Galley Proof 9/05/2019; 16:48 File: bmr–1-bmr181135.tex; BOKCTP/xjm p.

Journal of Back and Musculoskeletal Rehabilitation -1 (2019) 1–9 1

DOI 10.3233/BMR-181135
IOS Press

The effects of Mulligan’s mobilization with

movement technique in patients with lateral
epicondylitis
Aycan Cakmak Reyhana,∗ , Dilsad Sindelb and Elif Elcin Derelia
a
Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Istanbul Bilgi University, Turkey
b
Department of Physical Medicine and Rehabilitation, Istanbul Faculty of Medicine, Istanbul University, Turkey

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Abstract.

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BACKGROUND: Lateral epicondylitis (LE) is a common problem of the arm. Mulligan has proposed the use of mobilization
with movement for LE.
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OBJECTIVES: To investigate the effects of Mulligan’s mobilization with movement (MWM) in LE.
METHODS: Forty patients were included in the study and randomly assigned to group 1 (n = 20), who received MWM,
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exercise and cold therapy, or group 2 (n = 20), who received exercise and cold therapy. The sessions were conducted five times a
week for two weeks. All measures were conducted at baseline, after treatment, at 1st and 3rd months follow-ups. Mann-Whitney
U test, a visual analogue scale (VAS) for pain intensity, Patient-rated Tennis Elbow Evaluation (PRTEE) Questionnaire for pain
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intensity and functional disability and a dynamometer for hand grip strength were applied.
RESULTS: VAS activity pain significantly decreased in group 1 after treatment (p = 0.001), at the 1st (p < 0.001) and 3rd
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months (p = 0.040). There was a significant decrease in VAS night pain in group 1 (p = 0.024), and a significant increase in
pain-free grip strength (p = 0.002) after treatment. PRTEE-Pain scores decreased in group 1 after treatment (p < 0.001), 1st (p <
0.001) and 3rd months (p = 0.001).
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CONCLUSIONS: MWM plus exercise and cold therapy is a safe and effective alternative with positive effects on elbow pain,
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functional capacity, and pain-free, maximum grip strength.

Keywords: Lateral epicondylitis, Mulligan’s mobilization technique, exercise, cold therapy

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1 Nomenclature VAS Visual analogue scale

3
PRTEE Patient-rated (Tennis) Elbow Evaluation
LE Lateral epicondylitis
US Therapeutic ultrasound
1. Introduction 4
LDL Low-dose laser
MWM Mobilization with movement
2 Lateral epicondylitis (LE), also known as lateral 5
PNF Proprioceptive neuromuscular
elbow tendinopathy or tennis elbow, is among mus- 6
facilitation
culoskeletal injuries, which are the leading causes 7
BT Before treatment
of elbow pain [1,2]. Researchers have proposed over 8
AT After treatment
40 methods for the treatment of LE. However, an ideal 9

treatment method has not yet been defined. Therefore, 10

∗ Corresponding
diagnosis and treatment of LE is still controversial [3]. 11
author: Aycan Cakmak Reyhan, Department of
Physiotherapy and Rehabilitation, Faculty of Health Sciences, Istan-
While some studies advocate the effectiveness of ther- 12

bul Bilgi University, Turkey. Tel.: +90 5336483274; E-mail: aycan. apeutic ultrasound (US) [3,4], others report low-dose 13

cakmak@bilgi.edu.tr. laser (LDL) therapy to be effective [4]. Although there 14

ISSN 1053-8127/19/$35.00
c 2019 – IOS Press and the authors. All rights reserved
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2 A.C. Reyhan et al. / The effects of Mulligan’s MWM technique in patients with LE

15 are studies in the literature implementing methods such 2.2. Study design 64

16 as electrotherapy, manipulation and massage, the re-

17 ported evidence is insufficient [4,6]. The minimum number of subjects required for each 65

18 The Mulligan Concept is a new manual therapy group was 13 in order to make a significant difference 66

19 approach. The mobilization with movement (MWM) for 1.40 unit VAS value regarding VAS pain at rest be- 67

20 technique, which is unique to the Mulligan Concept, tween the two groups, and with type I error = 0.05, test 68
21 can be safely and effectively applied for diseases of power was calculated as 0.80 for the current study. 69
22 both the musculoskeletal and nervous system. It fea- A total of 40 subjects were randomized into two 70
23 tures significant differences from other approaches re- groups after choosing the closed envelopes including 71
24 garding the methods and codes of practice. The Mul- the numbers that were randomly generated via a com- 72
25 ligan Concept may also be defined as a combination puter based system and assigned for the each group. 73
26 of passive mobilization concepts which is known as This allocation process was performed by a therapist 74
27 Kaltenborn, Maitland, Cyriax, Butler and with active who was not included in the treatment sessions (Fig. 1). 75
28 mobilization techniques known as Pilates, propriocep- Group 1 (n = 20) was treated with the Mulligan’s 76
29 tive neuromuscular facilitation (PNF) and kinetic con-
MWM technique, exercise and ice therapy, and group 77

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30 trol. The privilege of the Mulligan Concept is enabling
2 (n = 20) was treated with exercise and ice therapy. 78
31 the acquisition of functional abilities within a short
Subjects were evaluated before and after the treatment 79
time but for the long-term. As the major goal of the

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32
(BT and AT) and in the 1st and 3rd months following 80
33 Mulligan Concept is functional restoration, the tech-
the treatment and were followed up for 3 months.

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81
34 niques are applied in functional positions in order to
35 improve patients’ daily function [7,10]. This study was
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2.3. Treatment procedures 82
36 planned based on our hypothesis that when the MWM
37 technique is added to an exercise program, a signifi-
The MWM technique (lateral glide) (see Fig. 1) was
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38 cantly higher success can be achieved in treatment of 83

39 patients with LE. To the best of our knowledge, no sim- applied to the patients by a physiotherapist who man- 84

ilar study can be found in the literature. aged the therapy sessions in group 1, using hands with
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40 85

the patients in the supine position. First, the angle for 86

pain-free application was determined for each patient. 87

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41 2. Methods The distal humerus was fixed by the physiotherapist 88

holding it down with their web space positioned just 89

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42 2.1. Subjects above the elbow joint on the lateral humeral condyle. 90

The patients were requested to repeat the elbow joint 91

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43 This study was conducted at the Istanbul University, movement 10 times. The same procedure was applied 92
44 School of Physical Therapy and Rehabilitation on 40
for pain control as three sets, each set involving 10 rep- 93
patients with the diagnosis of LE who were referred
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45
etition of the exercise. The interval between the sets 94
46 by the outpatient clinics affiliated with the Department
was 15 to 20 seconds and the interval between the 95
47 of Physical Medicine and Rehabilitation and the De-
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repetitions within each set was 30 seconds. The pa- 96

48 partment of Orthopedics and Traumatology at Istan-
49 bul University Faculty of Medicine. The study was ap- tients were trained about the self-mobilization tech- 97

50 proved by the Istanbul University Faculty of Medicine niques (see Fig. 2) and asked to perform the 10 rep- 98

51 Ethics Committee. Patients with chronic LE diagnosis etition exercises every two hours in a day [8,11,13]. 99

52 (for > 6 weeks) whose pain reduced in the first MWM The exercise program prepared for group 1 was as 100

53 session who did not have a dysfunction related to the follows: 1. stretching the wrist extensors (30 sec of 101

54 shoulder, neck or thoracic region, who did not receive stretching followed by 30 sec of rest x to be repeated 102

55 any therapy within the last six months, and those who for three times, the elbow is extended and the forearm 103

56 were willing and suitable for continuing the program is pronated), 2. stretching the wrist flexor (30 sec of 104

57 were included in the study. Exclusion criteria were di- stretching followed by 30 sec of rest x to be repeated 105

58 agnosis of bilateral LE, major trauma (such as frac- for three times, the elbow is extended and the forearm 106

59 ture), history of tendon or ligament tear, > 3 cortisone is pronated), 3. stretching the wrist extensors (30 sec 107

60 injections in the last six months, LE surgery within the of stretching followed by 30 sec of rest x to be re- 108

61 last two months, history of rheumatic diseases, neuro- peated for three times, the elbow is extended and the 109

62 logical disorders such as stroke or brain trauma, and forearm is pronated), 4. flexing and extending the wrist 110

63 diagnosis of entrapment neuropathy. (3 sets with 20 repetitions with 1 minute rest between 111
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A.C. Reyhan et al. / The effects of Mulligan’s MWM technique in patients with LE 3

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Fig. 1. Flow diagram of the study.

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112 sets, the elbow is supported on the bed, the elbows are 3rd months following the treatment. The visual ana- 136

113 fully extended, starts with the forearm pronated and logue scale (VAS) (resting, movement, night) for pain 137
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114 the wrist become to be at full extension and full flex- evaluation; dynamometer for grip strength (painless 138

ion), 5. active elbow flexion and extension (20 repeti- and maximum) (Baseline hydraulic hand dynamome-
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115 139

116 tions), 6. isometric wrist extension (20 sec/20 repeti- ter, Irvington, NY, USA); the Patient-rated (Tennis) El- 140

117 tions), 7. isometric handgrip (tennis ball, 20 sec/20 rep- bow Evaluation (PRTEE) [16,17] for the assessment 141
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118 etitions while the elbow at full extension and forearm of functional status; and lastly, the Global Assess- 142

119 in pronation, the wrist in extension) [12,14]. Group ment [18,19] for an objective assessment of the pa- 143
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120 2 received the same exercise program. Additionally, tient’s status were employed in the current study. 144

121 cold application was suggested to both groups in or-

122 der to minimize potential symptomatic pain caused by 2.4. Outcome measures 145

123 stretching and strengthening exercises.

124 The patients were treated 5 days per week for The results obtained from VAS, dynamometer, 146

125 2 weeks. They were suggested to repeat the exercises PRTEE and Global Assessment were utilized in this 147

126 they had learned at home. The subjects in group 1 were study. To analyze pain level at rest, during move- 148

127 asked to implement the self-mobilization techniques ment and at night, we used a 10 cm horizontal VAS 149

128 every two hours with 10 repetitions. All patients re- line [7,9]. PRTEE is a 15 item questionnaire created 150

129 ceived 15-minute cold application on the elbow joint to investigate pain and weakness of the forearm in in- 151

130 after the exercise. Additionally, both groups were in- dividuals with LE [16,17]. This questionnaire has two 152

131 formed about the movements they should avoid dur- sub-categories: pain (PRTEE-P) and function (PRTEE- 153

132 ing treatment such as heavy lifting, knitting, handwrit- F). There are 10 questions in the PRTEE-P subcate- 154

133 ing, driving, using a screwdriver, opening a jar, wav- gory, which are scored from “0, no pain” to “10, the 155

134 ing the hand, and using a mouse [15]. All patients were worst pain that can be imagined”. In the PRTEE-F sub- 156

135 evaluated before and after treatment and in the 1st and 157 category, there are 10 questions; 6 questions are about
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4 A.C. Reyhan et al. / The effects of Mulligan’s MWM technique in patients with LE

Fig. 2. Comparison of the groups regarding the change in pain free grip strength after treatment and in the 1st and 3rd months of follow-up.

Table 1
158 specific activities and 4 questions are for daily activi- Comparison of pretreatment clinical and demographic features be-
159 ties. In the same way, the scoring is made on a 0–10 tween the groups

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160 scale: zero (0) means that the patient did not have any Characteristics Group 1 Group 2 p value
161 pain and ten (10) means that the patient had the worst mean ± SD mean ± SD
pain imaginable while performing an activity. At the

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162 Age (years), mean (SD) 43.40 ± 10.60 41.35 ± 9.39 0.521
163 end, three scores (i.e., total score, pain subscale score Duration of symptoms 4.05 ± 0.63 3.98 ± 0.91 0.763

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164 and function subscale score) are assessed on a scale VAS (pain at rest) 1.20 ± 1.01 1.60 ± 1.27 0.277
(months)
165 of 100, “0” being the best score and “100” being the VAS (pain during activity) 5.10 ± 1.52 5.20 ± 2.14
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166 worst score. The reliability and validity of the Turkish VAS (pain at night) 2.20 ± 1.40 2.85 ± 0.75 0.077
167 version has been verified [16]. Pain-free grip strength 21.79 ± 10.67 25.22 ± 8.93 0.278
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168 Grip strength (painless and maximum) was evalu- (kg)

Maximum grip strength 27.18 ± 10.02 30.15 ± 8.83 0.326
169 ated in kilogram using a dynamometer. Measurements (kg)
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170 were carried out while the patients were in the erect
171 sitting position with the shoulder abducted, the elbow and maximum grip strength, and PRTEE-P, PRTEE-F 195
in 90◦ flexion and forearm and the wrist in neutral
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172
and PRTEE-T scores. In-group comparisons regarding 196
173 position. The measurements were repeated bilaterally the baseline, post-treatment, 1st month and 3rd month 197
174 three times and the average result was recorded in kilo- scores, VAS (resting-activity-night) scores, PRTEE-F
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198
175 gram [20]. and Global Assessment scores were carried out us- 199
Global Assessment is a subjective measurement
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176
ing with the Friedman Variance Analysis. After detec- 200
177 method indicating how the patients benefitted from the tion of the parameters varying within the group, the 201
178 treatment and enables their self-evaluation. It is rated Wilcoxon test was applied in order to understand when
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202
179 on a 6-point scale: 1 = complete recovery, 2 = signif- the difference occurred (BT-AT, BT-1. month, BT-3. 203
180 icant recovery, 3 = mild recovery, 4 = no change, 5 month). In-group comparison of BT, AT, 1st month and 204
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181 = slight worsening, 6 = worse. The measurement was 3rd month painless and maximum grip strength and 205
182 applied to all subjects in control examinations in the PRTEE-P and PRTEE-T scores were analyzed using 206
183 1st and 3rd months of treatment [18,19]. the One-way Repeated Measures ANOVA. The change 207

in VAS (resting-activity-night), painless and maximum 208

184 2.5. Data analysis grip strength scores, PRTEE-P, PRTEE-F and PRTEE- 209

T scores in the 1st and 3rd months of treatment as com- 210

185 Study data was analyzed using the Statistical Pack- pared to BT was compared between the groups using 211
186 age for Social Sciences Software (SPSS 15.0, SPSS, the Mann-Whitney U test. The Pearson Chi-squared 212
187 Chicago, IL, USA) statistics program. A p value of test was performed to make comparisons between the 213
188 6 0.05 was considered statistically significant. Nom- groups regarding the results of Global Assessment. 214
189 inal variables in the study groups such as gender and
190 affected side were compared using the Fisher’s exact
191 test and the Chi-squared test with a 2 × 2 table. The 215 3. Results
192 Independent Samples T -test was applied for compar-
193 isons between the variables of age, duration of illness, 216 A total of 44 patients volunteered for the study.
baseline VAS (resting-activity-night) scores, painless 194
217 Four patients were excluded due to the diagnosis of
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A.C. Reyhan et al. / The effects of Mulligan’s MWM technique in patients with LE 5

Table 2
Comparison of pain-free grip strength scores between groups at baseline, after treatment, and in the first and third months of follow-up
Baseline After treatment First month Third month F p value
mean ± SD mean ± SD mean ± SD mean ± SD Baseline after treatment
Baseline first month
Baseline third month
Group 1 pain-free grip strength (kg) 24.47 ± 9.08 26.60 ± 8.85 28.20 ± 9.10 29.60 ± 8.85 6.66 0.000
0.000
0.000
Group 2 pain-free grip strength (kg) 25.44 ± 9,73 26.47 ± 9.58 27.20 ± 9.58 26.47 ± 9.58 50.72 0.000
0.000
0.000

Table 3
Comparisons of maximum grip strength between groups at baseline, after treatment, and in the first and third months of follow-up
Baseline After treatment First month Third month F p value
mean ± SD mean ± SD mean ± SD mean ± SD Baseline after treatment
Baseline first month

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Baseline third month
Group 1 maximum grip strength (kg) 26.45 ± 10.40 27.12 ± 10.05 29.47 ± 9.92 31.88 ± 9.79 34.51 p = 0.001

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p = 0.000
p = 0.000

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Group 2 maximum grip strength (kg) 30.15 ± 8.83 30.56 ± 8.64 31.10 ± 8.84 31.26 ± 8.88 19.29 p = 0.007
p = 0.000
fv p = 0.000
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218 fibromyalgia, elbow fracture and lateral epicondyle 3.3. Pain-free grip strength 245

219 steroid injection in the previous month and lack of

continuity in treatment, respectively. At the end, 40 Figure 2 indicates the comparison of the groups
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220 246

221 patients could complete all sessions of the treatment. regarding the change in pain-free grip strength after 247

222 The average age of the patients participating in the treatment and in the first and third months of follow- 248
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223 study was 43.40 years (standard deviation (SD) 10.60 up as compared to the baseline. When a comparison 249
224 in group 1 and 41.35 years (SD) 9.39 in group 2). There was made between the baseline and post-treatment grip 250
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225 were 15 women and 5 men in group 1 and 18 women strength in group 1, it was seen that pain-free grip 251
226 and 2 men in group 2. Table 1 shows that the groups strength of the patients increased significantly and the
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252
227 were similar with regards to clinical and demographi- amount of improvement was superior to that of group 253
228 cal characteristics before treatment. 2 (p 6 0.05). 254
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229 3.1. Pain

3.4. PRTEE score 255
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230 In both groups, patients’ VAS (resting-activity-night)

231 scores decreased in the 1st and 3rd months as com- The groups were found to be similar regarding their 256

232 pared to pre-treatment and that decrease was found to baseline PRTEE-P, PRTEE-F, and PRTEE-T scores 257

233 be statistically significant (p = 0.000). All changes in (p > 0.005). A statistically significant decrease was 258

234 VAS scores of both groups were statistically significant observed in the mean PRTEE-P, PRTEE-F, PRTEE-T 259

235 (p 6 0.05). scores of both groups after treatment as compared to 260

the baseline (p = 0.000). When the groups were com- 261

236 3.2. Grip strength
pared regarding the baseline-after treatment, baseline- 262

237 As shown in Table 2, pain free-grip strength in both 1st month of follow-up and baseline-3rd month of 263

238 groups increased significantly after treatment, and in follow up PRTEE-P, PRTEE-F and PRTEE-T scores, 264

the 1st and 3rd months of follow-up in comparison to 239 group 1 was found to be superior to group 2 (p 6 0.05). 265

the baseline values (p 6 0.05). Table 3 indicates that 240

maximum grip strength in both groups showed a sig- 266

241 3.5. Global assessment
nificant increase after treatment and in the 1st and 3rd 242

months of follow-up in comparison with the baseline 267

243 When the Global Assessment scores of the patients
(p 6 0.05). 244
268 after treatment were considered, the number of pa-
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6 A.C. Reyhan et al. / The effects of Mulligan’s MWM technique in patients with LE

Table 4
Comparison of the amount of change in PRTEE-P, PRTEE-F and PRTEE-T scores between groups after
treatment compared to baseline, first and third month
Group 1 Group 2 p value
Baseline after treatment PRTEE-P score PRTEE-P score 0.000
Med. (min.-max.) −26.50 ((−54.00)–(−6.00)) −7.50 ((−17.00)–(−4.00)) 0.000
PRTEE-F score PRTEE-F score 0.000
−23.00 ((−44.00)–(−5.00)) −5.50 ((−15.00)–(−1.00))
PRTEE-T score PRTEE-T score
−23.75 ((−49.00)–(−6.50)) −6.00 ((−14.50)–(−4.00))
Baseline 1st month PRTEE-P score PRTEE-P score 0.000
Med. (min.-max.) −31.00 ((−61.00)–(−15.00)) −14.00 ((−27.00)–(−6.00)) 0.000
PRTEE-F score PRTEE-F score 0.000
−24.00 ((−49.00)–(−11.00)) −11.00 ((−25.00)–(−4.00))
PRTEE-T score PRTEE-T score
−26.25 ((−53.50)–(−13.00)) −11.75 ((−25.00)–(−5.00))
Baseline 3rd month PRTEE-P score PRTEE-P score 0.001
Med. (min.-max.) −34.50 ((−66.00)–(−16.00)) −18.00 ((−42.00)–(−1.12)) 0.002
PRTEE-F score PRTEE-F score 0.001

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−25.00 ((−52.00)–(−13.00)) −15.00 ((−35.00)–(−10.00))
PRTEE-T score PRTEE-T score

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−15.00 ((−35.00)–(−10.00)) −16.50 ((−38.00)–(−12.00))

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269 tients expressing significant recovery in group 1 was improving functional status. Various treatment meth- 299

20 while the number of patients expressing significant ods are used for the treatment of LE, however, since
270
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271 recovery in group 2 was 6, and of those expressing the mechanisms of action of these methods are not fast 301

272 mild recovery was 13 (p = 0.000). In the 1st month of enough and permanent, patients’ complaints may re-
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302

273 follow-up, 8 patients noted complete recovery, and 12 cur in the long-term, which indicates the insufficiency 303

274 patients stated significant recovery in group 1 whereas of patients’ therapy [5,14]. In relevant studies in the 304
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275 17 patients expressed significant recovery, and 3 pa- literature, the aim was to decrease pain and improve 305
276 tients noted mild recovery in group 2 (p = 0.003). At functions of the joint. In this regard, over 40 different 306
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277 the end of the 3rd month, 15 patients mentioned com- treatment methods have been defined for the treatment 307
278 plete recovery, and 5 patients expressed significant re- of LE; nevertheless, there is no sufficient scientific ev- 308
covery in group 1 while 19 patients stated significant
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279
idence indicating which method provides optimal re- 309
280 recovery, and 1 patient noted mild recovery in group 2 covery [6,21,22]. A study performed in 2010 argued 310
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281 (p = 0.000). that it is not possible to specify an optimal treatment 311

282 In order to determine whether any applied treatment method for LE due to the characteristics of the dis- 312
method showed any superiority to the other one, each
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283
ease, variety of pathophysiological mechanisms, weak- 313
284 group’s measurement results obtained after treatment ness of methodological considerations in relevant stud- 314
285 and in the first and third months of follow-up were
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ies, and the presence of various factors that may affect 315
286 subtracted from the baseline values, and a compari-
the outcomes [23]. However, it is known that mobiliza- 316
287 son was made between the groups regarding the dif-
tion techniques have a positive effect on reducing pain 317
288 ferences obtained after subtraction. When the base-
within a short period especially in LE patients in clin- 318
289 line VAS scores of the groups were compared with the
ical practice [24]. Small sample sizes in trials apply- 319
290 VAS scores (resting-activity-night) after treatment and
ing mobilization techniques, trials limited with a single 320
291 in the first and third months of follow-up, the change in
292 the VAS scores of both groups was found to be statis- session, short follow-up period also contribute to low 321

293 tically significant (p 6 0.05). Additionally, the change quality rating of the body of evidence for reported out- 322

294 in the mean VAS score (night) from baseline to after comes which hinder precise conclusions regarding the 323

295 treatment was statistically significant (p 6 0.05). treatment of the disease. The technique was developed 324

in the 1980s, but it has only gained popularity within 325

the last decade. 326

4. Discussion 327
296 VAS is a common method to evaluate pain [25,26].
328 The VAS scores (resting-activity-night) showed a sig-
The present study investigated the effectiveness of 329
297 nificant decrease after treatment and in the first and
the MWM technique in minimizing elbow pain and 298
330 third months of follow-up as compared to baseline val-
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A.C. Reyhan et al. / The effects of Mulligan’s MWM technique in patients with LE 7

331 ues, in both group. VAS score changes of the groups number of studies of adequate methodological qual- 382

332 were compared from baseline to after treatment, base- ity indicating the positive effects of elbow manipu- 383

333 line to the 1st month and baseline to the 3rd month in lative therapy techniques [25]. In a study comparing 384

334 order to determine in which group the positive changes the Cyriax manipulation method with an exercise pro- 385

335 in the VAS scores were superior. When the changes gram, the researchers observed reduction in pain and 386

336 in VAS (during activity) scores were compared, the improvement in painless grip strength as well as func- 387

337 changes in group 1 were significantly higher than in tional status as reported in the current study [26]. In a 388

338 group 2. However, there was no significant difference review carried out to investigate the effectiveness ma- 389

339 between the groups except for VAS (at night) from nipulative therapies in the treatment of LE. According 390

340 baseline to after treatment when the changes in VAS to that review, the painless grip strength in groups re- 391

341 (resting and at night) scores from baseline to after treat- ceiving mobilization techniques improved significantly 392

342 ment, baseline to the 1st month and baseline to the 3rd as compared to the placebo and control groups [30]. 393

343 month. The changes in VAS (during activity) scores in Svernlöv and Adolfsson made a comparison between 394

344 the MWM-receiving group were superior to those in stretching and eccentric exercise programs and re- 395

345 the exercise group which may be because of the fact ported a statistically significant improvement in pain 396

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346 that MWM targets to eliminate pain associated with and grip strength in both groups however superior re- 397

347 the positional defect and facilitate painless functioning sults in favor of eccentric exercise program [31]. 398

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348 during daily life activities. Immediate reduction was There is strong evidence suggesting that exercise 399

observed in mobility-associated pain in the MWM- decreases pain level in studies involving only exer-

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349 400

350 treated patients. The continuation of the decrease in cise programs, however, the evidence regarding the
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351 pain in both groups at the 1st and 3rd months of effects on the advanced grip strength are not suffi- 402

352 follow-up may be due to the fact that the patients per- cient [6,25,32]. 403

formed exercise during the later periods. The MWM Although the treatment period was limited to two
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353 404

354 technique has been reported to be effective in reduc- weeks in our study, we observed a significant increase 405

355 ing pain [8,24]. A study reported significant reduction in painless grip strength. This can be explained by the 406
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356 in VAS scores via a home exercise program involving fact that the exercise practices in the study are per- 407

357 stretching and strengthening for LE treatment [27]. Ef- formed every day in the clinic under the supervision of 408
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358 fectiveness of stretching exercises in decreasing pain a physiotherapist, and thus, patients showed high par- 409

359 level of LE patients were stated earlier [14,28]. ticipation and harmony in the exercises. The painless 410
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360 A 12-week pilot study examining the efficiency of grip strength of LE patients was reported to be a more 411

361 therapies combining manipulation and exercise thera- sensitive parameter to the MWM application [11]. In 412
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362 pies in the treatment of chronic LE indicated that such the present study, the maximum grip strength increased 413

363 combined therapies can reduce pain and improve func- after treatment and in the first and third months of fol- 414
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364 tional status in LE patients [29]. low up, but the increase was not significant. 415

365 Pain-free grip strength of both groups significantly In this study, the PRTEE-P, PRTEE-F and PRTEE- 416

improved after treatment and in the 1st and 3rd months

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366 T scores in both groups showed a significant improve- 417

367 as compared to the baseline. Regarding the changes in ment after treatment and in the 1st and 3rd months when 418

368 pain-free grip strength scores of the groups, only the compared with the baseline scores. In the published 419

369 change from baseline to after treatment was found to literature [27,29], PRTEE-P, PRTEE-F and PRTEE-T 420

370 be significant in favor of group 1. The high increase in scores were reported to significantly decrease as com- 421

371 grip strength in group 1 can be explained by the fact pared to baseline. When the changes in the PRTEE- 422

372 that the mobilization technique applied in this group P, PRTEE-F and PRTEE-T scores was compared, the 423

373 provided higher reduction in pain. There are studies in amount of changes in the PRTEE-P, PRTEE-F and 424

374 the literature suggesting that the MWM technique im- PRTEE-T scores was significantly higher in group 1. 425

375 proves grip strength as a result of its favorable effects Such a change in PRTEE scores must have resulted 426

376 on pain. Nevertheless, as these studies involve single from the use of the MWM technique in group 1. It has 427

377 session therapies and did not include long-term out- been reported in the literature that 10-week combina- 428

comes, scientific evidences are insufficient for precise 378

429 tion therapies involving mobilization and exercise for
conclusions [11,21]. 379
430 the treatment of chronic LE patients had significantly
A systematic review analyzing treatment methods 380
431 positive effects on pain and functional status; however,
used in LE patients stated that there was no sufficient 381
432 no significant change was observed during the three
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8 A.C. Reyhan et al. / The effects of Mulligan’s MWM technique in patients with LE

433 weeks of follow-up [33]. In a randomized study com- 5. Conclusion 484

434 paring mobilization plus exercise with, corticosteroid

435 or wait-and-see therapies, functional status of all sub- It is not possible to point out a specific technique to 485

436 jects was evaluated using the PRTEE. As a result of the be superior to another or the applied mobilization tech- 486

437 study, positive improvements were reported in the mo- nique to have yielded more precise outcomes in LE pa- 487

438 bilization plus exercise groups considering pain, pain- tients or to reach a general conclusion. According to 488

439 free grip strength and PRTEE scores [21]. Similar to our observations, the decrease in pain level at the end 489

440 that study, we observed positive advancements in pain, of the sessions was higher in cases treated with MWM. 490
441 pain-free grip strength and PRTEE scores with appli- Even though the outcomes of the treatment are of clin- 491
442 cation of MWM technique along with exercise. Favor- ical importance, they are not sufficient. It is necessary 492
443 able improvements were observed in both groups, and to carry out well-designed further studies that can ob- 493
444 the change from baseline to the 1st and 3rd months of jectively measure the use and efficacy of the MWM 494
445 follow-up was found to be significant in either group technique in the treatment of LE cases and can present 495
446 for Global Assessment. All patients in the mobilization results and recommendation on the intensity (number 496
447 groups stated significant recovery at the end of treat- of sessions) and duration (number of repetitions) of 497
ment whereas only six patients expressed significant

on
448
the treatment. Due to the absence of a placebo/control 498
449 recovery in the exercise group. These changes after group in the study and limited number of study sub- 499
450 treatment are noteworthy. However, it is not possible

si
jects, we could not make a general interpretation from 500
451 to arrive at a definite judgment due to the fact that no the outcomes of the study. However, beneficial devel- 501

er
452 MWM application was performed after the two-week
opments were achieved in the treatment of LE with the 502
453 treatment period; it was not questioned whether the pa-
applied program, especially in reducing pain and im-
fv 503
454 tients continued exercises or self-mobilization plus ex-
proving functional status besides, the treatment did not 504
455 ercise practices; it is not known if the reported changes
bear any adverse effects.
oo
505
456 had resulted from the developments in the natural
In conclusion, the MWM technique is a reliable and 506
457 course of the disease; and there was no placebo/control
group. Depending on the results of the Global Assess- useful method for the treatment of patients with LE. 507
pr

458

459 ment Questionnaire, patient satisfaction was higher in However, since mobilization techniques can be applied 508

460 the MWM-receiving group at the end of the treatment. by trained and experienced physiotherapists and physi- 509
ed

461 In a systematic review [6] exercise and mobilization cians only, it may not be possible to provide patients 510

462 techniques were found to have a favorable effect on re- with these practices in every clinic. For this reason, 511

treatment methods for LE should be decided consider-

ct

512
463 ducing pain, improving grip strength, ensuring global
464 improvement and advancing patient satisfaction, sim- ing patients’ preferences and availability/accessibility 513
rre

465 ilar to our results. That review [6] also resembles our of the treatment methods. 514

466 study regarding some of its limitations, such as the ab-

co

467 sence of a control or placebo group, treatment dura-

468 tion of 6 6 weeks, and follow-up duration of less than Conflict of interest 515

6 months. Since there is no precise opinion in the lit-

un

469

470 erature on the mobilization technique or exercise pro- The authors declare that there is no conflict of inter- 516

471 gram, the duration of the mobilization technique and est in this study. 517

472 the number of repetition applied in this study were

473 planned by us [9,10]. One of the most important rea-
474 sons for failure to reach consensus in this regard is the References 518

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