gained when an MWM is ap-plied at either 66% or 100% of maximal force31. MWM treatment was also found
TABLE 3. external validity and power analysis via the Downs and black checklist for methodological quality
Author 11 12 13 14
Bisset et al30 1 1 1 1Kochar & Dogra4 0 0 1 0Slater et al42 0 0 0 1Teys et al5 0 0 0 1Collins et al3 0 0 0 0Paungmali et al14 0 0 0 1Paungmali et al15 0 0 0 0Teys et al40 0 0 0 0Vicenzino et al7 0 0 0 0Vicenzino et al18 0 0 0 0McLean et al31 0 0 0 1Reid et al32 0 0 0 0Yang et al33 1 0 0 0Abbot13 0 0 0 0Abbottet al41 0 0 0 1Paungmali et al6 0 0 0 1O’Brien & Vincenzino38 0 0 1 0Penso39 0 0 1 0Stephens20 0 0 1 0Vincenzino & Wright34 0 0 1 0Backstrom35 0 0 1 0DeSantis & Hasson16 0 0 1 0Folk36 0 0 1 0Hetherington19 0 0 1 0Hsieh et al37 0 0 1 0
11. Were the subjects asked to participate in the study representative of the entire population from which they were recruited?
12. Were those subjects who were prepared to participate representative of the entire population from which they were recruited?
13. Were the staff, places, and facilities where the patients were treated representative of the treat-ment the majority of patients received?
14. Did the study have sufficient power to detect a clinically important effect where the probability value for a difference being due to chance was less than 5%?
1 = yes, 0 = no
[e44] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
to be superior in the long term when compared to corticosteroid injection30. 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 ef-fects of spinal manipulation14. MWM applied at the elbow has shown to have beneficial effects on shoulder rotation ROM13.
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 im-proved function3,5,16,18,19,32,33,35-40. Again no change in TPT was found at the an-kle3. One study investigated MWM un-
der magnetic resonance imaging and found MWM to correct a position fault at the thumb, although this was not maintained post-MWM even though the positive effects were long lasting37.
Discussion
Methodological Quality
Overall, the results of this systematic re-view illustrate a moderate methodologi-cal quality among studies that have in-vestigated the use of Mulligan’s MWM technique at peripheral joints. RCTs that used participants as own controls had the highest methodological mean score (18.5/28) and the least variability (SD
±1.71). There was greater variability (range = 11–23) in the methodological quality of true RCTs in this area of re-search, however, this group includes the highest scoring study to date30. This study also displayed the highest overall score (23 out of 27), which illustrated consistency in all four categories as compared to all other studies, which had variable scoring in each category of the analysis. This illustrates that more con-sistently robust research is being pro-duced when participants are used as control groups; however, RCTs with true control groups are considered the high-est quality research design. As predicted, case studies and case reports had the lowest mean score; however, both had outliers, with large ranges from 8 to 16, and 4 to 14, respectively. This highlights the variability in the quality of this area of research.
The results from the methodologi-cal quality analysis via the Downs and Black critiquing tool displayed an over-all low to moderate level of quality across each category (Tables 1–6). The items within external validity and power were the least satisfied followed by internal validity (confounding and selection bias). Contributing to the low level of quality were two studies with the lowest score19,20, which as outliers resulted in an overall reduction of the mean values and increasing the variability of the data. The study that displayed the highest (Bisset et al30 with 23 out of 27) demonstrated the highest overall score with consis-tency in all four categories when com-pared to the other studies that only ex-celled in particular categories.
Strengths and Limitations of the Included Studies
This review has highlighted clear strengths and limitations within this area of research. These are clearly related to the analyses of categories and indi-vidual items of the Downs and Black critiquing tool, which are detailed in the following sections.
Reporting
Of the four categories within the Downs and Black critiquing tool, reporting per-
TABLE 4. internal validity—bias analysis via the Downs and black checklist for methodological quality
Author 15 16 17 18 19 20 21
Bisset et al30 0 1 1 1 0 0 1Kochar & Dogra4 0 0 1 1 1 0 1Slater et al42 0 0 1 1 1 0 0Teys et al5 1 1 1 1 1 1 1Collins et al3 1 1 1 1 1 0 1Paungmali et al14 0 1 1 1 1 1 1Paungmali et al15 1 1 1 1 1 1 1Teys et al40 1 1 1 1 1 1 1Vicenzino et al7 1 1 1 1 1 1 1Vicenzino et al18 1 1 1 1 1 1 0McLean et al31 1 0 1 1 1 0 1Reid et al32 0 1 1 1 1 0 1Yang et al33 0 1 1 1 1 0 1Abbot13 0 1 1 1 1 0 1Abbottet al41 0 1 1 1 1 1 1Paungmali et al6 1 1 1 1 1 1 1O’Brien & Vincenzino38 0 0 1 1 1 1 1Penso39 0 0 1 1 0 1 0Stephens20 0 0 1 1 0 0 0Vincenzino & Wright34 0 0 1 1 1 1 1Backstrom35 0 0 1 1 0 0 0DeSantis & Hasson16 0 0 1 1 0 1 1Folk36 0 0 1 1 0 1 0Hetherington19 0 0 0 0 0 0 0Hsieh et al37 0 0 1 1 0 0 0
15. Was an attempt made to blind study subjects to the intervention they have received?16. Was an attempt made to blind those measuring the main outcomes of the intervention?17. If any of the results of the study were based on “data dredging,” was this made clear?18. In trials and cohort studies, do the analyses adjust for different lengths of follow-up of patients,
or in case-control studies, is the time period between the intervention and outcome the same for cases and controls?
19. Were the statistical tests used to assess the main outcomes appropriate?20. Was compliance with the intervention/s reliable?21. Were the main outcome measures used accurate (valid and reliable)?1 = yes, 0 = no
The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e45]
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
formed at the highest level: 90% of the studies included a clear aim and descrip-tion of inclusion and exclusion criteria, which are important for generalizability of results and also closely relates to the adequate explanation of characteristics (items 1, 3). Consistent and appropriate choice of outcome measures was em-ployed across the studies (item 2); for example, all studies investigating the ef-fects of MWM at the elbow used either pain-free grip strength or maximal grip strength as part of their assessment. In general, interventions were well out-lined (item 4); however, explicit details of MWM prescription were variable, which impacted the analysis of findings. Further weaknesses were evident, in-
cluding documenting confounding variables, adverse effects, and probabil-ity values (items 5, 8, 10).
Internal Validity
Internal validity is necessary to deter-mine treatment efficacy. Statistical anal-ysis was performed appropriately in the majority of studies, which illustrates strength of result analysis. Generally, there was high compliance with a low level of dropouts when reported (item 27), possibly reflecting the minimal ad-verse events documented. Randomiza-tion of participants to intervention groups is important in research to di-minish possible bias; however it only oc-
curred in 15 of the studies (60%) re-viewed here3-5,7,13-15,18,30-33,40-42 although it should be noted that 9 studies were ei-ther case reports or studies and there-fore only 16 studies had the potential for randomization (item 24). Although only 9 studies incorporated follow-up assess-ment to examine long-lasting effects of MWMs, time periods between the inter-vention and assessment were always consistent (item 18)4,6,20,30,34-38.
Sixteen of the 25 studies to date have not incorporated any form of con-trol or placebo group. Control groups are important for confirming treatment effectiveness and for reducing the effect of confounding variables. Although 6 studies used participants as their own controls, which decreases the level of in-ternal validity, it is understood that it is not always ethical to have true control groups receiving nil or placebo treat-ment. Blinding and concealment of in-tervention groups was a major limiting factor of internal validity within the studies (items 15, 16, 25). Less than 50% of the studies incorporated blinding, with only 7 studies demonstrating dou-ble blinding3,5-7,15,18,40. The majority of these studies incorporated other forms of physiotherapy treatment in combina-tion with MWMs16,20,35,36,38. This high-lights how confounding variables have been poorly considered within this re-search with only 5 studies taking it into account (item 26)5-7,14,30.
External Validity
External validity was generally poor, as only one study recruited participants that represent the population (items 11, 12)30. This is related to the fact that methods of recruitment, assessment, and treatment were poorly documented. The ratio of males and females was rela-tively equal in general, in conjunction with a large age range (range = 17–79 years), which increases overall external validity. A specific sample size is re-quired to detect a clinically significant change, which is indicated in the power calculation. Only 10 studies demon-strated power of 95% or more, which may reflect the significant number of studies with low participant numbers (item 14)5,6,14,30-33,40-42. Because 7 studies
TABLE 5. internal validity—confounding (selection bias) via the Downs and black checklist for methodological quality
Author 22 23 24 25 26 27
Bisset et al30 1 1 1 1 1 1Kochar & Dogra4 1 0 1 0 0 0Slater et al42 0 0 1 0 0 0Teys et al5 1 0 1 0 1 1Collins et al3 1 0 1 0 0 1Paungmali et al14 1 0 1 0 1 1Paungmali et al15 0 0 1 0 0 1Teys et al40 1 0 1 1 1 1Vicenzino et al7 0 0 1 0 1 1Vicenzino et al18 0 0 1 1 0 1McLean et al31 0 0 1 0 0 0Reid et al32 1 0 1 0 0 1Yang et al33 1 0 1 0 1 1Abbot13 0 0 1 0 0 0Abbottet al41 1 0 1 0 0 1Paungmali et al6 1 0 0 0 1 1O’Brien & Vincenzino38 0 0 0 0 0 1Penso39 1 0 0 0 1 1Stephens20 1 1 0 0 0 1Vincenzino & Wright34 1 1 0 0 0 1Backstrom35 1 1 0 0 0 1DeSantis & Hasson16 1 1 0 0 0 1Folk36 1 1 0 0 0 1Hetherington19 1 0 0 0 0 0Hsieh et al37 1 1 0 0 0 1
22. Were the patients in different intervention groups (trials and cohort studies) or were the cases and controls (case-control studies) recruited from the same population?
23. Were the study subjects in different intervention groups (trial and cohort studies) or were the cases and controls (case-control studies) recruited over the same time period?
24. Were the study subjects randomized to intervention groups?25. Was the randomized intervention assignment concealed from both patients and health care staff
until recruitment was complete and irrevocable?26. Was there adequate adjustment for confounding in the analysis from which the main findings
were drawn?27. Were losses of patients to follow-up taken into account?1 = yes, 0 = no
[e46] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
TAB
LE
6.
Stud
y de
sign
s, s
core
s, a
nd m
etho
dolo
gica
l dat
a va
riatio
n
In
tern
al
Q
ual
ity
Ext
ern
al
Inte
rnal
va
lidit
y—
m
ean
Q
ual
ity
Stu
dy D
esig
n
R
epor
tin
g va
lidit
y an
d va
lidit
y—
con
fou
ndi
ng
To
tal
(SD
) sc
ore
Tota
l n
= 2
5 A
uth
ors
(/11
) po
wer
(/4
) bi
as (
/7)
(/6)
(/
28)
scor
e ra
nge
True
RC
T (4
) Bi
sset
et a
l30
9 4
4 6
23
17.5
(±5.
12)
11–2
3
Koch
ar &
Dog
ra4
7 1
4 2
14
Slat
er e
t al42
6
1 3
1 11
Te
ys e
t al5
10
1 7
4 22
RCT
with
par
ticip
ants
C
ollin
s et a
l3 8
0 6
3 17
18
.5 (±
1.71
) 16
–21
as o
wn
cont
rol (
6)
Paun
gmal
i et a
l14
9 1
6 4
20
Paun
gmal
i et a
l15
7 0
7 2
16
Teys
et a
l40
9 0
7 5
21
Vic
enzi
no e
t al7
9 0
7 3
19
Vic
enzi
no e
t al18
9
0 6
3 18
Qua
si-ex
perim
enta
l (3)
M
cLea
n et
al31
7
1 5
1 14
17
(±2.
16)
14–1
9
Reid
et a
l32
10
0 5
3 18
Ya
ng e
t al33
9
1 5
4 19
Non
-exp
erim
enta
l (3)
A
bbot
13
7 0
5 1
13
17.3
3 (±
3.68
) 13
–20
A
bbot
tet a
l41
7 1
6 3
17
Paun
gmal
i et a
l6 11
1
7 3
22
C
ase
stud
y (4
) O
’Brie
n &
Vin
cenz
ino38
6
1 5
1 13
12
.75
(±2.
95)
8–16
Pe
nso39
7
1 3
3 14
St
ephe
ns20
2
1 2
3 8
Vin
cenz
ino
& W
right
34
7 1
5 3
16
C
ase
repo
rt (5
) Ba
ckst
rom
35
5 1
2 3
11
10.4
(±3.
38)
4–14
D
eSan
tis &
Has
son16
6
1 4
3 14
Fo
lk36
5
1 3
3 12
H
ethe
ringt
on19
2
1 0
1 4
Hsie
h et
al37
5
1 2
3 11
Mea
n (S
D)
7.
16
0.84
4.
64
2.84
15
.48
(±2.
22)
(±0.
78)
(±1.
87)
(±1.
22)
(±4.
54)
Ra
nge
2–
11
0–4
0–7
1–6
4–23
The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e47]
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
tAb
le 7
. C
hara
cter
istic
s of
the
incl
uded
stu
dies
P
resc
ript
ion
of
A
uth
or
Des
ign
P
urp
ose
Part
icip
ants
In
terv
enti
on
MW
M/o
ther
Rx
Tim
es o
f Ax
O/C
mea
sure
s
Biss
et e
t al30
Tr
ue R
CT
To in
vest
igat
e th
e
198
part
icip
ants
G
roup
1:
PT: 8
sess
ions
6
wee
ks a
nd
Glo
bal i
mpr
ovem
ent
effica
cy o
f PT
12
8 m
ales
, 8
sess
ions
of P
T fo
r 30
min
s ove
r 52
wee
ks
Grip
forc
e
in
terv
entio
n
70 fe
mal
es
Gro
up 2
: 6
wee
ks. I
nclu
ded
A
sses
sor’s
ratin
g of
co
mpa
red
with
M
ean
age:
48
cort
icos
tero
id
MW
M, t
hera
band
seve
rity
cort
icos
tero
id
in
ject
ion
exer
cise
s, an
d
Pain
(VA
S)
inje
ctio
n an
d w
ait
G
roup
3:
stre
tchi
ng.
El
bow
disa
bilit
y (p
ain-
an
d se
e fo
r lat
eral
wai
t and
see
Cor
ticos
terio
d
free
func
tion
epic
ondy
lalg
ia
inje
ctio
n:
qu
estio
nnai
re
1
inje
ctio
n, a
nd a
2nd
one
if ne
cess
ary
after
2 w
eeks
.
Wai
t and
see:
adv
ice,
educ
atio
n on
mod
ifica
tions
to A
DLs
,
enco
urag
e ac
tivity
,
usin
g an
alge
sic d
rugs
,
heat
, col
d, a
nd b
race
s.
Koch
ar &
Tr
ue R
CT
To co
mpa
re th
e
66 p
artic
ipan
ts
Gro
up 1
: com
bina
tion
US:
3 M
Hz,
W
eek
1, 2
, and
3
Pain
—VA
S sc
ale
Dog
ra4
eff
ects
of a
36
mal
es,
of U
S an
d M
WM
on
1.5
W/c
m2 , p
ulse
d Fo
llow
-up
at
Abi
lity
to li
ft 0–
3kg
com
bina
tion
of
30 fe
mal
es
10 se
ssio
ns (d
iffer
ent
1:5,
5 m
ins.
4 m
onth
s w
eigh
ts w
ith n
o pa
in,
MW
M a
nd U
S
Mea
n ag
e: 4
1 Rx
on
alte
rnat
e da
ys)
MW
M: e
lbow
24hr
s afte
r Rx.
ve
rsus
US
alon
e,
co
mpl
eted
in 3
wee
ks
exte
nded
, for
earm
Grip
stre
ngth
.
fo
llow
ed b
y an
and
an e
xerc
ise
pron
ated
, 10
reps
,
Wei
ght t
est
exer
cise
pro
gram
,
prog
ram
(9 w
eeks
). no
pai
n, g
lide
for l
ater
al
G
roup
2: U
S on
ly
sust
aine
d w
hile
ep
icon
dyla
lgia
on 1
0 se
ssio
ns
part
icip
ant l
ifted
co
mpl
eted
in
wei
ght t
hat
3 w
eeks
and
pr
evio
usly
pro
duce
d
an
exe
rcise
pa
in, f
or 3
sets
,
pr
ogra
m (9
wee
ks).
10 se
ssio
ns.
Gro
up 3
(con
trol
):
Prog
ress
ed M
WM
by
no
Rx
incr
easin
g w
eigh
ts b
y
0.
5kg.
Exer
cise
: str
etch
ing,
PRT,
conc
entr
ic/
ec
cent
ric e
xerc
ises.
[e48] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic ReviewtA
ble
7.
Cha
ract
eris
tics
of th
e in
clud
ed s
tudi
es (
cont
inue
d)
P
resc
ript
ion
of
A
uth
or
Des
ign
P
urp
ose
Part
icip
ants
In
terv
enti
on
MW
M/o
ther
Rx
Tim
es o
f Ax
O/C
mea
sure
s
Slat
er e
t al42
Tr
ue R
CT
To e
xam
ine
the
24
par
ticip
ants
D
ay 0
—in
duce
d Ex
erci
ses t
o in
duce
Be
fore
exe
rcise
, PP
T.
eff
ects
of a
late
ral
11 m
ales
, D
OM
S (e
ccen
tric
D
OM
S: re
peat
ed
inje
ctio
n,
McG
ill p
ain
glid
e M
WM
in
13 fe
mal
es
exer
cise
s on
non-
ec
cent
ric w
rist
and
MW
M
ques
tionn
aire
he
alth
y su
bjec
ts
Mea
n ag
e: 2
3 do
min
ant a
rm).
exte
nsio
n A
fter R
x
Mus
cle
forc
e
w
ith in
duce
d
D
ay 1
—in
ject
ed
cont
ract
ions
—5
sets
Fo
llow
-up
Max
imal
grip
forc
e
la
tera
l
hype
rton
ic sa
line
of 6
0 re
ps, w
ith
at d
ay 7
(d
ynam
omet
er).
epic
ondy
lalg
ia
(2
4hrs
pos
t-ex
erci
se)
1 m
in re
st in
terv
al
M
axim
al w
rist e
xten
sion
pain
to m
imic
tenn
is el
bow
be
twee
n se
ts. M
WM
:
forc
e (fo
rce
tran
sduc
er)
sym
ptom
s (pa
in
sust
aine
d la
tera
l glid
e,
dura
tion
10 m
ins)
, w
ith P
T’s h
and
th
en ap
plie
d M
WM
ag
ains
t par
ticip
ant’s
or
pla
cebo
Rx
ulna
. Par
ticip
ant s
upin
e,
sh
ould
er a
bduc
ted
20°,
elbo
w e
xten
ded
and
fore
arm
pro
nate
d.
Plac
ebo:
appl
icat
ion
of a
firm
cons
tant
man
ual c
onta
ct a
roun
d
th
e m
edia
l and
late
ral
as
pect
s of t
he el
bow
Teys
et a
l5 Tr
ue R
CT
Exam
ine
the
24
par
ticip
ants
G
roup
1: M
WM
Rx
MW
M: p
oste
rola
tera
l Be
fore
and
afte
r Rx,
A
ROM
(act
ive
pain
-fre
e
eff
ect o
f MW
M
11 m
ales
, G
roup
2: p
lace
bo
glid
e w
ith p
atie
nt
on 3
sess
ions
sh
ould
er el
evat
ion)
of
the
shou
lder
13
fem
ales
G
roup
3: c
ontr
ol
seat
ed. P
T pl
aced
han
ds
PP
T
in
rela
tion
to
Mea
n ag
e: 4
6
over
pos
terio
r sca
pula
RO
M a
nd P
PT
and
then
ar e
min
ence
of
ot
her h
and
over
ant
erio
r
aspe
ct o
f hea
d of
hum
erus
. Pos
terio
r glid
e
appl
ied
to h
umer
al h
ead.
Part
icip
ant a
ctiv
ely
ab
duct
ed a
rm.
Pl
aceb
o: a
/a, b
ut h
ands
of P
T w
ere
ante
riorly
on th
e cl
avic
le a
nd
st
ernu
m, a
nd a
n an
terio
r
glid
e w
ith m
inim
al fo
rce
w
as ap
plie
d
Con
trol
: no
man
ual
co
ntac
t of P
T.
Col
lins e
t al3
RCT
with
Ev
alua
te th
e 16
par
ticip
ants
G
roup
1: M
WM
. M
WM
: at t
aloc
rura
l Be
fore
and
W
eigh
t-be
arin
g D
F RO
M
part
icip
ants
eff
ect o
f MW
M
8 m
ales
, G
roup
2: p
lace
bo
join
t. Pa
rtic
ipan
t aft
er R
x PP
T
as o
wn
fo
r lat
eral
ank
le
8 fe
mal
es
Gro
up 3
: con
trol
W
B in
stan
ce
TP
T
cont
rol
spra
ins o
n RO
M
Mea
n ag
e: 2
8
posit
ion
with
(rep
eate
d
and
hypo
alge
sia
Belt
arou
nd P
T
mea
sure
s,
pe
lvis
and
dist
al
cr
osso
ver)
tibia
and
fibu
la.
The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e49]
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
Pa
tient
lean
ed b
ack
to cr
eate
PA
glid
e,
w
ith ta
lus a
nd
fo
refo
ot st
abili
zed
by P
T’s h
and
and
othe
r han
d ov
er
pr
oxim
al ti
bia
and
fibul
a to
mai
ntai
n le
g
al
ignm
ent.
Pl
aceb
o: a
/a w
ith b
elt
ov
er c
alca
neum
and
min
imal
forc
e, w
ith
st
abili
zing
han
d ov
er
m
etat
arsa
ls.
Con
trol
: pat
ient
in
st
ance
pos
ition
for 5
min
s with
no
man
ual
co
ntac
t of P
T.
Paun
gmal
i RC
T w
ith
To d
eter
min
e 24
par
ticip
ants
Ea
ch p
artic
ipan
t Rx
gro
up: l
ater
al
Befo
re, d
urin
g PF
GS
et a
l14
part
icip
ants
w
heth
er M
WM
17
mal
es,
com
plet
ed th
e 3
glid
e M
WM
with
an
d aft
er R
x PP
T
as o
wn
te
chni
que
at th
e 7
fem
ales
ra
ndom
ized
Rx
pain
-fre
e
TPT
co
ntro
l el
bow
pro
duce
s M
ean
age:
49
grou
ps (R
x, p
lace
bo,
dyna
mom
eter
Cute
neou
s blo
od fl
ux
(r
epea
ted
ph
ysio
logi
cal
co
ntro
l), at
sam
e gr
ippi
ng. P
artic
ipan
t
Skin
cond
ucta
nce
m
easu
res)
eff
ects
such
as
tim
e of
day
48
hrs
supi
ne, w
ith
Sk
in te
mpe
ratu
re
hypo
alge
sia a
nd
be
twee
n ea
ch
shou
lder
inte
rnal
ly
BP
SN
S fu
nctio
n in
sess
ion
rota
ted,
elbo
w
H
R
pa
tient
s with
ex
tend
ed, f
orea
rm
late
ral
pron
atio
n. 1
0 re
ps,
epic
ondy
lalg
ia
for 6
secs
, 15
sec r
est
pe
riod.
Pl
aceb
o: P
T ap
plie
d a
firm
man
ual c
onta
ct
w
ith b
oth
hand
s ove
r
the
elbo
w jo
int w
hile
part
icip
ant g
rippe
d th
e
dy
nam
omet
er p
ain-
free
.
Con
trol
: inv
olve
d th
e
pa
in g
rippi
ng a
ctio
n
on
ly (n
o m
anua
l for
ce
ap
plie
d).
Paun
gmal
i RC
T w
ith
Eval
uate
the
effec
t 18
par
ticip
ants
A
ll pa
rtic
ipan
ts
MW
M: p
artic
ipan
t in
Befo
re in
fect
ion
PFG
S et
al15
pa
rtic
ipan
ts
of n
alox
one
on
14 m
ale,
re
ceiv
ed
supi
ne p
ositi
on.
and
Rx, a
nd
PPT
as
ow
n
pain
relie
f fro
m
4 fe
mal
e in
trav
enou
sly
Rx ap
plie
d im
med
iate
ly
after
Rx
TPT
co
ntro
l an
MW
M ap
plie
d M
ean
age:
49
nalo
xone
, sal
ine
after
the
inje
ctio
n.
U
pper
lim
b ne
ural
test
(rep
eate
d
to la
tera
l
or n
o-su
bsta
nce
One
han
d st
abili
zed
pr
ovoc
atio
n (r
adia
l
mea
sure
s ep
icon
dyla
lgia
cont
rol o
n 3
the
dist
al h
umer
us o
n
nerv
e)
cr
osso
ver)
di
ffere
nt o
ccas
ions
, th
e la
tera
l asp
ect,
and
then
a M
WM
was
th
e ot
her h
and
appl
ied
appl
ied
to th
e el
bow
a
late
ral g
lide
to th
e
pr
oxim
al ra
dius
and
ulna
.
[e50] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
tAb
le 7
. C
hara
cter
istic
s of
the
incl
uded
stu
dies
(co
ntin
ued)
P
resc
ript
ion
of
A
uth
or
Des
ign
P
urp
ose
Part
icip
ants
In
terv
enti
on
MW
M/o
ther
Rx
Tim
es o
f Ax
O/C
mea
sure
s
Teys
et a
l40
RCT
with
To
inve
stig
ate
24 p
artic
ipan
ts
3 se
ssio
ns o
f Rx
MW
M: p
artic
ipan
t Ba
selin
e an
d aft
er
Pain
-fre
e RO
M
part
icip
ants
th
e in
itial
11
mal
es,
with
24
hour
s in
seat
ed, t
hera
pist
on
each
appl
icat
ion
in th
e sc
apul
ar p
lane
as o
wn
eff
ects
of M
WM
13
fem
ales
be
twee
n ea
ch.
oppo
site
side,
one
hand
of
MW
M, s
ham
(g
onio
met
ric
co
ntro
l te
chni
que
on
Mea
n ag
e: 4
6.1
Rx w
as e
ither
pl
aced
on
the
scap
ula
or co
ntro
l m
easu
rem
ent)
(cro
ssov
er
shou
lder
RO
M
M
WM
, sha
m,
post
erio
rly w
hile
PPT
(dig
ital p
ress
ure
de
sign)
in
the
plan
e of
or co
ntro
l th
e th
enar
em
inen
ce
pa
in a
lgom
eter
)
th
e sc
apul
a an
d
of th
e ot
her h
and
was
PP
T in
par
ticip
ants
on
the
ante
rior a
spec
t
w
ith a
nter
ior
of th
e hu
mer
us.
shou
lder
pai
n
A
pos
tero
late
ral g
lide
to th
e aff
ecte
d sh
ould
er
at
the
hum
eral
hea
d.
Th
e pa
rtic
ipan
t the
n
el
evat
ed a
rm in
the
plan
e of
the
scap
ula
to
th
e pa
in o
nset
onl
y.
Sham
mob
iliza
tion:
repl
icat
ed th
e pr
evio
us
M
WM
exc
ept a
n an
terio
r
glid
e w
as p
erfo
rmed
with
han
ds p
ositi
oned
on th
e cl
avic
le/s
tern
um
an
d po
ster
ior h
umer
al
he
ad.
Min
imal
pre
ssur
e
w
as ap
plie
d w
hile
the
patie
nt a
ctiv
ely
elev
ated
the
arm
thro
ugh
half
of th
e av
aila
ble
pain
-
free
rang
e.
Con
trol
: par
ticip
ant s
at
fo
r the
sam
e le
ngth
of t
ime
but t
here
was
no
man
ual
co
ntac
t bet
wee
n th
e
th
erap
ist a
nd p
artic
ipan
t.
Vic
enzi
no
RCT
with
D
eter
min
e w
heth
er
24 p
artic
ipan
ts
Part
icip
ants
M
WM
: lat
eral
glid
e Be
fore
and
afte
r PF
GS
et a
l7 pa
rtic
ipan
ts
MW
M fo
r lat
eral
14
mal
e, re
ceiv
ed e
ither
of
the
elbo
w. O
ne
each
Rx
sess
ion
PPT
as
ow
n
epic
ondy
lalg
ia
10 fe
mal
e M
WM
Rx,
pla
cebo
ha
nd g
lidin
g th
e PF
GS
also
mea
sure
d
cont
rol
prod
uced
M
ean
age:
46
or co
ntro
l on
prox
imal
fore
arm
, du
ring
Rx
(r
epea
ted
hy
poal
gesia
affec
ted
and
and
othe
r sta
biliz
ing
m
easu
res)
an
d to
com
pare
un-a
ffect
ed a
rm.
the
dist
al h
umer
us,
effec
ts o
n th
e
Th
ey re
ceiv
ed
whi
le p
artic
ipan
t
aff
ecte
d an
d
al
l 3 in
terv
entio
n pe
rfor
med
pai
n-fr
ee
non-
affec
ted
arm
s
leve
ls on
diff
eren
t gr
ippi
ng.
days
Pl
aceb
o: fi
rm m
anua
l
cont
act o
ver e
lbow
join
t.
Con
trol
: no
man
ual
co
ntac
t fro
m P
T.
The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e51]
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
Vic
enzi
no
RCT
with
To
exp
lore
the
16 p
artic
ipan
ts
Gro
up 1
: WB
MW
M
WB
MW
M: i
n st
andi
ng
Befo
re a
nd a
fter
Post
erio
r tal
ar g
lide
et a
l18
part
icip
ants
de
ficits
in a
nkle
8
mal
es,
Gro
up 2
: NW
B M
WM
w
ith th
erap
ist m
anua
lly
Rx, o
n 3
sess
ions
W
B an
kle
DF
(a W
B
as o
wn
RO
M in
pat
ient
s 8
fem
ales
G
roup
3: c
ontr
ol
stab
ilizi
ng th
e fo
ot o
n
lung
e m
easu
red
with
a
co
ntro
l w
ith re
curr
ent
Mea
n ag
e: 2
0 A
ll pa
rtic
ipan
ts
the
plin
th, u
sing
belt
to
ta
pe m
easu
re)
(r
epea
ted
an
kle
spra
ins,
expe
rienc
ed 1
of
appl
y fo
rce
and
m
easu
res,
an
d in
vest
igat
e
the
3 co
nditi
ons
part
icip
ant m
ovin
g
cros
sove
r)
the
effec
t of a
in a
rand
omiz
ed
into
DF.
post
erio
r glid
e
se
quen
ce o
n 3
NW
B M
WM
: app
lied
MW
M ap
plie
d
se
para
te d
ays
with
the
part
icip
ant
in N
WB
and
WB
(at l
east
48
hour
s in
supi
ne ly
ing,
tibi
a
on
talo
crur
al D
F
apar
t).
rest
ing
on p
linth
and
ankl
e on
the
edge
.
Con
trol
gro
up: n
o
m
anua
l con
tact
or
m
ovem
ent.
The
part
icip
ant s
tood
for a
sim
ilar p
erio
d
of
tim
e sim
ilar t
o th
e
Rx
tim
e fo
r the
oth
er
tw
o gr
oups
.
McL
ean
Q
uasi-
To
ass
ess
6 pa
rtic
ipan
ts
MW
M fo
rce
leve
ls M
WM
: dire
cted
Be
fore
and
afte
r Rx
PFG
S et
al31
ex
peri-
di
ffere
nt m
anua
l 2
mal
es,
wer
e de
term
ined
to
war
ds th
e m
edia
l
Mus
cle
forc
e: m
easu
red
m
enta
l—
forc
es u
sed
in
4 fe
mal
es
for 3
3%, 5
0%, 6
6%
aspe
ct o
f the
uln
a.
w
ith a
flex
ible
pre
ssur
e
re
peat
ed
a M
WM
M
ean
age:
49
and
max
imum
. D
urat
ion
of e
ach
se
nsin
g m
at b
etw
een
m
easu
res
tech
niqu
e fo
r
All
part
icip
ants
Rx
tech
niqu
e w
as
ha
nd a
nd el
bow
(ran
dom
iz-
late
ral e
lbow
rece
ived
appl
icat
ions
no
mor
e th
an 1
0 se
cs.
at
ion,
no
ep
icon
dyla
lgia
of th
e M
WM
3
appl
icat
ions
with
cont
rol)
and
its e
ffect
s
tech
niqu
e co
ntra
ctio
n fo
r
on
hyp
oalg
esia
com
prisi
ng o
f the
ba
selin
e m
easu
re.
4 fo
rce
leve
ls in
a
2 ap
plic
atio
ns o
f the
ra
ndom
ord
er.
4 fo
rce
leve
ls, w
ith
2
min
rest
inte
rval
s.
Reid
et a
l32
Qua
si-
To in
vest
igat
e 23
par
ticip
ants
G
roup
1: s
essio
n 5
min
s war
m u
p Ba
selin
e, an
d aft
er
DF
ROM
usin
g a
WB
ex
peri-
th
e eff
ect o
f 8
mal
es,
1 =
sham
of
mod
erat
e in
tens
ity
each
appl
icat
ion
lung
e m
ovem
ent:
dist
ance
men
tal—
ta
locr
ural
join
t 15
fem
ales
m
obili
zatio
n,
of st
atio
nary
cyc
ling
of
gre
at to
e to
the
wal
l
cros
sove
r M
WM
on
DF
Mea
n ag
e: 2
5 se
ssio
n 2
=
ensu
ring
full
leg
(r
epea
ted
3 tim
es fo
r eac
h
desig
n
ROM
in
tr
ue M
WM
ex
tens
ion
prio
r
ankl
e)
(r
ando
miz
a-
part
icip
ants
Gro
up 2
: ses
sion
to A
x an
d Rx
tion,
no
w
ith d
ecre
ased
1 =
MW
M,
(for b
oth
sham
cont
rol)
rang
e fo
llow
ing
sess
ion
2 =
an
d M
WM
).
la
tera
l ank
le
sh
am
MW
M: p
artic
ipan
t
sp
rain
mob
iliza
tion
in h
igh
knee
ling,
7
day
perio
d in
aff
ecte
d an
kle
in
betw
een
sess
ions
W
B ne
utra
l pos
ition
,
belt
(pre
ssur
e
bi
ofee
dbac
k) at
infe
rior m
argi
n
of
the
med
ial m
alle
olus
.
[e52] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
TABL
E 7.
Cha
ract
eris
tics
of th
e in
clud
ed s
tudi
es (c
ontin
ued)
(co
ntin
ued)
P
resc
ript
ion
of
A
uth
or
Des
ign
P
urp
ose
Part
icip
ants
In
terv
enti
on
MW
M/o
ther
Rx
Tim
es o
f Ax
O/C
mea
sure
s
Ta
lus a
nd c
alca
neus
fixed
with
ther
apist
’s
ha
nds w
hile
bel
t
glid
ed d
istal
tibi
a
an
terio
rly cr
eatin
g a
rela
tive
post
erio
r tal
ar
gl
ide
by th
e th
erap
ist.
Sh
am m
obili
zatio
n:
pa
rtic
ipan
t pro
ne ly
ing,
the
knee
was
pas
sivel
y
fle
xed
and
exte
nded
,
ensu
ring
the
talo
crur
al
jo
int r
emai
ned
stat
iona
ry.
Yang
et a
l33
Qua
si-
To in
vest
igat
e 30
par
ticip
ants
G
roup
1: A
BAC
M
WM
: Par
ticip
ant
Base
line,
and
at
Disa
bilit
y A
x: F
LEX
-Sf.
ex
peri-
th
e eff
ect o
f 6
mal
es,
(MRM
, ERM
, sit
ting
in a
rela
xed
3-w
eek
inte
rval
s Sh
ould
er co
mpl
ex
m
enta
l-
mob
iliza
tion
24 fe
mal
e. M
RM, M
WM
) po
sitio
n. B
elt p
lace
d fo
r 12
wee
ks
kine
mat
ics (
FAST
RAK
mul
tiple
- tr
eatm
ent a
nd to
M
ean
age:
55
Gro
up 2
: AC
AB
arou
nd th
e he
ad o
f
mot
ion
anal
ysis)
: sca
pula
trea
tmen
t de
term
ine
(M
RM, M
WM
, hu
mer
us to
glid
e
orie
ntat
ion,
hum
eral
tria
l w
heth
er a
MRM
, ERM
) th
e hu
mer
us h
ead
or
ient
atio
n, a
bduc
tion,
(ran
dom
iza-
di
ffere
nce
of
appr
opria
tely,
with
the
ha
nd-t
o-ne
ck, h
and-
to-
tio
n, n
o
trea
tmen
t
th
erap
ist’s
hand
ove
r
scap
ula
co
ntro
l) effi
cacy
exi
sts
the
appr
opria
te a
spec
t
amon
g th
ree
of
the
head
of
mob
iliza
tion
hu
mer
us. A
coun
ter
tech
niqu
es in
pr
essu
re w
as ap
plie
d
pa
tient
s with
w
ith th
e ot
her h
and
froz
en sh
ould
er
at th
e sc
apul
a. E
RM:
synd
rom
(FSS
)
Th
erap
ist’s
hand
s pla
ced
clos
e to
the
GH
J, an
d
th
e hu
mer
us w
as
br
ough
t int
o a
posit
ion
of m
ax ra
nge
in
di
ffere
nt d
irect
ions
.
MRM
: Par
ticip
ant
re
laxe
d in
supi
ne w
ith
th
e hu
mer
us in
rest
ing
posit
ion,
mob
iliza
tions
appl
ied.
Abb
ot13
N
on-e
xper
i- To
inve
stig
ate
23 p
atie
nts
Rand
om a
ssig
nmen
t M
WM
: par
ticip
ant i
n Be
fore
and
afte
r Rx
Pass
ive
ROM
m
enta
l—
the
effec
ts o
f a
18 m
ales
, of
left
or ri
ght a
rm
supi
ne, a
nd p
erfo
rmed
(gon
iom
eter
): in
pre-
/pos
t-
singl
e in
terv
entio
n 5
fem
ales
to
be
Ax
and
Rx
the
norm
ally
pro
voki
ng
pa
rtic
ular
inte
rnal
and
test
of
MW
M at
the
Mea
n ag
e: N
S (M
WM
) firs
t m
ovem
ent o
n th
e le
ft
exte
rnal
rota
tion
(r
ando
miz
a-
elbo
w o
n
an
d rig
ht si
de
tio
n)
shou
lder
RO
M
for p
atie
nts w
ith
late
ral
epic
ondy
lalg
ia
The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e53]
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
Abb
otte
t al41
N
on-e
xper
- D
eter
min
e w
hat
25 p
artic
ipan
ts
All
part
icip
ants
M
WM
: lat
eral
glid
e Be
fore
and
afte
r PF
GS
im
enta
l—
prop
ortio
n of
17
mal
es,
rece
ived
MW
M
of p
roxi
mal
med
ial
Rx, o
n ea
ch a
rm
Max
imal
grip
stre
ngth
pre-
/pos
t-
pts r
espo
nd to
8
fem
ales
to
una
ffect
ed a
nd
fore
arm
with
the
te
st
MW
M fo
r lat
eral
M
ean
age:
46
affec
ted
arm
di
stal
hum
erus
(ran
dom
iza-
ep
icon
dyla
lgia
,
(ran
dom
ized
ord
er),
stab
ilize
d, w
hile
tion)
w
heth
er P
GFS
in 1
Rx
sess
ion.
pa
rtic
ipan
t
an
d m
axim
um
If
part
icip
ant’s
pai
n pe
rfor
med
G
S in
crea
ses
co
uld
not b
e pr
evio
usly
pai
nful
aft
er 1
Rx
of
el
imin
ated
, Rx
mov
emen
t (fis
t,
MW
M, a
nd
w
as st
oppe
d gr
ippi
ng, w
rist
dete
rmin
ants
ex
tens
ion,
3rd
of re
spon
siven
ess
finge
r ext
ensio
n).
Ei
ther
of t
he fo
llow
ing
glid
es w
ere
perf
orm
ed
de
pend
ing
on p
artic
ipan
t’s
pa
in re
spon
se: d
irect
ly
la
tera
l or a
ppro
x 5°
post
erio
r, an
terio
r or
ca
udal
of l
ater
al.
Paun
gmal
i N
on e
xper
i- Ex
amin
e 24
par
ticip
ants
A
ll pa
rtic
ipan
ts
MW
M: p
atie
nt su
pine
Be
fore
and
afte
r PF
GS
et a
l6 m
enta
l—
whe
ther
19
mal
es,
rece
ived
late
ral
with
shou
lder
in
ever
y Rx
PP
T
repe
ated
in
itial
5
fem
ales
gl
ide
MW
M.
inte
rnal
rota
tion,
mea
sure
s hy
poal
gesia
M
ean
age:
50
Appl
ied
on 6
el
bow
ext
ende
d an
d
eff
ects
from
occa
sions
, app
rox
supi
nate
d. Th
erap
ist
MW
M ap
plie
d
48
hrs
apar
t st
abili
zed
the
hum
erus
to
late
ral
and
appl
ied
late
ral g
lide
epic
ondy
lalg
ia
at fo
rear
m. T
echn
ique
w
ere
mai
ntai
ned
pe
rfor
med
was
pai
n-fr
ee
after
repe
ated
w
ith p
artic
ipan
ts
appl
icat
ions
m
aint
aini
ng a
grip
for
ap
prox
6 se
cs a
nd re
peat
ed
10
tim
es w
ith 1
5-se
c
rest
inte
rval
s.
O’B
rien
&
Cas
e To
det
erm
ine
2 m
ale
part
icip
ants
Rx
1: 6
sess
ions
M
WM
Rx:
pos
terio
r Be
fore
, dur
ing
Pain
: VA
S V
ince
nzin
o38
stud
y th
e eff
ectiv
enes
s w
ith re
cent
ov
er 2
wee
ks
glid
e of
dist
al fi
bula
(p
ain,
inve
rsio
n RO
M)
ROM
: inv
ersio
n an
d D
F
of
MW
M ap
plie
d
(2–3
day
s) la
tera
l Rx
2: 3
sess
ions
w
hile
par
ticip
ant
and
after
eac
h Rx
(W
B)
at th
e an
kle
for
ankl
e sp
rain
s. ov
er 1
wee
k in
vert
ed th
e an
kle.
Func
tiona
l per
form
ance
ac
ute
late
ral a
nkle
A
ged
17 a
nd 1
8 N
o Rx
1: 3
Pa
ssiv
e ov
erpr
essu
re
(K
aikk
onen
scal
e)
pain
sess
ions
ove
r w
as ap
plie
d.
Fu
nctio
n: V
AS
1 w
eek.
Re
peat
ed 4
tim
es.
No
Rx2:
5
Stra
ppin
g ta
pe w
as
mea
sure
men
t ap
plie
d to
mai
ntai
n th
e
se
ssio
ns o
ver
post
erio
r glid
e aft
er e
very
1
wee
k Rx
sess
ion.
[e54] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
tAb
le 7
. C
hara
cter
istic
s of
the
incl
uded
stu
dies
(con
tinue
d)
P
resc
ript
ion
of
A
uth
or
Des
ign
P
urp
ose
Part
icip
ants
In
terv
enti
on
MW
M/o
ther
Rx
Tim
es o
f Ax
O/C
mea
sure
s
Pens
o39
Cas
e st
udy
To a
sses
s the
effe
ct
25-y
ear-
old
2 se
ssio
ns w
ith
MW
M: I
nitia
lly
Base
line,
after
eac
h A
ctiv
e an
d pa
ssiv
e RO
M
of
MW
M u
sed
for
fem
ale
with
chro
nic
MW
M o
ver a
a
PA g
lide
on th
e M
WM
, 1 a
nd 4
mon
th
(DF,
PF, i
nver
sion,
th
e m
anag
emen
t m
edia
l left
ank
le
2-w
eek
perio
d di
stal
tibi
a an
d fib
ula
follo
w-u
ps
ever
sion)
of
a ru
nner
pa
in
Educ
atio
n re
gard
ing
was
per
form
ed in
Gas
troc
nem
ius a
nd so
leus
co
mpl
aini
ng o
f
stre
tchi
ng o
f W
B; h
owev
er, w
as
m
uscl
e le
ngth
ch
roni
c med
ial
ca
lf m
uscl
e an
d in
effec
tive.
An
AP
Pa
in-f
ree
ROM
(DF,
PF,
ankl
e pa
in
ru
nnin
g te
chni
que
glid
e to
the
dist
al
in
vers
ion,
eve
rsio
n)
tib
ia, w
ith st
abili
zatio
n
Fu
nctio
n (r
unni
ng,
to
the
post
erio
r foo
t,
hi
king
, effe
ctiv
e ca
lf
whi
le th
e pa
tient
stre
tch)
perf
orm
ed a
ctiv
e D
F
in
WB
on a
step
was
then
effe
ctiv
e.
Step
hens
20
Cas
e st
udy
NS
43-y
ear-
old
fem
ale
Rx
: 3 ti
mes
a w
eek
MW
M: l
ater
al
NS
Pain
: VA
S
with
left
sided
fo
r 1st
4 w
eeks
, m
obili
zatio
n of
the
A
ROM
: sho
ulde
r, el
bow
chro
nic l
ater
al
then
onc
e a
wee
k fo
rear
m at
the
elbo
w
an
d th
umb
ep
icon
dylit
is fo
r the
follo
win
g 4
du
ring
activ
e w
rist
St
reng
th: s
houl
der,
elbo
w,
wee
ks, t
hen
once
ex
tens
ion,
fore
arm
wris
t and
grip
ev
ery
2 w
eeks
for
supi
natio
n an
d
Spec
ial t
est:
resis
ted
wris
t
th
e la
st 6
wee
ks
grip
ping
. Dor
sal
ex
t with
elbo
w at
45°
Rx: M
WM
s, ic
e,
glid
e of
the
hand
Palp
atio
n
U
S, tr
ansv
erse
ap
plie
d at
the
wris
t
fr
ictio
ns, e
xerc
ises
durin
g ra
dial
be
gan
after
MW
M
devi
atio
n an
d th
e
Rx
, mas
sage
, m
etac
arpa
l of t
he
stre
tchi
ng, H
EP
thum
b w
as m
obili
zed
palm
erly
at th
e C
MC
durin
g th
umb
oppo
sitio
n.
Elbo
w w
as ta
ped
into
a la
tera
l glid
e.
Self-
mob
iliza
tions
wer
e
pe
rfor
med
aga
inst
a
do
orw
ay to
pro
vide
pain
relie
f.
Vin
cenz
ino
C
ase
stud
y To
inve
stig
ate
39-y
ear-
old
fem
ale
PT fo
r 6 se
ssio
ns
Initi
al p
hysio
Rx:
Be
fore
Rx,
dur
ing
VAS
& W
right
34
eff
ects
of a
w
ith ri
ght t
enni
s ov
er 5
wee
ks.
deep
and
pai
nful
2-
wee
k A
x ph
ase,
PPT
man
ipul
ativ
e
elbo
w
Incl
uded
2 w
eeks
m
assa
ge, i
ce, l
aser
, an
d at
6 w
eeks
G
rip st
reng
th
PT te
chni
que
Ax,
2 w
eeks
Rx
som
e fo
rm o
f sen
sory
fo
llow
ing
Rx
Func
tion
VAS
on p
ain
and
(4 se
ssio
ns),
and
stim
ulat
ion.
Pain
-fre
e fu
nctio
n
dy
sfun
ctio
n of
6 w
eeks
HEP
Ex
erci
ses—
stre
tchi
ng
qu
estio
nnai
re
The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e55]
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
a
patie
nt w
ith
and
grip
ping
exe
rcise
s.
tenn
is el
bow
Ex
perim
enta
l Rx:
MW
M—
late
ral g
lide
appl
ied
at th
e pr
oxim
al
pa
rt o
f the
fore
arm
whi
le st
abili
zing
the
late
ral a
spec
t of t
he
di
stal
hum
erus
(par
ticip
ant i
n su
pine
,
shou
lder
inte
rnal
rota
tion,
elbo
w e
xten
ded,
fore
arm
pro
nate
d).
Pa
rtic
ipan
t was
taug
ht
se
lf-m
obili
zatio
n an
d
ta
ping
(tap
ing
was
use
d to
repl
icat
e th
e la
tera
l for
ce
ap
plie
d at
the
elbo
w b
y
th
e M
WM
).
Back
stro
m35
C
ase
repo
rt
Intr
oduc
e M
WM
61
-yea
r-ol
d fe
mal
e Rx
: Man
ipul
atio
n M
WM
: rad
ial g
lide
of
At e
ach
sess
ion
Pain
(VA
S)
in
the
Rx o
f de
w
ith d
e Q
uerv
ain’s
of
cap
itate
on
prox
imal
row
of c
arpa
l Fo
llow
-up
at 4
mon
ths
Obs
erva
tion
Que
rvai
n’s
teno
syno
-viti
s of
first
sess
ion
only,
bo
nes.
3 se
ts o
f 10
reps
an
d 12
mon
ths
ROM
(gon
iom
eter
) Wris
t
te
nosy
novi
tis
the
right
wris
t M
WM
, ela
stic
of
eac
h of
the
post
-Rx
flexi
on, e
xten
sion,
radi
al
splin
t with
m
ovem
ents
(wris
t an
d ul
na d
evia
tion.
Th
umb
palm
er a
nd ra
dial
ho
rses
hoe
type
fle
xion
, ext
ensio
n,
ab
duct
ion.
in
sert
(int
rodu
ced
ul
na a
nd ra
dial
Stre
ngth
—iso
met
ric a
nd
on se
ssio
n 6)
, de
viat
ion,
and
thum
b
MM
T
ec
cent
ric a
nd
radi
al o
r pal
mer
Acc
esso
ry m
otio
n te
stin
g
co
ncen
tric
ab
duct
ion)
(pai
n-fr
ee).
Palp
atio
n
st
reng
then
ing,
D
one
at a
ll Rx
Fink
lest
ein
test
A
ROM
, ten
don
se
ssio
ns.
glid
ing,
tran
sver
se
WB
tech
niqu
e—
fric
tion,
ant
i- pa
rtic
ipan
t WB
thro
ugh
infla
mm
ator
ies a
nd
the
hand
and
the
sam
e
H
EP (A
ROM
, ra
dial
glid
e w
as
stre
ngth
enin
g,
perf
orm
ed a
s
te
ndon
glid
ing,
pa
rtic
ipan
t
fr
ictio
ns, s
elf-
MW
M)
prog
ress
ivel
y W
B
th
roug
h th
e rig
ht
up
per l
imb.
U
lna
glid
e of
trap
eziu
m
an
d tr
apez
oid
for
th
umb
radi
al a
bduc
tion.
Se
lf-M
WM
—W
B of
uppe
r lim
b. P
artic
ipan
t
appl
ied
ulna
glid
e on
fore
arm
(the
refo
re ra
dial
glid
e of
car
pal b
ones
),
sh
ifted
BW
(wris
t
flexi
on/e
xten
sion)
with
thum
b ab
duct
ed.
[e56] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic ReviewtA
ble
7.
Cha
ract
eris
tics
of th
e in
clud
ed s
tudi
es (c
ontin
ued)
P
resc
ript
ion
of
A
uth
or
Des
ign
P
urp
ose
Part
icip
ants
In
terv
enti
on
MW
M/o
ther
Rx
Tim
es o
f Ax
O/C
mea
sure
s
DeS
antis
C
ase
repo
rt
To d
escr
ibe
27-y
ear-
old
mal
e Ph
ysio
ther
apy
War
m-u
p: 5
min
M
easu
rem
ents
of
ARO
M (g
onio
met
er)—
&
Has
son16
the
effec
ts o
f w
ith le
ft sh
ould
er
3 tim
es a
wee
k w
arm
up
on c
ycle
pa
in a
nd A
ROM
ab
duct
ion
mai
nly
an M
WM
su
pra-
spin
atus
fo
r 30
min
s with
er
gom
eter
prio
r at
eve
ry P
T se
ssio
n M
MT
Rx re
gim
e fo
r te
ndin
opat
hy
a to
tal o
f 12
to e
ach
sess
ion.
Impi
ngem
ent t
ests
(Nee
r,
sh
ould
er
se
ssio
ns
Phas
e 1:
focu
sed
H
awki
ns K
enne
dy, e
mpt
y
im
ping
emen
t
on
dec
reas
ing
pain
can,
appr
ehen
sion)
(edu
catio
n on
rest
,
Func
tiona
l sta
tus:
cryo
ther
apy,
rest
orin
g
sh
ould
er p
ain
and
RO
M w
ith M
WM
).
disa
bilit
y in
dex
M
WM
: AP
glid
e
SF
-36
(glo
bal s
elf-
repo
rt
w
ith a
bduc
tion
ques
tionn
aire
)
mov
emen
t (gu
idin
g
Pa
in (V
AS)
mov
emen
t of t
he
sc
apul
ar a
nd h
umer
us
w
ith b
oth
hand
s).
Ph
ase
2: fo
cuse
d on
stre
ngth
enin
g ro
tato
r
cuff,
scap
ular
stab
ilizi
ng m
uscl
es,
im
prov
ing
func
tion,
educ
atio
n re
gard
ing
post
ure.
Ea
ch se
ssio
n en
ded
with
10
min
s of
cr
yoth
erap
y.
Folk
36
Cas
e re
port
To
des
crib
e th
e
39-y
ear-
old
fem
ale,
Rece
ived
OT
(7
2 co
rtiso
ne in
ject
ions
M
easu
rem
ent t
aken
Pa
in (M
CP
ext)
diffe
rent
ial
4.5
wee
ks a
fter
sess
ions
in 6
wee
ks),
for d
e Q
uerv
ain’s
. th
roug
hout
Rx
Swel
ling
diag
nosis
and
st
rain
to 1
st M
CP,
th
en re
ferr
ed fo
r O
T Rx
: spl
int
Follo
w-u
p at
2
ROM
(MC
P ex
t)
Rx
tech
niqu
es
with
dia
gnos
is tr
igge
r thu
mb
and
gutte
r use
, m
onth
s and
1
MM
T
fo
r str
aine
d 1st
of
de
Que
rvai
n’s
rele
ase
surg
ery,
activ
e RO
M e
xerc
ises.
year
pos
t-Rx
G
rip st
reng
th
M
CP
join
t. of
the
left
hand
th
en b
ack
to O
T,
Ope
ratio
n: tr
igge
r
Upp
er li
mb
tens
ion
test
s
w
hich
then
refe
rred
th
umb
rele
ase.
C
ervi
cal s
pine
Ax
to P
T PT
Rx:
MW
M at
De
Que
rvai
n’s te
sts
OT
eval
uatio
n/Rx
1st
MC
P w
ith
(fi
nkel
stei
ns, p
ince
r
pe
rfor
med
3 w
eeks
su
stai
ned
pain
-fre
e
stre
ngth
, pal
patio
n)
la
ter
inte
rnal
axi
al ro
tatio
n,
w
ith o
verp
ress
ure
at
the
end.
Het
herin
gton
19
Cas
e re
port
N
S N
S M
ajor
ity o
f pat
ient
s M
WM
: lat
eral
mal
leou
s Be
fore
, dur
ing,
and
Pa
in o
n in
vers
ion
Peop
le w
ith
Patie
nt’s
post
- w
ere
trea
ted
only
of
fibu
la g
lided
aft
er R
x RO
M
ankl
e in
jurie
s an
kle
spra
in w
ith
with
MW
Ms a
nd
post
erio
rly w
ith
O
ne le
g st
andi
ng te
st
wer
e ex
amin
ed
limite
d an
d ta
ping
ac
tive
inve
rsio
n
(bal
ance
—ey
es cl
osed
)
to
det
ect a
pa
infu
l RO
M
No
elec
tro-
phys
ical
(w
ith a
nd w
ithou
t
Swel
ling
posit
iona
l fau
lt
th
erap
ies w
ere
used
a
bel
t).
G
ait p
atte
rns
and
man
aged
Ta
ping
: tw
o st
rips
usin
g M
WM
of
25m
m ta
pe ap
prox
The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e57]
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
and
tapi
ng
15cm
in le
ngth
.
m
etho
ds
Post
erio
r glid
e ap
plie
d
an
d th
en ta
pe ap
plie
d
ov
er th
e la
tera
l mal
leol
us
an
d tr
avel
led
arou
nd th
e
lo
wer
leg
(tap
ing
chan
ged
after
24
hrs)
.
Hsie
h et
al37
C
ase
repo
rt
Inve
stig
ate
the
79
-yea
r-ol
d fe
mal
e M
WM
was
appl
ied
Self
MW
M:
MRI
: pre
-Rx,
M
RI
us
e of
MRI
for
with
righ
t thu
mb
to th
e pr
oxim
al
supi
natin
g th
e du
ring
1st R
x,
Pain
: VA
S
po
sitio
nal f
ault
pa
in
phal
anx
MRI
was
pr
oxim
al p
hala
nx
after
Rx
ARO
M: g
onio
met
er
and
MW
M e
ffect
s
take
n be
fore
, of
the
thum
b W
eek
1: p
ain,
(fl
exio
n of
IPJ a
nd M
PJ)
in th
e th
umb
du
ring
MW
M, t
hen
us
ing
othe
r han
d’s
ROM
, dist
ract
ion/
PR
OM
: thu
mb
radi
al
after
a co
urse
of
inde
x an
d th
umb,
co
mpr
essio
n, P
ROM
ab
duct
ion
MW
M R
x w
hile
per
form
ing
Wee
k 2
- a/a
G
rip st
reng
th: h
and
Part
icip
ant p
erfo
rmed
fle
xion
of t
he th
umb
Wee
k 3
- a/a
, grip
dy
nam
omet
er
self-
MW
Ms
unde
rgoi
ng M
WM
. st
reng
th
Com
pres
sion/
di
stra
ctio
n of
the
MPJ
.
Not
e: M
WM
= m
obili
zatio
n w
ith m
ovem
ent;
Rx =
trea
tmen
t; A
x =
asse
ssm
ent;
O/C
= o
utco
me;
RC
T =
rand
omiz
ed co
ntro
lled
tria
l; PT
= p
hysio
ther
apy;
AD
Ls =
act
iviti
es o
f dai
ly li
ving
; VA
S =
visu
al a
nalo
gue
scal
e; U
S =
ultr
asou
nd; M
Hz =
meg
a he
rtz;
W/c
m2 =
wat
ts p
er ce
ntim
eter
squa
red;
min
s = m
inut
es; P
RT =
pro
gres
sive
resis
tant
trai
ning
; rep
s = re
petit
ions
; kg
= ki
logr
am; h
rs =
hou
rs; D
OM
S =
dela
yed
onse
t m
uscl
e so
rene
ss; P
PT =
pre
ssur
e pa
in th
resh
old;
ARO
M =
act
ive
rang
e of
mot
ion;
a/a
= a
s abo
ve; W
B =
wei
ght-
bear
ing;
pt =
pat
ient
; PA
= p
oste
rior-
ante
rior;
DF
= do
rsifl
exio
n, R
OM
= ra
nge
of m
otio
n; S
NS
= sy
m-
path
etic
ner
vous
syst
em; T
PT =
tem
pera
ture
pai
n th
resh
old;
secs
= se
cond
s; PF
GS
= pa
in-f
ree
grip
stre
ngth
; BP
= bl
ood
pres
sure
; HR
= he
art r
ate;
NW
B =
non-
wei
ght-
bear
ing;
NS
= no
t sta
ted;
GS
= gr
ip st
reng
th;
appr
ox =
appr
oxim
atel
y; H
EP =
hom
e ex
erci
se p
rogr
am; C
MC
= c
arpo
met
acar
pal;
BW =
bod
y w
eigh
t; M
MT
= m
anua
l mus
cle
test
ing;
AP
= an
terio
r-po
ster
ior;
SF-3
6 =
Shor
t For
m 3
6; M
CP
= m
etac
arpo
phal
ange
al;
OT
= oc
cupa
tiona
l the
rapy
; ext
= e
xten
sion;
mm
= m
illim
eter
s; cm
= ce
ntim
eter
s; M
RI =
mag
netic
reso
nanc
e im
agin
g; IP
J = in
terp
hala
ngea
l joi
nt; M
PJ =
met
acar
pal p
hala
ngea
l joi
nt.
[e58] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2
tAb
le 8
. St
atis
tics,
resu
lts,
str
engt
hs, a
nd li
mita
tions
of t
he in
clud
ed s
tudi
es
Au
thor
St
atis
tica
l an
alys
is
Res
ult
s St
ren
gths
Li
mit
atio
ns
Biss
et e
t al30
Be
twee
n-gr
oup
C
ortic
oste
roid
inje
ctio
n sh
owed
sig
bette
r effe
cts a
t 6 w
eeks
but
• R
ando
miz
ed co
ntro
lled
tria
l • R
x pr
oced
ure
for P
T
diffe
renc
es a
naly
zed:
w
ith h
igh
recu
rren
ce ra
tes t
here
after
(47/
65 re
gres
sed)
and
• S
ingl
e bl
indi
ng
gr
oup
not c
lear
ly
Re
lativ
e ris
k
sig p
oore
r out
com
es in
long
-ter
m co
mpa
red
with
PT.
PT
was
supe
rior
• Lar
ge sa
mpl
e siz
e
defin
ed (r
efer
red
re
duct
ion.
to
wai
t and
see
at 6
wee
ks, b
ut th
ere
was
no
diffe
renc
e at
52
• Fol
low
-up
mea
sure
s
to a
noth
er st
udy
for
N
umbe
rs n
eede
d
wee
ks w
ith b
oth
repo
rtin
g a
succ
essf
ul o
utco
me.
PT w
as su
perio
r • C
onfo
undi
ng v
aria
bles
and
pres
crip
tion
expl
anat
ion)
to tr
eat.
to in
ject
ions
afte
r 6 w
eeks
. Thus
, cor
ticos
tero
id R
x sh
ould
be
avoi
ded
adve
rse
even
ts w
ere
take
n in
to
• Onl
y sin
gle
blin
ding
6-
poin
t im
prov
emen
t du
e to
its h
igh
recu
rren
ce, a
nd P
T sh
ould
be
impl
emen
ted
due
to it
s
cons
ider
atio
n
(Lik
ert s
cale
) su
perio
r ben
efit a
nd d
ecre
ase
in N
SAID
S pu
rcha
sing
• Mai
n fin
ding
s of s
tudy
clea
rly
de
scrib
ed
• Dro
p-ou
ts d
escr
ibed
• G
ood
exte
rnal
val
idity
and
pow
er
Koch
ar
One
-way
AN
OVA
. Su
bjec
tive:
Rx
grou
p 1
pain
dec
reas
ed b
y 5.
9cm
(p <
0.01
), an
d in
Rx
• Ver
y sim
ilar p
artic
ipan
t • B
lindi
ng w
as n
ot st
ated
&
Dog
ra4
Two-
way
AN
OVA
. gr
oup
2 by
1.6
7cm
(p <
0.01
). Rx
gro
up 1
was
supe
rior t
o th
e co
ntro
l
char
acte
ristic
s bet
wee
n gr
oups
• Th
e 2
Rx g
roup
s wer
e
Chi
squa
re te
stin
g.
and
grou
p 2
in th
e A
x sc
ore
at 1
2 w
eeks
.
and
base
line
mea
sure
men
ts
ra
ndom
ized
but
the
5%
leve
l of p
roba
bilit
y
Obj
ectiv
e: R
x gr
oup
1 w
as a
ble
to li
ft he
avie
r wei
ghts
than
gro
up 2
and
• R
ando
miz
atio
n, co
ntro
l gro
up
co
ntro
l gro
up w
as n
ot
ad
opte
d co
ntro
l gro
up (p
<0.0
1) fr
om th
e 2nd
wee
k on
war
ds.
• Val
id o
utco
me
mea
sure
s • C
ontr
ol g
roup
rece
ived
no
Grip
stre
ngth
in g
roup
1 im
prov
ed fr
om 2
2.74
kg–3
1.57
kg in
the
3 w
eeks
, • A
ppro
pria
te st
atist
ical
ana
lysis
Rx, i
.e., n
o pl
aceb
o gr
oup
and
was
sig
diffe
rent
from
the
cont
rol.
No
sig d
iffer
ence
s wer
e fo
und
in
• Cle
ar R
x pr
oces
s • L
earn
ing
effec
t of
grou
p 2.
• C
lear
incl
usio
n/ex
clus
ion
crite
ria
lift
ing
the
wei
ghts
O
vera
ll, co
ntro
l gro
up sh
owed
no
stat
istic
ally
sig
chan
ges i
n an
y pa
ram
eter
. • F
ollo
w-u
p m
easu
res
m
ay h
ave
occu
rred
Mos
t pat
ient
s in
the
inte
rven
tion
grou
ps sh
owed
com
plet
e re
cove
ry.
• D
rop-
outs
wer
e no
t
5
recu
rren
ces i
n th
e U
S gr
oup
indi
cate
d
Slat
er e
t al42
Sh
apiro
-Wilk
D
urin
g sa
line-
indu
ced
pain
and
in re
spon
se to
the
inte
rven
tion
of M
WM
• R
ando
miz
ed co
ntro
l tria
l • N
o bl
indi
ng
norm
ality
test
s. or
pla
cebo
, the
re w
ere
no si
g be
twee
n-gr
oup
diffe
renc
es in
VA
S, p
ain
• Pla
cebo
, and
inte
rven
tion
• Effe
ct o
f the
M
ann
Whi
tney
- di
strib
utio
ns, i
nduc
ed d
eep
tissu
e hy
pera
lges
ia, a
nd fo
rce
prod
uctio
n.
gr
oup
pr
ovok
ed D
OM
S
U te
st.
Ove
rall,
dat
a su
gges
ts th
at M
WM
doe
s not
act
ivat
e m
echa
nism
s • A
ppro
pria
te st
atist
ical
a
nd in
ject
ed
Two-
way
repe
ated
as
soci
ated
with
ana
lges
ia o
r for
ce au
gmen
tatio
n in
peo
ple
with
indu
ced
an
alys
is
hype
rton
ic sa
line
m
easu
res A
NO
VA.
late
ral e
pico
ndyl
algi
a • V
alid
out
com
e m
easu
res
• No
follo
w-u
p
Post
-hoc
test
s.
mea
sure
s
Stud
ent N
ewm
an
• Pos
sible
exc
essiv
e
Keul
s (SN
K) t
est
am
ount
of e
xerc
ise to
indu
ce D
OM
S, w
ith n
o
in
dica
tion
of w
hat t
he
am
ount
was
bas
ed o
n
• I
nduc
ed p
atho
logy
• No
recr
uitm
ent p
roce
ss
do
cum
ente
d
• N
o dr
op-o
ut o
r
com
plia
nce
docu
men
ted
Teys
et a
l5 Tw
o-w
ay A
NO
VA.
ROM
: mea
n in
crea
se o
f 16°
, 4°,
and
0° fo
r MW
M, p
lace
bo, a
nd co
ntro
l • R
ando
miz
ed, c
ontr
ol, a
nd
• No
follo
w-u
p
Post
-hoc
test
s gr
oup,
resp
ectiv
ely.
pl
aceb
o gr
oups
• L
imite
d ou
tcom
e
PP
T: m
ean
incr
ease
of 6
3kPa
, 26k
Pa, a
nd 2
0kPa
for M
WM
, pla
cebo
, and
• D
oubl
e bl
indi
ng
m
easu
res
cont
rol g
roup
, res
pect
ivel
y • C
lear
des
crip
tion
of d
iffer
ent
• Sub
ject
s may
not
in
terv
entio
n le
vels
re
pres
ent t
he p
opul
atio
n
The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e59]
• A
ppro
pria
te st
atist
ical
ana
lysis
from
whi
ch th
ey w
ere
• N
o dr
op-o
uts
re
crui
ted
• V
alid
out
com
e m
easu
res
• C
lear
incl
usio
n/ex
clus
ion
cr
iteria
Col
lins e
t al3
Paire
d sa
mpl
e
DF
ROM
: sig
incr
ease
in o
nly
the
MW
M R
x gr
oup.
• R
ando
miz
atio
n, p
lace
bo,
• No
follo
w-u
p
t-te
st.
PPT
and
TPT:
no
sig re
sults
, exc
ept a
n in
crea
se in
PPT
and
cont
rol
m
easu
rem
ents
O
ne-w
ay
in th
e pl
aceb
o gr
oup
post
-Rx
• App
ropr
iate
stat
istic
al
• Stu
dy d
id n
ot d
iscus
s
AN
OVA
an
alys
is
drop
-out
s
• Val
id o
utco
me
mea
sure
s • I
nade
quat
e po
wer
• D
oubl
e bl
indi
ng
• C
lear
incl
usio
n/ex
clus
ion
crite
ria a
nd d
iffer
ent g
roup
s
Paun
gmal
i 2
way
AN
OVA
. Th
e M
WM
tech
niqu
e ill
ustr
ated
hyp
oalg
esic
effe
cts w
ith si
mul
tane
ous
• Rx’s
rand
omiz
ed to
par
ticip
ants
• P
atie
nts,
how
ever
, act
ed
et a
l14
3 w
ay A
NO
VA.
sym
path
oexc
itatio
n (p
hysio
logi
cal e
ffect
s sim
ilar t
o th
ose
repo
rted
• C
ontr
ol a
nd p
lace
bo g
roup
s
as co
ntro
l/pla
cebo
Po
st-h
oc a
naly
ses.
with
spin
al M
WM
s).
• Ass
esso
r blin
ded
(c
ross
over
)
Paire
d t t
ests
with
PF
GS
incr
ease
d fr
om 1
27.1
N to
166
.2N
dur
ing
Rx a
nd th
en 1
74.1
N p
ost-
Rx
• Sam
ple
size
adeq
uate
to p
rodu
ce
• Onl
y sin
gle
blin
ding
bo
nfer
roni
(o
nly
durin
g an
d aft
er in
Rx
grou
p, n
ot p
lace
bo a
nd co
ntro
l).
a
high
pow
er
• Tes
ting
took
pla
ce in
a
ad
just
men
t PP
T on
ly in
crea
sed
in th
e Rx
gro
up.
• Mai
n fin
ding
s of s
tudy
clea
rly
co
ntro
lled
envi
ronm
ent
TPT
did
not c
hang
e in
the
Rx o
r pla
cebo
gro
up b
ut d
ecre
ased
in th
e co
ntro
l.
desc
ribed
(not
real
istic
)
M
WM
onl
y pr
oduc
ed m
ean
incr
ease
s of 4
.1%
HR,
3.5
% sy
stol
ic B
P, 3
.1%
• R
x pr
oced
ure
clea
rly d
escr
ibed
• N
o fo
llow
-up
mea
sure
s
di
asto
lic B
P.
• Alth
ough
cros
sove
r, al
low
ed
SN
S fu
nctio
n (s
kin
cond
ucta
nce,
cuta
neou
s blo
od fl
ux, a
nd te
mp)
wer
e al
l
for a
t lea
st 4
8-ho
ur in
terv
al
activ
ated
in th
e Rx
gro
up o
nly
(MW
M)
be
twee
n se
ssio
ns
Paun
gmal
i O
ne-w
ay A
NO
VA
No
sig d
iffer
ence
bet
wee
n gr
oups
with
diff
eren
t IV
inje
ctio
ns. A
ll gr
oups
• R
ando
miz
atio
n an
d co
ntro
l • Th
e st
udy
did
not d
iscus
s et
al15
impr
oved
on
scor
es p
ost-
MW
M w
ith av
erag
es b
eing
29%
, 18%
, 1.6
%,
• Dou
ble
blin
ding
how
long
nal
oxon
e m
ay
an
d 0.
2% fo
r PFG
S, P
PT, U
LTT,
and
TPT
, res
pect
ivel
y • N
o dr
op-o
uts
ta
ke to
hav
e eff
ects
, and
• C
ompl
ianc
e w
as m
easu
red
Rx/A
x w
ere
take
n
vi
a a
ques
tionn
aire
imm
edia
tely
afte
r
• Val
id o
utco
me
mea
sure
s
adm
inist
ratio
n
• C
arr-
over
effe
ct o
f Rx
• No
signi
fican
ce le
vels
wer
e in
dica
ted
whe
n
co
mpa
ring
pre-
and
post
-Rx
• Poo
r ext
erna
l val
idity
.
• N
o in
form
atio
n as
to
w
here
par
ticip
ants
wer
e re
crui
ted
from
• No
follo
w-u
p
Teys
et a
l40
AN
OVA
. Si
gnifi
cant
and
clin
ical
ly m
eani
ngfu
l im
prov
emen
ts in
bot
h RO
M
• Ran
dom
izat
ion
of R
x • N
il fo
llow
up
or lo
ng
Post
-hoc
test
s on
(1
5.3%
, F (2
,46)
= 1
6.31
P =
0.0
0) a
nd P
PT (2
0.2%
, F (2
, 46)
= 3
.44,
• D
oubl
e bl
indi
ng
te
rm A
x
each
dep
ende
nt
P =
0.04
) occ
urre
d im
med
iate
ly p
ost-
Rx. N
il sig
nific
ant d
iffer
ence
s • C
lear
Rx
proc
ess
• Par
ticip
ants
rece
ived
all
va
riabl
e. in
PPT
pre
-app
licat
ion.
The
chan
ge in
RO
M w
as n
ot re
late
d to
• C
lear
incl
usio
n/
th
ree
Rx’s–
?car
ry-o
ver
Pe
arso
n’s
impr
ovem
ent i
n PP
T (R
= 0
.29,
P =
0.1
7)
ex
clus
ion
crite
ria
eff
ect d
ue to
sam
e Rx
on
co
rrel
atio
n
• Val
id a
nd re
liabl
e
part
icip
ants
with
onl
y a
co
effici
ent
outc
ome
mea
sure
s
24-h
our w
ait
• C
ontr
ol g
roup
incl
usio
n • D
ecre
ased
ext
erna
l
• No
loss
to fo
llow
-up
va
lidity
due
to co
ntro
lled
labo
rato
ry e
nviro
nmen
t
[e60] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2
tAb
le 8
. St
atis
tics,
resu
lts,
str
engt
hs, a
nd li
mita
tions
of t
he in
clud
ed s
tudi
es (c
ontin
ued)
Au
thor
St
atis
tica
l an
alys
is
Res
ult
s St
ren
gths
Li
mit
atio
ns
Vic
enzi
no
One
-way
, Rx
gro
up h
ad a
sig
incr
ease
in P
FGS
and
PPT
post
-Rx,
com
pare
d • B
lindi
ng o
f par
ticip
ant a
nd
• Lim
ited
outc
ome
et a
l7 tw
o-w
ay,
to p
lace
bo a
nd co
ntro
l.
outc
ome
mea
sure
r
mea
sure
s
thre
e-w
ay
The
unaff
ecte
d ar
m h
ad a
dec
reas
e in
PFG
S po
st a
ll Rx
leve
ls • C
ontr
ol a
nd p
lace
bo
• No
follo
w-u
p m
easu
res
A
NO
VA
• T
ook
into
acc
ount
• I
nade
quat
e po
wer
conf
ound
ing
fact
ors
• Poo
r ext
erna
l val
idity
w
ith a
que
stio
nnai
re
(p
atie
nts n
ot
• No
drop
-out
s or a
dver
se e
ffect
s
repr
esen
tativ
e of
the
• A
ppro
pria
te st
atist
ical
popu
latio
n)
an
alys
is
• Cle
ar R
x pr
oces
ses
Vic
enzi
no
One
-way
W
B an
d N
WB
MW
M R
x te
chni
ques
bot
h pr
oduc
ed si
g ch
ange
s in
• Ran
dom
izat
ion
of R
x • N
o tr
ue co
ntro
l/pla
cebo
et
al18
A
NO
VA.
post
erio
r tal
ar g
lide
(effe
ct si
zes:
0.8,
0.9
).
cond
ition
s
grou
p—pa
tient
s
Post
hoc
test
s. Re
duce
d po
ster
ior t
alar
glid
e de
ficit
by 5
0% a
nd 5
5% fo
r the
affe
cted
• H
ad a
cont
rol c
ondi
tion
ex
perie
nced
all
3 Rx
Eff
ect s
ize
side
resp
ectiv
ely—
sig g
reat
er th
an co
ntro
l (p=
.003
). • D
oubl
e bl
indi
ng
co
nditi
ons (
cros
sove
r
calc
ulat
ions
. W
B D
F w
as im
prov
ed in
all
thre
e gr
oups
(WB,
NW
B, co
ntro
l gro
ups)
, • N
o dr
op-o
uts/
high
desig
n)
Pear
son
effec
t siz
e—0.
4, 0
.3, 0
.1.
co
mpl
ianc
e • P
oor s
ampl
e siz
e
corr
elat
ions
M
WM
s red
uced
affe
cted
side
defi
cit b
y ap
prox
26%
com
pare
d to
9%
• A
ppro
pria
te st
atist
ical
• N
o ou
tcom
e m
easu
re
redu
ctio
n in
cont
rol g
roup
.
test
ing
va
lidity
or r
elia
bilit
y
Th
ere
was
a si
g an
d su
bsta
ntia
l cor
rela
tion
betw
een
post
erio
r tal
ar g
lide
• C
lear
Rx
proc
edur
e • N
o fo
llow
-up
and
WB
DF
follo
win
g th
e W
B M
WM
but
no
corr
elat
ion
follo
win
g th
e
• Equ
al fe
mal
e/m
ale
m
easu
rem
ents
N
WB
MW
M.
re
pres
enta
tion
fo
r ana
lysis
of l
ong-
term
Ove
rall,
MW
Ms i
mpr
oved
dep
ende
nt v
aria
bles
imm
edia
tely
afte
r Rx
in
• Rep
eate
d m
easu
res
eff
ects
pa
tient
s with
chro
nic r
ecur
rent
late
ral a
nkle
spra
in
McL
ean
et a
l31
Sing
le-t
aile
d,
Mea
n ra
w fo
rce
data
rang
ed fr
om 3
6.8N
—11
3N. M
ean
stan
dard
ized
forc
e • S
ubje
ct w
as b
linde
d to
the
• Sm
all s
ampl
e siz
e
paire
d t-
test
. da
ta w
as 1
.2N
/cm
and
3.8
N/c
m.
PF
GS
scor
es th
roug
hout
• N
o co
ntro
l/pla
cebo
O
rtho
gona
l a
The
2 lo
wer
stan
dard
ized
forc
e le
vel s
core
s (1.
2 an
d 1.
9N/c
m) c
ause
d a
drop
• R
ando
miz
atio
n of
the
Rx
• Onl
y 1
outc
ome
mea
sure
prio
ri co
ntra
sts
in P
FGS,
whe
reas
the
high
er tw
o (2
and
3.8
N/c
m) c
ause
d an
incr
ease
in P
FGS.
forc
es g
iven
• S
hort
-ter
m st
udy
fo
r rep
eate
d
A p
riori
cont
rast
s sho
wed
no
sig ch
ange
in P
FGS
betw
een
the
2 lo
wer
forc
e • V
alid
out
com
e m
easu
res
• No
follo
w-u
p m
easu
res
m
easu
res a
naly
sis
leve
ls bu
t was
sig
grea
ter f
or th
e 3rd
(66%
) for
ce le
vel.
• Cle
ar in
clus
ion/
excl
usio
n • D
iffer
ent f
orce
s wer
e
O
vera
ll, le
vel o
f for
ce ap
plie
d du
ring
an M
WM
det
erm
ines
the
hypo
lage
sic
cr
iteria
appl
ied
with
onl
y 2
effec
ts.
• App
ropr
iate
stat
istic
al a
naly
sis
m
inut
e re
st (p
ossib
le
G
rip st
reng
th ch
ange
s obs
erve
d =
15–1
8%
accu
mul
ativ
e eff
ect o
f
pain
relie
f)
• N
o bl
indi
ng o
f the
rapi
sts
• No
indi
catio
n of
recr
uitm
ent p
roce
ss
Reid
et a
l32
Paire
d t-t
est.
Sign
ifica
ntly
gre
ater
impr
ovem
ent i
n ta
locr
ural
join
t DF
ROM
with
the
• Inc
reas
ed w
asho
ut p
erio
d •?
carr
y-ov
er e
ffect
des
pite
Shap
iro-W
ilk te
st.
true
WB
mob
iliza
tion
(t (2
2) =
2.5
23, P
= 0
.019
). M
ean
diffe
renc
e be
twee
n
(7 d
ays)
to re
duce
7 da
y w
asho
ut p
erio
d
Also
: ind
epen
dent
th
e tr
ue a
nd sh
am m
obili
zatio
n Rx
scor
es w
as e
qual
to 0
.45c
m (9
5%
ca
rry-
over
effe
ct
•?eff
ect o
f war
m u
p an
d
t-
test
(exc
lusio
n of
co
nfide
nce
inte
rval
= 0
.08—
0.82
cm).
Betw
een-
grou
p an
alys
es w
as e
qual
• U
se o
f pre
ssur
e bi
ofee
dbac
k
mea
sure
men
t of i
nten
sity
se
cond
Rx
findi
ngs)
0.
65cm
incr
ease
in R
OM
(95%
confi
denc
e in
terv
al =
0.1
5—1.
2cm
)
to e
nsur
e sa
me
forc
e fo
r
per p
artic
ipan
t
sa
me
part
icip
ant
•? cl
inic
al re
leva
nce
due
to
• R
ando
miz
atio
n to
Rx
sm
all c
hang
e de
tect
ed—
• B
lindi
ng o
f the
ass
esso
r
how
ever
, onl
y 2
Rx’s
• C
lear
Rx
proc
ess
pe
rfor
med
• C
lear
incl
usio
n/ex
clus
ion
• N
o tr
ue co
ntro
l gro
up
crite
ria
The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e61]
Yang
et a
l33
AN
OVA
Si
gnifi
cant
impr
ovem
ents
(p<.
01) i
n FL
EX-S
F, ar
m el
evat
ion,
• R
ando
miz
atio
n • P
artic
ipan
ts w
eren
’t
Inde
pend
ent t
-tes
ts
scap
ulo-
hum
eral
rhyt
hm, h
umer
al e
xter
nal r
otat
ion,
hum
eral
• I
nten
tion
to tr
eat a
naly
sis
bl
inde
d
in
tern
al ro
tatio
n fo
r bot
h ER
M a
nd M
WM
Rx.
No
signi
fican
t diff
eren
ce
• Thor
ough
stat
istic
al a
naly
sis
• Par
ticip
ants
rece
ived
all
betw
een
ERM
and
MW
M e
xcep
t for
scap
ulo-
hum
eral
rhyt
hm re
stor
atio
n • B
lindi
ng o
f the
ass
esso
r
thre
e Rx
’s - ?
carr
y-ov
er
• Cle
ar R
x pr
oces
s
effec
t
• Cle
ar in
clus
ion/
excl
usio
n
crite
ria
Abb
ot13
O
ne ta
iled
t-te
st
92%
resp
onde
d to
MW
M R
x (i.
e., R
x w
as p
ain-
free
). • R
x an
d A
x of
left
or ri
ght
• Onl
y pr
e-/p
ost-
test
PFG
S an
d m
ax g
rip st
reng
th w
ere
sig in
crea
sed
post
-Rx,
for t
he
ar
ms w
as ra
ndom
ly a
ssig
ned
de
sign,
i.e.,
no
grou
p
aff
ecte
d lim
b on
ly.
• Out
com
e m
easu
re w
as
co
mpa
rison
of
PFG
S w
as fo
und
to b
e m
ore
resp
onsiv
e to
chan
ge v
ersu
s max
grip
stre
ngth
relia
ble
fin
ding
s ove
r tim
e
• Cle
ar re
sults
• O
nly
1 ou
tcom
e m
easu
re
• Val
id st
atist
ical
test
ing
for a
• P
artic
ipan
ts w
ere
not
pre-
/pos
t-te
st d
esig
n
blin
ded
• No
follo
w-u
p m
easu
res
• Sam
ple
size
was
not
larg
e
an
d pr
edom
inan
tly m
ale
• Sam
ple
recr
uitm
ent
w
as n
ot e
xpla
ined
Abb
otte
t al41
O
ne-t
aile
d t-
test
92
% re
spon
ded
to M
WM
Rx
(i.e.,
Rx
was
pai
n-fr
ee).
• Suffi
cien
t pow
er to
det
ect
• Con
veni
ence
sam
ple
PFG
S an
d m
ax g
rip st
reng
th w
ere
sig in
crea
sed
post
-Rx,
for t
he a
ffect
ed
a
clin
ical
ly si
g ch
ange
• N
o fo
llow
-up
mea
sure
s
lim
b on
ly.
• Atte
mpt
to b
lind
outc
ome
• Onl
y on
e Rx
sess
ion
PFG
S w
as fo
und
to b
e m
ore
resp
onsiv
e to
chan
ge v
ersu
s max
grip
stre
ngth
mea
sure
r
(for a
chro
nic c
ondi
tion)
• R
ando
miz
atio
n of
lim
b • O
nly
one
inte
rven
tion
• R
x or
der
le
vel
• O
utco
me
mea
sure
s wer
e
• No
com
paris
on, c
ontr
ol,
appr
opria
te a
nd w
ell
or
pla
cebo
in
vest
igat
ed
• Goo
d de
scrip
tion
of R
x
prot
ocol
and
ada
ptat
ions
Paun
gmal
i O
wn
form
ula:
Th
e hy
poal
gesic
effe
ct o
f MW
M at
the
elbo
w d
id n
ot re
duce
with
repe
ated
• B
lindi
ng w
as a
dmin
ister
ed
• Num
ber o
f set
s was
not
et a
l6 m
axim
al p
ossib
le
appl
icat
ions
of t
he R
x te
chni
que
durin
g 6
succ
essiv
e se
ssio
ns.
• Val
id o
utco
me
mea
sure
s
stat
ed in
MW
M R
x
effec
t to
inve
stig
ate
A
ll Rx
sess
ions
resu
lted
in h
ypoa
lges
ic e
ffect
s, in
dica
ted
by a
n in
crea
se in
• C
lear
Rx
proc
ess
• No
cont
rol g
roup
or
th
e to
lera
nce
of th
e
PFG
S an
d PP
T.
• Cle
ar in
clus
ion/
excl
usio
n
rand
omiz
atio
n
hypo
alge
sic e
ffect
. PF
GS
sig in
crea
sed
over
the
sess
ions
but
PPT
rem
aine
d sim
ilar
cr
iteria
• P
artic
ipan
ts w
ere
not
O
ne w
ay A
NO
VA
• C
onfo
undi
ng v
aria
bles
and
rand
omly
sele
cted
ad
vers
e ev
ents
wer
e ta
ken
into
for t
he st
udy
(vol
unte
ers)
co
nsid
erat
ion
• N
o dr
op-o
uts/
high
com
plia
nce
• C
alcu
latio
n of
effe
ct si
ze
O’B
rien
&
Pear
son
corr
elat
ion
ROM
: (in
vers
ion)
impr
oved
dur
ing
MW
M a
nd to
a le
sser
ext
ent
• Cle
ar R
x pr
oces
s • I
nade
quat
e po
wer
(onl
y V
ince
nzin
o38
po
st R
x. D
F im
prov
ed p
ost M
WM
Rx.
• A
ppro
pria
te o
utco
me
mea
sure
s 2
subj
ects
)
Pa
in: i
mpr
oved
dur
ing
MW
M a
nd to
a le
sser
ext
ent p
ost R
x.
• Str
ong
and
sig co
rrel
atio
ns
• No
data
doc
umen
ted
for
Func
tion:
incr
ease
d w
ith R
x.
(pe
rfor
med
som
e st
atist
ical
c
ontr
ol p
erio
ds
Fu
nctio
nal p
erfo
rman
ce: s
tron
g po
sitiv
e co
rrel
atio
n be
twee
n M
WM
a
naly
sis a
s onl
y a
case
stud
y)
• Sub
ject
s do
not r
epre
sent
Rx
and
func
tion.
Str
ong
corr
elat
ions
bet
wee
n fu
nctio
nal p
erfo
rman
ce a
nd
• Pat
ient
s tre
ated
in a
n t
he g
ener
al p
opul
atio
n
fu
nctio
n, p
ain
and
func
tion,
func
tiona
l per
form
ance
and
pai
n, fu
nctio
nal
env
ironm
ent t
hat r
epre
sent
s (
both
spor
t pla
yers
/
pe
rfor
man
ce a
nd D
F, D
F an
d fu
nctio
n. M
oder
ate
corr
elat
ions
with
pai
n an
d
nor
mal
PT
Rx
ath
lete
s)
func
tion,
inve
rsio
n an
d D
F, fu
nctio
nal p
erfo
rman
ce a
nd in
vers
ion,
inve
rsio
n
• N
o bl
indi
ng o
r
an
d fu
nctio
n
ran
dom
izat
ion
• No
follo
w-u
p m
easu
res
[e62] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2
tAb
le 8
. St
atis
tics,
resu
lts,
str
engt
hs, a
nd li
mita
tions
of t
he in
clud
ed s
tudi
es (c
ontin
ued)
Au
thor
St
atis
tica
l an
alys
is
Res
ult
s St
ren
gths
Li
mit
atio
ns
Pens
o39
No
stat
istic
al a
naly
sis
Imm
edia
te re
lief o
f pai
n w
ith a
cces
sory
PA
mov
emen
t • C
lear
des
crip
tion
of c
ase
stud
y • N
o co
ntro
l,
repo
rted
an
d W
B D
F. In
crea
se in
ank
le D
F an
d ev
ersio
n RO
M. I
ncre
ase
in
w
ith th
orou
gh in
itial
Ax
ra
ndom
izat
ion,
or
gast
rocn
emiu
s and
sole
us m
uscl
e le
ngth
. Pat
ient
was
abl
e to
run
pain
-fre
e • F
ollo
w-u
p m
easu
res
bl
indi
ng
• Pat
ient
Rx
as in
a “r
eal-l
ife”
• No
stat
istic
al a
naly
sis
setti
ng
• Not
all
resu
lts w
ere
repo
rted
on
follo
w-u
p
• O
nly
one
part
icip
ant;
ther
efor
e po
or e
xter
nal
va
lidity
Step
hens
20
No
stat
istic
al a
naly
sis
Dec
reas
e in
pai
n im
med
iate
ly a
fter M
WM
, whi
ch la
sted
1–2
day
s. • L
itera
ture
revi
ew o
n • N
o ra
ndom
izat
ion,
repo
rted
W
hen
pain
was
agg
rava
ted,
self-
mob
iliza
tions
elim
inat
ed th
e pa
in.
co
nditi
on (l
ater
al e
pico
ndyl
itis)
cont
rol,
or b
lindi
ng
A
fter 4
wee
ks, e
lbow
was
still
TO
P, T
rP st
ill te
nder
on
mas
sage
, inc
reas
e in
and
Rx ch
oice
s • R
x is
not r
epro
duci
ble
stre
ngth
and
end
uran
ce.
• Cle
ar c
ase
hist
ory
• Stu
dy d
id n
ot st
ate
thei
r
D
/C a
fter 2
3 Rx
’s. A
t D/C
, pat
ient
repo
rted
succ
essf
ul se
lf -x
for r
elie
ving
• R
epre
sent
s rea
l-life
aim
pa
in 1
00%
of t
he ti
me,
had
prog
ress
ed e
xerc
ises t
o pa
in-f
ree.
Repe
ated
situa
tion
in re
gard
s to
• Onl
y 1
subj
ect,
so re
sults
m
ovem
ents
and
hea
vy li
fting
at w
ork
still
exa
cerb
ated
sym
ptom
s.
Rx
rece
ived
are
not g
ener
aliz
able
and
M
obili
zatio
ns st
ill e
ffect
ive
in d
ecre
asin
g pa
in
inad
equa
te p
ower
• Did
not
incl
ude
data
for
ou
tcom
e m
easu
res
• Did
not
disc
uss
co
mpl
ianc
e w
ith H
EP
• N
o st
atist
ical
ana
lysis
• Did
not
disc
uss r
elia
bilit
y
or
val
idity
of o
utco
me
mea
sure
s
• N
o fo
llow
-up
mea
sure
s
Vin
cenz
ino
Pe
arso
n co
rrel
atio
n Li
ttle
prog
ress
mad
e w
ith in
itial
PT
Rx p
rior t
o th
e st
udy.
• Cle
ar c
ase
hist
ory,
• S
ingl
e ca
se st
udy
limits
&
Wrig
ht34
co
effici
ents
. PF
GS
incr
ease
d du
ring
Rx p
hase
s B a
nd C
.
outc
ome
mea
sure
s,
gene
raliz
abili
ty o
f
Line
ar re
gres
sion
A
ll 6
item
s on
the
pain
-fre
e fu
nctio
n qu
estio
nnai
re, w
hich
cau
sed
Rx
pro
cedu
res a
nd re
sults
findi
ngs
m
odel
pa
in b
efor
e, ha
d im
prov
ed fo
llow
ing
Rx.
• Val
idity
and
relia
bilit
y • M
any
diffe
rent
Rx’s
Impr
ovem
ent i
n gr
ip st
reng
th w
as co
rrel
ated
with
impr
ovem
ents
in fu
nctio
n
of
out
com
e m
easu
res s
tate
d
appl
ied;
ther
efor
e di
fficu
lt
an
d de
crea
se in
pai
n.
• Adv
erse
eve
nts s
tate
d
to d
eter
min
e w
hich
sole
ly
At
6 w
eeks
: no
pain
, ful
l fun
ctio
n, a
stro
ng co
rrel
atio
n w
as il
lust
rate
d th
at a
s
pr
oduc
ed e
ffect
s
fu
nctio
n in
crea
sed,
pai
n de
crea
sed
(r=
-0.9
2, p
<0.
0001
)
• No
rand
omiz
atio
n,
co
ntro
l gro
up
• N
o lo
ng-t
erm
follo
w-u
p
m
easu
res
Back
stro
m35
N
o st
atist
ical
ana
lysis
Ra
pid
redu
ctio
n in
pai
n le
vel:
25%
afte
r firs
t ses
sion,
and
50%
afte
r 3rd
sess
ion.
• C
lear
out
com
e m
easu
res
• No
rand
omiz
atio
n or
re
port
ed
Afte
r 12
sess
ions
(2 m
onth
Rx
perio
d), a
ll im
pairm
ents
reso
lved
exc
ept 0
.5cm
• C
lear
Rx
prot
ocol
cont
rol
of sw
ellin
g at
the
right
wris
t • F
ollo
w-u
p m
easu
res a
t • I
nade
quat
e po
wer
as o
nly
Ther
e w
ere
no p
ainf
ul li
mita
tions
for A
DLs
.
4 m
onth
s and
12
mon
ths
1
part
icip
ant
At 1
2-m
onth
follo
w-u
p, th
ere
was
still
no
evid
ence
of w
rist/t
hum
b pa
in o
r • R
epre
sent
s rea
listic
PT
Rx
• No
stat
istic
al a
naly
sis
func
tiona
l defi
cits
for a
pat
ient
with
com
plic
ated
• N
o bl
indi
ng o
f out
com
e
de
Que
rvai
n’s te
nosy
novi
tis
m
easu
rer o
r par
ticip
ant
The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e63]
• Una
ble
to g
ener
aliz
e
re
sults
to p
opul
atio
n as
only
1 p
artic
ipan
t
• U
ncle
ar o
f stu
dy d
esig
n
(w
heth
er is
was
a c
ase
repo
rt o
r stu
dy, a
s ter
ms
w
ere
used
inte
r-
ch
ange
ably
)
• N
otes
wer
e no
t com
plet
e
fo
r all
outc
ome
mea
sure
s
DeS
antis
N
o st
atist
ical
D
urin
g ea
ch M
WM
sess
ion,
NRP
S sc
ore
was
redu
ced
by 2
–3 p
oint
s. • C
lear
cas
e hi
stor
y, ou
tcom
e • C
ase
repo
rt (n
on-
& H
asso
n16
anal
ysis
repo
rted
Rx
sess
ions
4–6
of M
WM
impr
oved
pai
n-fr
ee R
OM
by
30–4
5°; b
y th
e
m
easu
res,
Rx p
roce
dure
s
expe
rimen
tal)
last
sess
ion
= 17
5° (o
vera
ll in
crea
se =
80°
) (cl
inic
ally
sig)
.
and
resu
lts
• No
rand
omiz
atio
n,
M
WM
stop
ped
on 7
th se
ssio
n as
par
ticip
ant n
o lo
nger
repo
rted
pai
n du
ring
• C
ontin
uous
Ax
repo
rted
cont
rol g
roup
, blin
ding
,
ac
tive
abdu
ctio
n, h
ad a
chie
ved
near
-ful
l ARO
M, a
nd h
ad v
ery
little
pai
n on
• R
elev
ant i
mpr
ovem
ents
of
or
gro
up co
mpa
rison
s
ov
erhe
ad a
ctiv
ities
.
sym
ptom
s pre
- and
pos
t-
• Sin
gle
case
repo
rt d
oes
Ove
rall,
at D
/C th
e pa
tient
had
no
posit
ive
impi
ngem
ent t
ests
, im
prov
ed
• Rep
rese
nts r
ealis
tic P
T Rx
not p
rovi
de co
mpa
rison
fu
nctio
n, im
prov
emen
t (>1
0%) o
n di
sabi
lity
scal
es
fo
r sho
ulde
r im
ping
emen
t
of R
x eff
ects
• R
epor
ted
valid
ity a
nd re
liabi
lity
• M
any
diffe
rent
Rx’s
of
out
com
e m
easu
res
ap
plie
d; th
eref
ore
diffi
cult
to d
eter
min
e
w
hich
sole
ly p
rodu
ced
effec
ts
• N
o st
atist
ical
test
ing
repo
rted
Folk
36
No
stat
istic
al
OT
Rx h
ad n
ot im
prov
ed p
atie
nt’s
sym
ptom
s ove
rall
over
pas
t 10
mon
ths.
• Cle
ar c
ase
hist
ory,
outc
ome
• Cas
e re
port
(non
-
anal
ysis
repo
rted
Pa
tient
had
per
siste
nt lo
ss o
f mot
ion,
tend
erne
ss, t
rigge
r sym
ptom
s, an
d lo
ss
m
easu
res,
Rx p
roce
dure
s,
ex
perim
enta
l)
of
dai
ly fu
nctio
n.
an
d re
sults
• N
o ra
ndom
izat
ion,
Pa
tient
’s pr
eope
rativ
e sy
mpt
oms h
ad n
ot im
prov
ed a
fter t
he o
pera
tion.
• C
ontin
uous
ass
essm
ent
co
ntro
l gro
up, b
lindi
ng,
Onc
e re
ferr
ed to
PT
and
perf
orm
ed M
WM
Rx,
1 se
ssio
n of
MW
M R
x
re
port
ed
or
gro
up co
mpa
rison
s
ab
olish
ed p
ain
with
MC
P ex
tens
ion
and
the
patie
nt c
ance
lled
2nd P
T
• Fol
low
-up
com
mun
icat
ion
• Sin
gle
case
repo
rt d
oes
appo
intm
ent,
as a
ll ac
tiviti
es w
ere
now
sym
ptom
-fre
e. At
follo
w-u
p (2
mon
ths
2
mon
ths,
then
1 y
ear l
ater
not p
rovi
de co
mpa
rison
an
d 1
year
), th
e pa
tient
confi
rmed
she
had
rem
aine
d sy
mpt
om-f
ree
post
-the
• S
ig im
prov
emen
ts o
f sym
ptom
s
of R
x eff
ects
M
WM
Rx
pr
e- a
nd p
ost-
MW
M R
x w
ith
• Man
y di
ffere
nt R
x’s
su
stai
nabi
lity
up to
a y
ear
ap
plie
d; th
eref
ore
diffi
cult
to d
eter
min
e w
hich
sole
ly
pr
oduc
ed e
ffect
s
• N
o re
port
ed st
atist
ical
test
ing
• No
repo
rted
relia
bilit
y
or
val
idity
of o
utco
me
mea
sure
s sta
ted
Het
herin
gton
19
No
stat
istic
al
Re-e
valu
atio
n of
pai
n-fr
ee m
ovem
ent a
fter t
he M
WM
s res
ulte
d in
a m
arke
d • C
lear
Rx
proc
edur
e w
ith
• Onl
y a
retr
ospe
ctiv
e ca
se
anal
ysis
incr
ease
in p
ain-
free
RO
M.
eff
ectiv
e re
sults
serie
s rev
iew
re
port
ed
One
-legg
ed st
andi
ng te
st (e
yes c
lose
d) p
ost-
MW
Ms a
nd ta
ping
reve
aled
• S
ome
appr
opria
te o
utco
me
• No
rand
omiz
atio
n,
incr
ease
d ba
lanc
e eq
ual t
o th
at o
f the
uni
njur
ed si
de.
m
easu
res u
sed
bl
indi
ng, o
r con
trol
Gai
t pat
tern
s also
subs
tant
ially
impr
oved
• Stu
dy is
not
repr
oduc
ible
due
to la
ck o
f inf
orm
atio
n
and
poor
met
hodo
logi
cal
qu
ality
[e64] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2
tAb
le 8
. St
atis
tics,
resu
lts,
str
engt
hs, a
nd li
mita
tions
of t
he in
clud
ed s
tudi
es (c
ontin
ued)
Au
thor
St
atis
tica
l an
alys
is
Res
ult
s St
ren
gths
Li
mit
atio
ns
• No
stat
istic
al a
naly
sis
• N
o fo
llow
-up
mea
sure
s
• N
o da
ta p
rodu
ced
for
ou
tcom
e m
easu
res
• No
relia
bilit
y or
va
lidity
disc
usse
d
• N
o ch
arac
teris
tics o
r
base
line
mea
sure
s
opar
ticip
ants
stat
ed
Hsie
h et
al37
N
o st
atist
ical
D
urin
g M
WM
, pos
ition
al fa
ult w
as co
rrec
ted
(und
er M
RI).
• Blin
ding
of p
erso
n in
terp
retin
g • N
o st
atist
ical
ana
lysis
an
alys
is re
port
ed
End
of w
eek
1—st
ill h
ad p
ain,
lim
ited
ROM
, pai
n on
dist
ract
ion,
MRI
• P
oor p
ower
, as o
nly
pain
with
PRO
M.
• Fol
low
-up
at 3
wee
ks
on
e pa
rtic
ipan
t
En
d of
wee
k 2—
pain
, lim
ited
ROM
, pai
n w
ith d
istra
ctio
n.
• App
ropr
iate
out
com
e • N
o bl
indi
ng, c
ontr
ol,
End
of w
eek
3—no
pai
n, n
orm
al R
OM
, nor
mal
grip
stre
ngth
, pai
n-fr
ee
m
easu
res
or
rand
omiz
atio
n
di
stra
ctio
n. M
RI d
emon
stra
ted
patie
nt h
ad h
ad a
pos
ition
al fa
ult.
• Cle
ar R
x pr
oces
s • U
nabl
e to
gen
eral
ize
• C
lear
des
crip
tion
of c
ase
hist
ory
re
sults
to p
opul
atio
n
as
onl
y on
e pa
rtic
ipan
t
• P
artic
ipan
t per
form
ed
se
lf Rx
, and
ther
e w
as n
o
m
entio
n of
com
plia
nce
Not
e: si
g =
signi
fican
t; PT
= p
hysio
ther
apy;
NSA
IDS
= no
n-st
eroi
dal a
nti-i
nflam
mat
orie
s; Rx
= tr
eatm
ent;
AN
OVA
= a
naly
sis o
f var
ianc
e; cm
= ce
ntim
eter
s; p
= pr
obab
ility
; Ax
= as
sess
men
t; kg
= k
ilogr
am; U
S =
ultr
asou
nd; i
.e. =
ther
efor
e; M
WM
= m
obili
zatio
n w
ith m
ovem
ent;
DO
MS
= de
laye
d on
set m
uscl
e so
rene
ss; P
PT =
pre
ssur
e pa
in th
resh
old;
VA
S =
visu
al a
nalo
gue
scal
e; R
OM
= ra
nge
of m
otio
n; k
Pa =
kilo
pasc
al; D
F =
dors
iflex
ion;
TPT
= th
erm
al p
ain
thre
shol
d; P
FGS
= pa
in-f
ree
grip
stre
ngth
; N =
new
tons
; HR
= he
art r
ate;
BP
= bl
ood
pres
sure
; SN
S =
sym
path
etic
ner
vous
syst
em; I
V =
intr
aven
ous;
ULT
T =
uppe
r lim
b te
nsio
n te
st;
WB
= w
eigh
t-be
arin
g; N
WB
= no
n-w
eigh
t-be
arin
g; ap
prox
= ap
prox
imat
ely;
max
= m
axim
um; N
/cm
2 =
new
tons
per
cent
imet
er sq
uare
d; T
OP
= te
nder
on
palp
atio
n; T
rP =
trig
ger p
oint
; D/C
= d
ischa
rge;
HEP
= h
ome
exer
cise
pro
gram
; AD
Ls =
act
iviti
es o
f dai
ly li
ving
; NRP
S =
num
eric
pai
n ra
ting
scal
e; A
ROM
= a
ctiv
e ra
nge
of m
otio
n; O
T =
occu
patio
nal t
hera
py; M
CP
= m
etac
arpo
phal
ange
al; P
ROM
= p
assiv
e ra
nge
of m
otio
n; M
RI
= m
agne
tic re
sona
nce
imag
ing.
The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e65]
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
(28%) were case studies or reports with only one participant, this decreases the overall level of power and therefore va-lidity of the results in general16,20,23,35-37.
Characteristics and Efficacy
As discussed previously, there are many established effects of MWMs at various joints, whether it is positional fault cor-rection or hypoalgesic effects. A recent review discusses the different concepts of the effects of an MWM in relation to positional faults and pain relief12. It is evident that many joints are yet to be examined including, for example, the hip and knee. The majority of studies (12/25; 48%) reviewed here examined elbow joint-related pathology (lateral epicondylagia), followed by ankle sprains (6/25; 24%), shoulder joint dys-function (4/25; 16%), MCP strains (2/25; 8%), and de Quervain’s at the wrist (1/25; 4%). Research has not been limited to age with subjects ranging from 17 to 79 years of age, which exem-plifies the technique’s effects on various populations. In general, the efficacy of MWM as a manual therapy technique, as analyzed, is well established with pos-itive results in 24 out of 25 studies. The most common effects studied to date in-clude increases in strength, reduction in pain levels, increase in PPT, improved neural tests, and improved function. The clinical benefit of this technique is there-fore confirmed and well supported by research.
Strengths and Limitations of this Systematic Review
The specific aims of this systematic re-view have been clearly outlined, which originated from a global search sur-rounding Mulligan manual therapy techniques. The need for the investiga-tion into the commonly prescribed MWM technique was indicated, as it had not yet been reviewed and it was evident that it is generally an ill-defined area. The methods of critiquing and ana-lyzing have been consistently and thor-oughly performed by two researchers throughout in an attempt to reduce bias. Extensive use of search terms, databases, and cross-referencing ensured that all
possible studies relative to MWM pre-scription at peripheral joints were in-cluded for analysis. A valid and reliable critical appraisal checklist to assess the methodological quality of randomized and non-randomized studies was em-ployed, and previous categorization of the tool was located.
This systematic review consists of some unavoidable limitations. This in-cludes the access of only-English written articles and a search performed up until August 2008. This leads to the possibility of the exclusion of other studies that may be pertinent to this review and, therefore, the guidelines for clinical practice. Lastly, this review lacks a com-plete statistical analysis that may, to an extent, weaken the interpretation of re-sults. However, the primary focus of this systematic review was a descriptive analysis in order to fulfill the outlined purposes.
Future Research
Subsequent to the extensive research and analysis undertaken for this system-atic review, it is evident that there are inconsistencies, gaps, and methodologi-cal limitations within the literature sur-rounding MWM treatment at periph-eral joints.
The methodological quality of fu-ture research needs to be more robust in order to build an improved evidence base in this commonly used area of manual therapy, as currently it is of a moderate level. Internal validity of stud-ies can be strengthened via the use of randomized controlled trials, optimally including double blinding and placebo groups. The external validity can be en-hanced by the inclusion of a greater number of participants, who are repre-sentative of populations that may benefit from MWM treatment. This will con-tribute to creating sufficient power and, therefore, the detection of clinically sig-nificant results. A limiting factor that can be easily resolved is the reporting within studies. This needs to be im-proved by documenting adverse events, dropouts, confounding variables, and specific explanation of methods of re-cruitment, assessment, and the MWM treatment procedure. Inclusion of fol-
low-up assessment will further examine the long-lasting effects of MWMs. Out-come measures used in studies should aim to be valid and reliable to further increase consistency of results and therefore internal validity.
Conclusion
Mulligan’s peripheral MWM techniques are commonly used within musculo-skeletal physiotherapy. This systematic review of the MWM prescription at pe-ripheral joints highlighted that this area of research has an overall moderate methodological quality, with evident strengths, limitations, and inconsisten-cies. The specific parameters identified for MWM prescription in the literature are variable and in general inconsis-tently implemented and explained. The efficacy of MWMs is well established for various joints and pathologies; however, due to the methodological quality of the studies, it is apparent that further re-search is warranted into the specific pa-rameters of MWMs.
To conclude, this manual therapy technique is widely used and advocated for many aspects of peripheral joint dys-function. This systematic review has presented an evaluation of MWMs spe-cific to peripheral joints, in an attempt to guide the clinician appropriately and to provide a basis for future research into this area.
REFERENCES
1. Mulligan B. Manual Therapy: “NAGS”, “SNAGS”, “MWMS” etc. 5th ed. Wellington: Plane View Services Ltd., 2004.
2. Mulligan B. The Mulligan Concept. April 5, 2007. Is the date retrieved? Should read: Retrieved April 5, 2007 from . . . http://www.bmulligan.com.
3. Collins N, Teys P, Vicenzino B. The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains. Man Ther 2004;9:77–82.
4. Kochar M, Dogra A. Effectiveness of a spe-cific physiotherapy regimen on patients with tennis elbow. Physiotherapy 2002;88:333–341.
5. Teys P, Bisset L, Vicenzino B. The initial ef-fects of a Mulligan’s mobilization with
[e66] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2
MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review
movement technique on range of movement and pressure pain threshold in pain-limited shoulders. Man Ther 2006;11:1–6.
6. Paungmali A, Vicenzino B, Smith M. Hypo-algesia by elbow manipulation in lateral epi-condylalgia does not exhibit tolerance. J Pain 2003;4:448–454.
7. Vicenzino B, Paungmali A, Buratowski S, Wright A. Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypolge-sia. Man Ther 2001;6:205–212.
8. Mulligan B. Manual Therapy: “Nags”, “Snags”, “Prp’s” Etc. 1st ed. Wellington, NZ: Plane View Services Ltd., 1989.
9. Mulligan B. Manual Therapy: “NAGS”, “SNAGS”, “MWMS” etc. 6th ed. Wellington. NZ: Plane View Services Ltd., 2006.
10. Wilson E. The Mulligan concept: NAGS, SNAGS and mobilizations with movement. J Bodywork Movement Ther 2001;5:81–89.
11. Kavanagh J. Is there a positional fault at the inferior tibiofibular joint in patients with acute or chronic ankle sprains compared to normals? Man Ther 1999;4:19–24.
12. Vicenzino B, Paungmali A, Teys P. Mulli-gan’s mobilization-with-movement, posi-tional faults, and pain relief: Current con-cepts from a critical review of literature. Man Ther 2007;12:98–108.
13. Abbott JH. Mobilization with movement ap-plied to the elbow affects shoulder range of movement in subjects with lateral epicon-dylalgia. Man Ther 2001;6:170–177.
14. Paungmali A, O’Leary S, Souvlis T, Vicen-zino B. Hypoalgesic and sympathoexcit-atory effects of mobilization with movement for lateral epicondylalgia. Phys Ther 2003; 83:374–383.
15. Paungmali A, O’Leary S, Souvlis T, Vicen-zino B. Naloxone fails to antagonize initial hypoalgesic effect of a manual therapy treat-ment for lateral epicondylalgia. J Man Ma-nip Ther 2004;27:180–185.
16. DeSantis L, Hasson SM. Use of mobilization with movement in the treatment of a patient with subacromial impingement: A case re-port. J Man Manip Ther 2006;14:77–87.
17. Exelby L. Peripheral mobilisations with movement. Man Ther 1996;1:118–126.
18. Vicenzino B, Branjerdporn M, Teys P, Jor-dan K. Initial changes in posterior talar glide and dorsiflexion of the ankle after mobiliza-tion with movement in individuals with re-
current ankle sprain. J Ortho Sports Phys Ther 2006;36:464–471.
19. Hetherington B. Lateral ligament strains of the ankle: Do they exist? Man Ther 1996; 1:274–275.
20. Stephens G. Lateral epicondylitis. J Man Ma-nip Ther 1995;3:50–58.
21. Downs SH, Black N. The feasibility of creat-ing a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377–384.
22. Saunders LD, Soomro GM, Buckingham J, Jamtvedt G, Raina P. Assessing the method-ological quality of nonrandomized inter-vention studies. West J Nurs Res 2003;25:223–237.
23. Altman DG, Burton MJ. The Cochrane col-laboration. Langenbecks Arch Surg 1999;384: 432–436.
24. Hartling L, Brison RJ, Crumley ET, Klassen TP, Picket W. A systematic review of inter-ventions to prevent childhood farm injuries. Pediatrics 2004;114:483–496.
25. Hignett S. Intervention strategies to reduce musculoskeletal injuries associated with handling patients: A systematic review. Oc-cup Environ Med 2003;60:1–8.
26. Hignett S. Systematic review of patient handling activities starting in lying, sitting and starting positions. J Adv Nurs 2003;41:545–552.
27. Monteiro POA, Victora CG. Rapid growth in infancy and childhood and obesity in later life: A systematic review. Obes Rev 2005; 6:143–154.
28. Roddy E, Zhang W, Doherty M, et al. Evi-dence-based recommendations for the role of exercise in the management of osteoar-thritis of the hip or knee. The MOVE con-sensus. Rheumatology 2005;44:67–73.
29. Zhang W, Doherty M, Leeb BF, et al. EULAR evidence-based recommendations for the management of hand osteoarthritis: Report of a Task Force of the EULAR Standing Committee for International Clinical Stud-ies Including Therapeutics (ESCISIT). Ann Rheum Dis 2007;66:377–388.
30. Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: Randomised trial. Br Med J 2006;333:939–944.
31. McLean S, Naish R, Reed L, Urry S, Vicen-
zino B. A pilot study of the manual force levels required to produce manipulation-induced hypoalgesia. Clin Biomech 2002; 17:304–308.
32. Reid A, Birmingham TB, Alcock G. Efficacy of mobilization with movement for patients with limited dorsiflexion after ankle sprain: A crossover trial. Physio Canada Summer 2007;59:166–172.
33. Yang J-L, Chang C-W, Chen S-Y, Wang S-F, Lin J-J. Mobilization techniques in subjects with frozen shoulder syndrome: Random-ized multiple-treatment trial. Phy Ther 2007;87:1307–1315.
34. Vicenzino B, Wright A. Effects of a novel manipulative physiotherapy technique on tennis elbow: A single case study. Man Ther 1995;1:30–35.
35. Backstrom KM. Mobilization with move-ment as an adjunct intervention in a patient with complicated De Quervain’s tenosyno-vitis: A case report. J Orthop Sports Phys Ther 2002;32:86–97.
36. Folk B. Traumatic thumb injury management using mobilization with movement. Man Ther 2001;6:178–182.
37. Hsieh CY, Vicenzino B, Yang CH, Hu MH, Yang C. Mulligan’s mobilization with movement for the thumb: A single case report using magnetic resonance imaging to evaluate the positional fault hypothesis. Man Ther 2002;7:44–49.
38. O’Brien T, Vicenzino B. A study of the effects of Mulligan’s mobilization with movement treatment of lateral ankle pain using a case study design. Man Ther 1998;3:78–84.
39. Penso M. The effectiveness of mobilisation with movement for chronic medial ankle pain: A case study. S Afr J Phys 2008;64:13–16.
40. Teys P, Bisset L, Vicenzino B. The initial effects of a Mulligan’s mobilization with movement technique on range of movement and pressure pain threshold in pain-limited shoulders. Man Ther 2008;13:37–42.
41. Abbott JH, Patla CE, Jensen RH. The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral epicondylalgia. Man Ther 2001;6:163–169.
42. Slater H, Arendt-Nielson L, Wright A, Graven N. Effects of a manual therapy technique in experimental lateral epicon-dylalgia. Man Ther 2006;11:107–117.