EFFECTIVENESS OF MULLIGAN MOBILISATION WITH MOVEMENT COMPARED TO SUPERVISED EXERCISE PROGRAM IN SUBJECTS WITH LATERAL EPICONDYLITIS

ISSN 2321-1822

Original Research Article

EFFECTIVENESS OF M ULLIGAN M OBILISATION W ITH M OVEM ENT

COM PARED TO SUPERVISED EXERCISE PROGRAM IN SUBJECTS

W ITH LATERAL EPICONDYLITIS

Hafizur Rahman

_{, Pilladi A Chaturvedi *}

_{, Patchava Apparao}

_{, Pilladi R Srithulasi}

_.

1 _{Post Graduate St udent , Swatant ra Inst it ute of Physiot herapy and Rehabilitat ion, Rajahmundhry,}

Andhra Pradesh, India.

* 2 _{Vice Principal, Swatant ra Inst it ute of Physiot herapy and Rehabilitat ion, Rajahmundhry, Andhra}

Pradesh, India.

3 _{Principal, Swatantra Inst it ute of Physiot herapy and Rehabilitation, Rajahmundhry, Andhra Pradesh,}

India.

4 _{Assistant Professor, Swatantra Inst it ute of Physiotherapy and Rehabilitat ion, Rajahmundhry, Andhra}

Pradesh, India.

Background and Purpose: Lat eral epicondylit is com m only refer red t o as lat eral elbow Tendinopat hy or t ennis elbow is one of t he m ost com m on lesions of t he arm . M en and w om en are equally affect ed. There are m any t reat m ent opt ions available for t ennis elbow ; an exercise program is used as t he first t reat m ent opt ion. M ulligan has proposed t he use of m obilizat ion w it h m ovem ent for lat er al epicondylit is. The m ain Purpose of t he st udy is t o com pare t he ef fect s of m ulligan m obilizat ion w it h m ovem ent and supervised exercise pr ogram in subject s w it h lat er al epicondylit is.

M aterials and M et hods: 60 Subject s fulfilled t he inclusive crit eria and w ere random ly assigned int o t w o groups. Group A w ere given M obilizat ion w it h m ovem ent and Group B perform ed Supervised Exercise Progr am . Bot h groups perform ed t hree sessions per w eek for t he durat ion of 4 w eeks. Aft er t he t r eat m ent , subject s w ere evaluat ed for t heir pain profile using visual analogue scale, and grip st rengt h by Hand grip dynam om et er.

Results: Paired t-t est analysis is used w ithin group and Independent t -t est is used for bet w een group com parisons. At t he end of 4 w eeks M ulligan m obilisat ion w it h m ovem ent group show ed signif icant im provem ent in VAS and hand grip st r engt h scores t han t he supervised exercise pr ogram group (P<0.000).

Conclusion: It is concluded t hat bot h t echniques show ed im provem ent s in hand grip st rengt h and VAS. The group t hat per form ed m ulligan m obilisat ion w it h m ovem ent show ed signif icant ly great er im provem ent in r educt ion of pain and increase in hand gr ip st rengt h t han t he supervised exercise progr am .

KEYW ORDS: M u lli gan M o bi l izat ion w i t h M ovem ent (M W M ), V i sual Anal ogu e Scale (VAS), Hand Gr ip Dynamom eter (HGD).

ABSTRACT

INTRODUCTION

Address for correspondence: Dr. Pilladi A Chart urvedi, M PT Sport s, Vice Principal, Swat ant ra Inst i t u t e o f Phy si ot h er ap y an d Reh ab i l it at i on , Raj ah m u nd hr y, An d h ra Prad esh, Ind ia.

E-M ail: chat urvedipilladi@gmail.com

International Journal of Physiotherapy and Research, Int J Physiother Res 2016, Vol 4(2):1394-1400. ISSN 2321-1822 DOI: ht t p:/ / dx.doi.org/10.16965/ ijpr.2016.104

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DOI: 10.16965/ ijpr.2016.104

Received: 16-01-2016 Peer Review : 16-01-2016 Revised: None

Accept ed: 16-02-2016 Published (O): 11-04-2016 Published (P): 11-04-2016

Lat eral epicondylit is comm only referred t o as lateral elbow Tendinopat hy or Tennis elbow is

t he elbow, especially in gripping act ivit ies and w hen resist ance is applied t o t he ext ensor muscles of t he forearm [1].

Lat eral epicondylit is is a degenerat ive or failed healing t endon response charact erised by t he incr eased presence of f ibr oblast s, vascular hyperplasia, and disorganised collagen in t he or igin of t he ext ensor car pi r adialis br evis (ECRB), t he most commonly affect ed st ruct ure [2].

It is very com m on in individuals w hose jobs necessit at e f r equent r ot ar y m ot ion of t he forearm (e.g., t ennis players and carpent ers). It is commonly due t o more quick, monot onous, cyclic eccent ric cont ract ions and w rist griping act ivit ies. The average period of an episode of lat eral epicondylit is ranges bet w een 6 mont hs and 2 years.

The Epidemiology of annual incidence in t ennis elbow in general pract ice is 4-7 Cases per 1,000 pat ient s. The peak incidence is bet w een 40 and 50 years age [3]. M en and w omen are equally af f ect ed. Hist ological st udies suggest t hat lat eral epicondylit is involves a degenerat ive process, cit ing t he presence of disorganized collagen as opposed t o inflammat ory cells [4]. Acupunct ure, ort hot ics, t aping, ext ra corporeal shock wave t herapy, LASER and ionizat ion are considered for managing lat eral epicondylit is. Act ivit y m odif icat ions such as avoidance of grasping in pronation and substituting controlled supinat ion during lift ing may relieve sympt oms [5].

An exer ci se p r o gr am i s u sed as t h e f i r st t r eat m ent opt ion f or pat ient s w it h lat er al epicondylit is. There are t w o t ypes of exercise program m e-home exercise program mes and exercise program mes carried out in a clinical set t ing.

A hom e exer cise progr am m e is com m only advocat ed for pat ient s and can be performed any t im e during t he day w it hout r equiring supervision from a pract it ioner, w hereas t he exercise program mes carried out in a clinical set t i ng i s call ed as su p er v i sed exer cise programme [6].

St asinopoulos Dim it ro (2013) show ed in t heir st u d y t h at a sp ecif i c su p er v i sed exer ci se program is superior t o a specific home exercise

M ATERIALS AND M ETHODS

program in reducing pain and improving funct ion in pat ient s w it h lat eral epicondylit is [6].The supervised exercise program of t ennis elbow is m ost oft en accom panied by st r engt hening, flexibilit y, or endurance t raining [7].

M o bil izat io n w it h M o vem ent (M W M ) is a modern t echnique developed by M ulligan for t reat ing lat eral epicondylit is. M WM is a form of manual t herapy t hat includes a sust ained lat eral gli d e t o t h e el b o w j o in t w i t h co n cu r r en t physiological m ovem ent . This m obilisat ion t echnique is oft en used t o correct t he fault y posit ion of t he elbow joint is being w idely used in management of musculoskeletal disorders. M iller (2000) described in his case report t he u se o f t h e M W M f or l at er al ep icon dy li t i s result ing in reduced pain, improvement of pain-free grip st rengt h (PFGS), and increased abilit y t o t olerat e resist ed isomet ric w rist ext ension [13].

The purpose of t his st udy is t o compare t he effect s of M ulligan M obilisat ion wit h M ovement and supervised exercise program in the reduct ion of pain and improving grip st rengt h in subject s w it h lat eral epicondylit is.

Present st udy is designed as an experim ent al design, dat a w as collect ed from t he GSL general hospit al, Rajahm undry and in and around t he Rajahmundry, Andhra Pradesh, India. Durat ion of t he st udy w as for 4 w eeks. Pat ient s w it h Pain w it h gripping, pain w it h resisted w rist ext ension, pain w it h passive w rist flexion w it h t he elbow ext ension, and tenderness on palpat ion over the lat eral epicondyle of humerus w ere included in t he st udy w here as pat ient s w it h pr evious surgery t o t he elbow region, peripheral nerve en t r ap m en t , cer v i cal r adi cu lo p at hy, cor t ico st er oi d i n j ect io n w i t hi n 6 m o n t hs, previous t herapy for elbow joint (minim izing exp ect at ion bias) , neu r olo gical or nuer o-m uscular io-m pairo-m ent s, aver sion t o o-m anual cont act , cardiovascular diseases w ere excluded from t he st udy,

ISSN 2321-1822

Hafizur Rahm an et al. EFFECTIVENESS OF M ULLIGAN M OBILISATION WITH M OVEM ENT COM PARED TO SUPERVISED EXERCISE PROGRAM IN SUBJECTS W ITH LATERAL EPICONDYLITIS.

Outcome M easures:

1 Pain intensit y: M easured by means of Visual Analogue Scale (VAS).

2 Hand grip st rengt h: M easured by means of Hand grip Dynamometer.

M ethodology: A t ot al of 60 subject s meet ing t he inclusion criteria w ere recruited for st udy. All t he pat ient s w ere recruit ed from t he GSL gener al h o sp i t al , i n an d ar ou n d t h e Rajahm undry. Af t er obt aining t he inform ed consent from t he pat ient s t hey w ere randomly assigned int o t w o groups, Group A and Group B respect ively, having 30 subject s in each group. Perm ission from t he et hical com m it t ee w as taken. The purpose of t he st udy was explained t o all t he subject s w ho w ere t aking part in t he study.

Init ial evaluat ion of t heir pain pr o f ile w as measured using visual analogue scale and Hand Grip st rengt h by Dynam om et er. Each subject holds the dynamometer in the hand to be t ested, and t he subject s w ere asked t o squeeze t he handle grip of dynam om et er w it h maximum effort w hich is maint ained for about 5 seconds. Pain i nt en si t y i s m easu red usi n g V i su al Analogue Scale (VAS), t he subject s w ere asked t o mark t heir intensity of pain on a 10 centimetre long line marked w it h numbers 0-10 w here 0 indicat ed no pain and 10 maximum pain.

Intervention: Aft er t he init ial measurement s, t he subj ect s ar e r andom ly assigned int o 2 groups.

Fig. 1: Show ing t he flow chard for m et hodology.

Group A:

M ulliga n M o b iliza t io n w it h M o ve m e nt :

M obilizat ion w it h movement is performed w it h subject lying in supine posit ion having t heir elbow ext ended and forearm pronat ed. The t herapist is st anding at side of subject t o be t r eat ed. Pl acing t he belt ar oun d t her apist shoulder and subject ’s forear m , belt placed closed t o elbow joint line. The t herapist performs t he lat eral glide of forearm using belt sust aining t his glide, subject s are asked t o perform fist w it hout pain. M obilizat ions w it h m ovem ent performed 10 t imes in one set and 3 set s w ere given per session. Total Treat ment includes 12 sessions.

Group B:

Supervised Exercise Programm e: Supervised Exercise programme includes st at ic st ret ching of t he Ext ensor Carpi Radialis Brevis follow ed b y eccen t r ic st r en gt h en in g of t he w r i st ext ensors. St at ic st ret ching w as performed in t he seat ed posit ion w it h elbow ext ension, forearm pronat ion, and w rist flexion w it h ulnar deviat ion. St ret ch force w as applied according t o t he pat ient t olerance and t he posit ion w as held for durat ion of 30–45 seconds performed 3 t im es before and 3 t imes aft er t he eccent ric exercise port ion of t he t reat ment for a t ot al of 6 repet it ions. There w as a 30-second rest int erval bet w een each bout s of st ret ching.

Eccent ric strengt hening exercise was performed in t he seat ed posit ion wit h full elbow ext ension, f or ear m p r o n at i o n , an d m axi m u m w r ist extension. From t his posit ion, t he pat ient slow ly low ered w rist int o flexion for a count of 30, using t he cont ra lat eral hand t o ret urn t he w rist t o maximum ext ension. Pat ient s w ere inst ruct ed t o con t in ue t h e exer cise even w hen t h ey experience m ild discom fort and t o st op t he exer cise if t he pain w or sens and becom es disabling. The load w as increased using free w eights based on t he pat ients 10 RM (Repet it ion M aximum).

RESULTS

Data Analysis

Table 1: Dist ri but ion of st udy sam ples according t o age (in year s) in group A and group B.

Age group %

20-35 36.66%

36-50 40%

51-65 23.33%

20-35 56.66%

36-50 33.33%

51-65 10%

Group A

Group B

Graph 1A

Graph 1B

Table 2: Dist r ibut ion of st udy sam ples according t o m ale and fem ale in group A and group B.

M ale 14 46.66 10 33.33 24 40

Female 16 53.33 20 66.66 36 60

Total 30 100 30 100 60 100

Group B

GENDER Group A % % Total %

The above t able represent s t he gender dist ribu-t ion of subjecribu-t s. 40% male and 60% female in Group A and Group B respect ively.

Graph 2A

Graph 2B

Table 3: Pain Relief (M ean changes in VAS: Hand grip st rengt h (M ean changes in HGD Scor e).

M ean SD M ean SD

Groups Pre Treatment

0.03 6.76 0.76 3.1 0.75 0.02

23.88 3.73 55.37867 6.09 0.01

Significant Group A

Group B VAS

HGD

VAS

HGD

6.8 0.76 3.8 0.75 0.04

23.32233 3.73 49.69367 6.09

Inference p value Post Treatment

Significant

Significant

Significant

Graph 3A: Pre and Post Vas w it hin Group A.

Graph 3B: Pr e and Post HGD w it hin Group A.

ISSN 2321-1822 Graph 4B: Pre and Post VAS w it hin Group B.

Table 4: Post VASs M ean Bet w een Group A and Group B.

GROUP M EAN OF

POST VAS SD P VALUE INFERENCE

A 3.1 0.75

B 3.8 0.76 0.01 Significant

Graph 5: Post VASs M ean Betw een Group A and Group B.

Table 5: Post HGD M ean Bet w een Group A and Group B.

GROUP M EAN OF

POST HGD SD P VALUE INFERENCE

A 53.94 6.09

B 49.69 3.73 0.01 Significant

Graph 6: HGD Bet w een Group A and Group B.

DISCUSSION

Hand grip st rengt h (HGS) w as measured by t he means of hand grip dynamometer. For t his HGS score w as not ed on t he first day and t he last day (Aft er 4 w eeks) of t he t reat ment for all t he subject s. How ever t he difference bet w een t he 2 sco r es w as con si der ed f o r an aly si s o f difference bet w een t he t w o groups.

Bet w een group post test analysis of VAS P-value is <0.01, and HGD is <0.02.

The st udy focused in comparing t he effect ive-ness of M WM and supervised exercise program in pat ient s w it h t ennis elbow. There w as a significant change in t erms of reducing pain and i ncr easi ng h an d gr i p st r en gt h in Gr ou p A compared t o group B.

The result of t his st udy demonst rat ed t hat bot h mulligan mobilisat ion w it h movement (Group A) and the supervised exercise program t reat ment (Gr o up B) gr o u ps exp er i enced sign i f i can t improvements in pain and grip st rength following 4 w eeks t r eat m ent sessions. The m ulligan mobilisation w it h movement group experienced great er out comes for all variables in comparison t o t hose receiving supervised exercise program t reat ment . The report ed success of m ulligan mobilisat ion w it h movement program in t his st udy is consist ent .

A Paungmali (2004) showed that M WM produces sensory input sufficient t o recruit and act ivat e descending pain inhibit ory syst ems t hat result in som e or all of t he pain relieving effect s. It p r od u ces h yp o algesic ef f ect s d u r i n g an d follow ing it s applicat ion, as w ell as sympat ho-excit at ory effect [8].

In a r ecent st udy by Anap DB et al [ 9] , 40 subject s w ere randomly assigned int o 2 groups. On e gr ou p w as gi v en M W M al on g w i t h convent ional physiot her apy and t he ot her received conventional physiotherapy alone. They concluded t hat M W M t reat m ent t echnique produced significant improvement in Pain free grip st rengt h combined w it h t he convent ional physiot herapy (t =5.45,p<0.01).

St asinopoulus et al. compared t he effect iveness of supervised exercise, Cyriax physiot herapy, and treatment with polychromat ic non-coherent light in managing tennis elbow. They concluded t hat sup er vi sed exer ci se con si st i n g o f st at i c st retching and eccent ric strengt hening produced t he largest effect in reducing pain and improving funct ion [2].

The early ret urn of funct ional st at us is very useful for a sport s person, as it w ill facilit at e his/ her ret urn t o sport s in less durat ion. This im provem ent in f unct ional st at us w ill also prevent disuse at rophy or m uscle w eakness result ing from less or no act ivit y due t o pain and

disabilit y caused by tennis elbow. It has been assumed t hat t he underlying mechanism of pain relief secondary t o frict ion massage may be due t o modulation of pain impulses at t he spinal cord level [10,11].

Kochar and Dogra (2002) [12], w ho concluded t hat M WM and US group demonst rat ed a 97% improvement in VAS w hen compared w it h t he US and cont rol group. Furt hermore, t he result s are also consist ent w it h t hose of M iller (2000) [13] w ho also found t hat t he use of t he M WM for LE as t he primary modalit y for t he correct ion of “ po sit io nal f au lt ” o f t h e elb ow j o in t is effect ive in relieving pain.

Result s highl ight ed t he ef f ect of M ulli gan t echniques in increasing funct ional act ivit ies, as t h e exper i m en t al gr o u p sh o w ed m o r e improvem ent of PRTEE (pat ient rat ed t ennis elbow evaluat ion) t han t he cont rol group. Our result s are, thus, in agreement w ith the of Geet u and Deepak (2008) [14] w ho found t hat M WM led t o st at ist ically significant improvement in funct ional performance.

Alt hough a home exercise programme can be performed any t im e during t he day w it hout requiring supervision from a t herapist , clinical experience has show n t hat pat ient s f ail t o com ply w it h t he regim en of hom e exercise programmes. It is believed t hat t his problem can be really solved by t he supervised exercise pr ogram m es perform ed in a clinical set t ing under t he supervision of a t herapist .

Eccent ric and st at ic st ret ching exercises appear t o r ed uce t he pain and im p r ove f un ct io n, reversing t he pat hology of lat eral epicondylit is [15,6] as support ed by experiment al st udies on anim als [17]. The w ay t hat eccent ric t raining achieves t he goals remains uncert ain, as t here is a lack of good qualit y evidence t o confirm t hat physiological effect s t ranslat e int o clinically meaningful out comes and vice versa.

Lim it at ions of t his st udy are t hat t he group assignment was not done randomly, No follow-up dat a w as collect ed; t herefore, t he long-t erm effect s of t he int ervent ions in t he present st udy remain unknow n and Absence of t rue cont rol group affect s t he internal validit y of t he st udy.

Further Recommendation: The st udy can be conduct ed w it h larger sample size, longer

durat ion and w it h a cont rol group.

CONCLUSION

This st udy concluded t hat a 4 w eeks t reat ment programme using bot h M WM and supervised exercise program are effect ive in reducing pain and increasing hand grip st rengt h in pat ient s w it h lat eral epicondylit is.

How ev er t her e i s a si gn i f ican t ch an ge i n reducing pain and increasing hand grip st rengt h in group A (M WM ) t han group B (supervised exercise program). Hence w e reject t he null hypot hesis. The groups t hat performed mulligan m ob il isat io n w i t h m ov em en t f o r 4 w eek s show ed significant ly great er improvement in r educt ion of pain and incr easing hand grip st rengt h t han t he supervised exercise program.

Conflicts of interest: None REFERENCES

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How to cite this article:

Hafizur Rahman, Pilladi A Chat urvedi, Pat chava Apparao, Pilladi R Srit hulasi. EFFECTIVENESS OF M ULLIGAN M OBILISATION WITH M OVEM ENT COM -PARED TO SUPERVISED EXERCISE PROGRAM IN SUBJECTS WITH LATERAL EPICONDYLITIS. Int J Physiot her Res 2016;4(2):1394-1400. DOI: 10.16965/ ijpr.2016.104

Hafizur Rahm an et al. EFFECTIVENESS OF M ULLIGAN M OBILISATION WITH M OVEM ENT COM PARED TO SUPERVISED EXERCISE PROGRAM IN SUBJECTS W ITH LATERAL EPICONDYLITIS.

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[11]. R. de Bruijn. Deep t r ansverse f rict ion; it s analgesic eff ect . Int ernat ional Journal of Sport s M edicine. 1984;5:35–36.

[12]. M oneet Kochhar, Ankit Dogra. Effect iveness of a specific physiot herapy regim en on pat ient s w it h t ennis elbow. Physiot herapy. 2002; 88(6):333-341.

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