Immediate reduction in pain and earlier return to function are claimed as results of Mulligan’s Mobilization with Movement (MWM) (Mulligan 1992, 1993) which is now widely used in the management of musculoskeletal disorders (Teys et al 2006). MWM is a system of manual therapy interventions that combines sustained manual accessory joint gliding with the physiological movement of the joint (Mulligan 1995) The technique is indicated if during its application, it enables the impaired joint to move freely without pain or impingement (Vicenzino & Wright 1995).
Mulligan (1995) has described a MWM technique for LE which had been detailed in other literature (Abbot 2001, Vicenzino 1995, 2001). It involves lateral glide to the proximal forearm while the distal humerus is fixed. The glide is applied for 6-10 seconds while patient performs pain free gripping action and three sets of about 10 repetitions are given depending on the patient response. The technique is contra-indicated if it provokes pain.
This paper aims to determine the effectiveness of MWM for patients with LE on patient centered outcomes of pain and physical function.
Criteria for considering studies for this review
Types of studies-
This paper incorporated RCT’s, CCT’s, pre & post studies with no control group. Case studies, reports in dissertations, personal/anecdotal experience and letters to editors were excluded. The interventional studies assessing the effect of MWM on LE, either alone or in comparison to some other form of management approach were included. The clinical studies assessing the effects of MWM were also included to develop an understanding of the underlying mechanisms of MWM on LE.
Types of Participants-
The review included adults 18 years or older who had been diagnosed with lateral epicondylitis.
Types of outcome measures-
The primary outcomes of interest are- Pain, Physical function and Grip strength
The following electronic databases were used to identify relevant studies published between January 1992 (Vicenzino 2007) and November 2007 – MEDLINE, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Musculoskeletal Group Trials Register, Web of Science, SPORTdiscus, ScienceDirect (Elsevier). Only English language papers were considered. The following search terms were used either alone or in combination using BOOLEAN logic (AND,OR,NOT) ‘Mulligan’, ‘Mobilization’, ‘Mobilization with movement’, ‘MWM’, ‘tennis elbow’, ‘lateral epicondylitis’, ‘lateral epicondylagia’ .
The reference lists of the articles, review papers were scanned for additional papers. The bibliographies listing the works of experts in the field were searched to ensure the list of publications is complete. Unpublished papers, reports and other documents were not included.
A total of 119 non overlapping studies were retrieved and were screened. Eight studies which fulfilled the inclusion criteria were selected for this review by the author.
Description of Studies-
Bisset et al (2006) conducted a pragmatic randomised single blinded control trial to assess the effect of MWM and exercise (n= 66), corticosteroid injections (n=65) or wait and see (n=67) on 198 subjects with LE. Patients in the physiotherapy (MWM & exercise) group received a standardised protocol of mobilization and exercises for eight sittings of 30 minutes over six weeks along with home exercise program. The patients allocated to injection group received local injection, at the tender point while those allocated to the wait and see group were reassured, proper activity modification was done and asked to take analgesics, thermotherapy or braces as required. The primary outcomes (global improvement, pain free grip strength, and assessor’s rating of severity) and the secondary outcomes (VAS for pain, pain free function questionnaire for elbow disability) were assessed at baseline and then at 3, 6, 12, 26, and 52 weeks. At 3 weeks (short term) assessment, injection was superior to both physiotherapy and wait & see but at 52 weeks (long term), injection was significantly worse than either physiotherapy or wait and see groups. Overall physiotherapy had better results than injection for all primary outcomes and over wait & see for pain free grip and assessor severity.
Though this study placed emphasis on methodological rigour with adequate sample size, clearly defined population criteria, blinded randomisation, validated outcome measures and long term follow up, but as the authors (Bisset et al 2006) have acknowledged, the discrepancy between the treatment sessions of physiotherapy and other protocols may be the potential reason for its efficacy. Another issue is that it also included exercises thus making it impossible to attribute the effects to MWM alone.
Abbott et al (2001) in their single pre- post design investigated the effect of a single intervention of MWM on pain, pain free grip strength and maximum grip strength on 25 subjects with LE. They obtained a convenient purposive sample of patients with unilateral epicondylitis. MWM was applied as per the guidelines provided by the authorities (Mulligan 1995). Though the pre and post test results indicated that about 92% (23 out of 25) responded favourably to MWM with decrease in previously experienced pain, increase in pain free grip strength (17%) and the maximum grip strength (5%) on the affected side, the results cannot be generalised as clinically significant as a single group design may introduce bias due to sampling methods. Another issue which prevents author from drawing strong positive conclusions from this study is the use of a single measurement to analyse the effects with no follow up. But it does present the results of a single session effectively and wider scope for future research.
Groups( No.of subjects)
Single Blind RCT
Wait & see(67)
Assessor severity rating.
At 6 weeks-
Injection (78%) better than physiotherapy(65%) & wait & see(27%).
At 52 weeks- Physiotherapy better than injections & wait& see.
Other physiotherapy was also used making it difficult to dileaneate the effects of MWM.
Discrepancy in No. of Rx sessions.
Abbott et al 2001
Single pre post design
pain free grip strength,
maximum grip strength
92% had decrease in pain,
17% had increase in PFG
5% had increase in MGS
Convenient sampling and single session compromise the reliability of results.
Kochar M 2002
Randomised control trial
UST alone (23),
No treatment (20).
VAS, weight test, grip strength, patient assessment
On all parameters, MWM group was significantly better than UST which was better than no treatment.
The No treatment group was not randomised.
No placebo group,
No Long term follow up.
Double Blind RCT
Pain free grip strength,
Pressure pain threshold.
Increase PFG (46%) and
PPT (10%), which were
greater than placebo and
No long term effects were studied.
Placebo ,controlled ,repeated measures
MWM, placebo , Control
Increase PFG (48%) and PPT (15%), which were
greater than placebo and
_ Sympatho-excitation also
(immediate) effects were
Placebo ,controlled ,repeated measures
MWM, placebo , Control
45.29% increase in PFG
17.51% in PPT across all therapy sessions.
Hypoalgesia was non tolerant to repetition.
Double blind RCT, placebo
Naloxone, Saline and
Control delivered prior
to the MWM
Changes in outcome
measures were not
different from placebo
and control conditions
McLean et al 2002
randomised, single blind, repeated measures pilot study,
4 levels of force applied to same subjects.
33% & 50% force did not produce hypoalgesia, while 66% did significantly.
Pilot study, not investigated further, optimum level of force required to produce analgesic effect.
Table 1: Studies on the effectiveness of MWM in LE.
Kocher & Dogra (2002) conducted a randomised control trial on 66 patients diagnosed with LE, divided into three groups - Mulligan’s MWM (n= 23), Ultrasound (n=23), Control (n=20, non randomised)
The variables measured included VAS, weight test, isometric grip strength, patient assessment at baseline, 1, 2, 3 and 12 weeks. The patients were given 10 treatment sessions over three weeks and then asked to continue with the exercises (stretching & strengthening) for further nine weeks. The authors reported significant change at the final assessment on VAS (97%), weight lift (4.4kg) and the grip strength (9 Kg) in MWM group but not the other groups, though not much detail is provided into the result which compromises the validity of the study. The use of ultrasound in the MWM group makes it difficult to delineate the effects of MWM. Also the non randomisation of the control group affects the validity of the results.
Vicenzino et al (2001) conducted a randomized, repeated measures, double-blind, placebo-controlled trial on 24 patients presenting with chronic lateral epicondylagia. The study aimed to evaluate the pain relieving effect of MWM as compared to placebo or control conditions. The outcome measures assessed were pain free grip strength (PFG) and pressure pain threshold (PPT) which were assessed before and after the application of MWM, placebo or control interventions. The results showed a significantly important change in both these variables (PFG-58%, PPT-10%) as compared to control and placebo. This effect was observed only in the affected side. This study provides useful insight into the short term effects of MWM on tennis elbow which is in accordance with the studies described earlier but did not investigate the time course of therapeutic effects. This study followed stringent methodology thus lending reliability and validity to the results.
Based on the study by Vicenzino et al (2001), Paungmali et al (2004) analysed the effect of naloxone administration on the hypoalgesic effect of MWM. They conducted a randomised, repeated measures trial on 18 participants with pain-free grip strength (PFG), pressure pain threshold (PPT), thermal pain threshold (TPT) and ULTT2b as the outcome measures assessed pre and post intervention. The experiment involved comparison of the effects of MWM with injection of naloxone, saline or no substance control. There was a change of 29% in PFG, 18% in PPT, 1.6% in ULTT2b, and 0.2% in TPT across all experimental conditions, thus demonstrating that naloxone could not antagonise the pain relieving effects of MWM. The authors of the study concluded that MWM induced hypoalgesia involves nonopioid endogenous pain modulation mechanism. They have taken into consideration the various confounding factors like dose and half life of naloxone and the small sample size but stressed that failure of naloxone cannot be taken as a definitive test as various other endogenous peptides could be involved which are not antagonised by naloxone.
Another related study by Paungmali et al (2003) assessed the tolerance of the analgesic effect of MWM to repeated applications. They did a repeated measures design analysis on 24 subjects with unilateral LE and gauged the effects on PFG and PPT. The variables were measured, MWM given on the affected side and reassessment of the outcome measures was done. Six sessions of treatment were given with a minimum 48 hour gap between sessions. The results showed a 45.29% increase in PFG and 17.51% in PPT across all therapy sessions. As there was no significant difference between sessions, the authors concluded that the patients did not develop tolerance towards the initial hypoalgesic effects of MWM.
Paungmali et al (2003) conducted a placebo controlled, repeated measures study on 24 subjects to analyse the initial hypoalgesic and sympatho excitatory effects of MWM on LE when compared with placebo and control groups. The outcome measures were grouped into pain related measures (PFG, PPT, TPT) and the sympathetic nervous system related measures (cutaneous blood flow, skin conductance, skin temperature, blood pressure, and heart rate). There was a 47.5% increase in PFG while there was no mean percentage increase in either PPT or TPT for MWM group. There was a 4.1% increase in heart rate, 3.5% for systolic BP and 3.1% for diastolic BP. MWM induced reductions in hand skin temperature (1.1%) and hand blood flux (72.4%) and a increases in skin conductance (55.0%), elbow skin temperature (2.1%), and elbow blood flux (123.7%). Though this study effectively addressed the research question, it does not relate the findings to clinical practice in terms of improved function or the long term effects of MWM.
In a randomised, single blind, repeated measures pilot study, McLean et al (2002) assessed the levels of force required to produce hypoalgesic effects of MWM in LE. They assessed the PFG in six LE patients with four different levels of force applied (100%, 66%, 50%, 33%) and concluded that the lower two force levels (e.g. 37–56 N) did not produce a significant change in PFG while the third standardised level (75N (95% confidence interval: 62–87 N) did have a significant difference as compared to the lower levels but not with the maximum level of force applied (113N). The authors thus implicated that there may be an optimum level of force required to produce the hypoalgesic effect of MWM in LE. This was a pilot study but has not been followed up with a large sample study.
This paper searched for evidence regarding the efficacy of MWM in LE and explored the pain science studies in an effort to understand the underlying mechanism involved for the effects obtained.
MWM involves a combination of active movement (repeated gripping action) and passive mobilization (manual sustained lateral glide of the elbow) which have both been effective individually in the management of LE (Pienimaki et al 1996, Drechsler 1997). It is a relatively new treatment concept; the proponents of this concept have claimed its efficacy in both the spinal and peripheral conditions (Mulligan 1992, 1993, 1995, Vicenzino 1995, 2001, Abbott 2001).
The studies undertaken have incorporated assessment of pain and physical function loss in terms of pain free grip strength as the primary outcome measures, these being the principal features of LE (Abbott 2001, Vicenzino 2001, Kocher & Dogra 2002, Bisset et al 2006).
All these studies have concluded that application of MWM produces a strong hypoalgesic effect in patients with LE. This significant hypoalgesic effect of manual treatment corroborates the results of various other manual treatment studies on peripheral joints. (Vicenzino et al 1995, 1996, 1998, 2001, Sterling et al 2000, Zusman et al 1989).
Vicenzino et al 2001 concluded that the results were found only on the affected side but this is in contradiction to the previous studies on spinal manual therapy (Vicenzino et al 1995) which have found the same effects in asymptomatic subjects as well, though it is in accordance with Mulligan’s (1995) positional fault hypothesis, which states that there is a mechanical alteration in alignment of joints due to chronic dysfunction, which if corrected leads to pain free functional movements.
Pain free grip strength showed significantly greater improvement after the application of MWM (Abbott 2001, Vicenzino 2001, Kocher & Dogra 2002, Bisset et al 2006) rather than maximum grip strength which implies that PFG is a better predictor of the outcome than MGS which is in contradiction with the results of Stratford et al (1993) who concluded that MGS was more responsive to change in LE.
The pain science studies (Paungmali 2003, 2004, Mclean 2002) also positively related to the findings of the clinical studies. They found significant improvements in pain and function on application of MWM and went on to consider the underlying mechanisms of the effects. While there is an agreement that a non opoid form of analgesia which is not tolerant to repetition, caused the hypoalgesic effect of MWM, the studies have been done by a single group of authors (Paungmali et al 2003, 2004, Vicenzino et al 2001) and most likely the data collection was done only once using the same group of subjects which inadvertently may have introduced bias into the results as the study design, number of subjects, research protocol are similar.
Apart from these effects, Paungmali et al (2003) have demonstrated an excitatory response in sympathetic nervous system following application of MWM. This is elicited by changes in heart rate, blood pressure and cutaneous sudomotor and vasomotor function. This is in concordance with the previous studies on manual therapy (Vincenzino et al 1998, Sterling et al 2001).
Although the overall quality of studies used was satisfactory, there were some methodological shortcomings. None of the studies did a long term follow up to evaluate the time course of the therapeutic effects achieved and most of the studies were same subject pre- post designs. The studies evaluating the mechanisms of pain relief were performed in experimental conditions and thus did not take into account the co morbidities associated with the condition.
Only a qualitative analysis of the studies was done as data is statistically and clinically heterogenous, there are only two RCTs and most are pain science studies (Cochrane musculoskeletal review group guidelines)
The author’s clinical experience has also proven this technique to be quite beneficial in management of LE, reducing the number of treatments and improving the quality of life even in cases recalcitrant to other management approaches. This is also corroborated by other case studies (Vicenzino & Wright 1995) which have followed the standardised prescribed treatment protocol as described by Mulligan (1993).
Scope for future research-
This review presents some emerging trends towards the effectiveness of MWM in LE. High quality longitudinal RCTs, which will assess the standardised outcome measures over a period of long term follow up, are needed to confirm the clinical effectiveness of MWM in LE.
The neurophysiological mechanisms thought to be responsible for effects of MWM also need to be explored further. Another area of research into MWM is the confirmation of the positional fault hypothesis using radiographic techniques and MRI studies. It needs to be investigated whether there are mechanical alterations in alignment that are corrected by MWM.
These will help confirm the effects and basis of MWM and lay the foundation for effective clinical practice.
Lateral epicondylitis has been a perplexing problem for physiotherapists due to its recalcitrant nature, but the results from the research evidence show that MWM presents a useful clinical option for management of this rather difficult condition due to its immediate pain relieving effects and earlier return to function and its effects need to be explored further to devise proper and effective management protocols based upon sound clinical judgement and research.
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