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Peripheral mobilizationswith movement

Linda ExelbyPhysiotherapy Department, Pinehill Hospital, NorthHerts, UK

CHAPTER CONTENTS

Introduction 129

Proposed mechanisms 130

Principles of treatment 130

Examination 131

Treatment 132

Conclusion 138

Postscript 141

129

The use of mobilizations with movement (MWM)for peripheral joints has been developed byMulligan. A mobilization is applied parallel or atright angles to the restricted joint movement. If theapplied mobilization achieves immediate improve-ment in the functional movement and abolishesthe pain, the treatment involves sustaining themobilization while the patient performs the activemovement repetitively. On re-assessment of the

joint function, the movement should remainimproved without the mobilization. Theories as towhy these techniques provide rapid improvementin pain-free range are proposed, and the generalprinciples of examination and treatment are out-lined. Specific clinical examples demonstrate howMWM can be used in isolation or integrated withother manual approaches to improve the quality of

joint intraarticular gliding and neurodynamics andthe facilitation of correct muscle recruitment.

Manual Therapy (1996) 1/1, 118126

INTRODUCTION

The use of Brian Mulligans treatment approachof combining passive mobilizations with activemovement in the management of musculoskele-

tal dysfunction has become widespread amongmanual physiotherapists in recent years. Thesetechniques were pioneered by Mulligan in NewZealand in the 1970s. Mulligan incorporatedKaltenborns (1989) principles of passive mobi-lization in this approach. The combination of anactive movement with simultaneous passiveaccessory mobilizations directed along thezygapophyseal joint planes was used initially inthe cervical spine. The techniques, performed inthe weight-bearing position, were later found to be


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equally effective when treating other areas of thespine. They are thought to achieve painless move-ment by restoring the reduced accessory glide.

Similar principles can be applied to the treat-ment of peripheral musculoskeletal disorders

and are termed MWM (Mulligan 1993, 1995).In essence, the limited painful physiologicalmovement is performed actively while thetherapist applies a sustained accessory glide atright angles or parallel to the joint. The aim is torestore a restricted, painful movement to apain-free and full range state. These principlesapply not only to painful active joint movements

but may be equally effective when thepresenting problem is pain on an isometriccontraction of muscle around a joint. The treat-

ment of choice would be a glide to the joint thatallows a pain-free isometric contraction. Thelatter was found to be particularly useful in thetreatment of tennis elbow when the contraction ofthe wrist extensor muscles was painful (Mulligan1995; Vicenzino & Wright 1995).

This article proposes possible reasons for therapid increase in pain-free movement, outlines theprinciples of treatment and illustrates via clinicalexamples how MWMs can be successfully utilizedin the peripheral joints.

PROPOSED MECHANISMS

Mulligan (1995) proposed that a minor positionalfault of the joint may occur following an injury orstrain, resulting in movement restrictions or pain.Lewit (1985) has shown that reduced joint mobil-ity can often be a result of a mechanical blockfrom inert structures within a joint. Joint afferent

discharge and optimal muscle recruitment areclosely linked (Stokes & Young 1984; Schaible &Grubb 1993). Joint movement can be reduced as aresult of reflex muscle splinting (Lewit 1985;Schaible & Grubb 1993; Taylor et al 1994), whichprevents further damage and reduces nociceptordischarge from the joint by holding it in themidrange position. It is suggested that treatmentdirected at the joint will have an effect on muscleactivity and vice versa. Experiments carried out byThabe (1986), Taylor et al (1994) and Murphy et al

(1995) using electromyography demonstrated thatjoint mobilization and manipulation had a reflexeffect on the activity of segmental muscles.Baxendale & Ferrell (1981) and Lundberg et al(1978) have shown that end-range passive move-

ments have a reflex inhibitory effect on the muscleacting over the joint. Gerrard and Matyas (1980),on the other hand, were unable to demonstrate anychanges in muscle activity with gentle mobiliza-tion techniques performed in the resistance-freepart of the range. This seems to indicate that toaffect muscle reflexly via joint afferents the mobi-lization technique must be performed into resist-ance. However, to achieve the desired effect onmuscle the mobilization must be performed intoresistance without excessive pain, which would

lead to an adverse effect on the segmental muscle(Cobb et al 1975). This can be demonstrated clini-cally when a mobilization performed too stronglyresults in protective muscle spasm.

MWMs provide a passive pain-free end-rangecorrective joint glide with an active movement.The combination of joint mobilization with activemovement may be responsible for the rapid returnof pain-free movement.

PRINCIPLES OF TREATMENT

Human joint surfaces are not fully congruent andphysiological movements occur as a combinationof a rotation and a glide (Williams 1995).The Kaltenborn and Mulligan concepts placeparticular emphasis on restoration of the glidecomponent of joint movement to facilitate fullpain-free range of movement. The various glidesused with MWMs can be determined by applying

Kaltenborns conceptual model (1989):

CONVEX/CONCAVE RULE

The direction of decreased joint gliding in ahypomobile joint, and thus appropriate treatment,can be deduced by this rule. When the convex

joint partner moves, the glide occurs in theopposite direction (Fig. 10.1); for example withshoulder abduction, a longitudinal caudad glideof the humerus occurs. With movement of a con-

130 GENERAL


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PERIPHERAL MOBILIZATIONS WITH MOVEMENT 131

cave joint partner, the glide occurs in the samedirection (Fig. 10.2); for example with knee flex-ion in non-weight-bearing, there is an anteropos-terior (AP) glide of the tibia on the femur.

TREATMENT PLANE RULE

A treatment plane passes through the joint and liesat a right angle to a concave joint partner(Fig. 10.3). Treatment is always applied parallel tothis treatment plane. Hinge joints often respondparticularly well to this glide, and this may bea first treatment choice (Mulligan 1995).

In summary the mobilization or glide can beapplied to a joint in two ways: (i) at right anglesto the joint movement, e.g. a medial or lateral

glide on the tibia when improving flexion andextension (Fig. 10.4). (ii) the appropriate glide can

be determined by applying the concave convexrule, e.g. an AP glide on the tibia when improvingknee flexion (Fig. 10.5).

If applying the above principles does notprovide sufficient improvement, a more recentdevelopment is to apply a sustained rotation tothe moving joint partner. The conjunct rotationnormally accompanying the physiological activemovement being treated may be the initial choiceof technique.

When pain with movement occurs in the carpalor tarsal bone regions, this pain can often beeliminated by gliding one bone relative toanother and combining this with the painfulmovement. With joint movements that involveadjacent long bones, such as at the wrist (radiusand ulna), the ankle (tibia and fibula), themetatarsals and the metacarpals, it is often neces-sary to glide one long bone relative to the other to

achieve pain-free movement.

EXAMINATION

The clinical examination of the musculoskeletaldysfunction aims to establish the diagnosis anddetermine the underlying causative factors ofthe patients symptoms so that the appropriatetreatment can be implemented. It is essentialto identify and analyse both the movement

Figure 10.1 When the convex joint partner moves theglide occurs in the opposite direction. (Reproduced withkind permission from Physiotherapy1995 81(12):726729.)

Fix. Mobil.

Figure 10.2 When the concave joint partner moves theglide occurs in the same direction. (Reproduced withkind permission from Physiotherapy1995 81(12):726729.)

Fix. Mobil.

Figure 10.3 A treatment plane passes through the jointand lies at 90to a concave joint partner. (Reproducedwith kind permission from Physiotherapy1995 81(12):726729).

ConvexMobil

.

glide


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that precipitated the injury and functional activi-ties that continue to exacerbate the symptoms.A knowledge of normal anatomy and biome-chanics is essential so that abnormalities can

be identified. Active and passive physiological

movements and accessory glides are performedso that their contribution to the movementdysfunction and symptoms can be analysed.For example, if a patient has a painful limitationof wrist extension, the passive physiologicaland accessory components of radiocarpaland midcarpal extension should be assessed aswell as the quality of the intercarpal accessorygliding. Taking the Kaltenborn (1989) concave/convex concept into consideration, if the radio-carpal joint is implicated the posteroanterior (PA)

glide of the proximal row of the carpal bonesmay be restricted. The testing of intercarpalgliding will specifically identify movementabnormalities between the proximal carpal bonesand the adjacent radius or triangular fibro-

cartilage complex.

TREATMENT

Once the aggravating movement has been identi-fied, an appropriate glide is chosen. The decisionto use a weight-bearing or non-weight-bearingrestricted movement will depend on the severity,irritability and nature of the condition (Maitland1991). For example MWMs would preferably be

132 GENERAL

Figure 10.4 Lateral glide on tibia with active flexion. (Reproduced with kind permission from Physiotherapy199581(12): 726729.)


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performed in non-weight bearing if a patient withtibiofemoral limitation of extension had a historyof recent trauma. Attempting to improve the samemovement in weight bearing at this stage mayfurther exacerbate the condition.

Once the glide has been chosen it must besustained throughout the physiological move-ment until the joint returns to its original startingposition. As the joint moves the therapist mustsustain the pressure, being constantly awareof minor alterations in the treatment plane.The mobilizations performed are always intoresistance but without pain. Immediate relief ofpain and improvement in range of movement areexpected. If this is not achieved the therapist maytry a different glide or a rotation.

If pain-free movement is not achieved whenperforming an MWM a complex movement can

be split into its various components andthe MWM performed with one of the restrictedsingle plane movements. For example, if a

patient has tibiofemoral pain when performinga half squat, this movement involves a combina-tion of flexion, adduction and medial rotation ofthe tibia. Medial rotation in flexion may berestricted and painful when tested in non-weight

bearing. Performing an MWM at right anglesor parallel to the joint line on active medialrotation in flexion in this non-weight-bearingposition may achieve greater improvement inpain-free range than an MWM performed withthe half squat. If pain relief is still not achieved

Figure 10.5 AP on the tibia with active flexion. (Reproduced with kind permission from Physiotherapy199581(12): 726729.)


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then another manual treatment approachshould be pursued. This clinical decision can bemade instantly.

Clinical experience suggests that while sus-taining the pain-free glide, the movement should

be repeated 10 times. After this set of MWMs thejoint function is re-assessed to see if the move-ment remains improved without the passivemobilization component. It may be necessary torepeat this set of 10 MWMs two to three times toensure prolonged correction of tracking and suf-ficient afferent input. However, the number ofrepetitions is dependent on joint irritability.Taping can also be applied to help maintain jointposition and increase proprioceptive awareness.Teaching the patient to perform their own

MWMs is also useful to prolong pain-free move-

ment. Clinically, therapists using these tech-niques have often reported more instantaneous,dramatic results than those obtained when usingrepeated accessory or physiological passivemobilizations alone.

The following examples will illustrate theclinical application of MWMs to peripheral joints.

ANKLE INJURIES

The talocrural joint is relatively congruent andthe gliding is usually successfully applied in thesagittal plane to improve plantar or dorsiflexion.The direction of the glide is determined using theconcave/convex concept. An acute ankle sprainwith limitation of dorsiflexion may be treated in

non-weight bearing with the patient lying on the

134 GENERAL

Figure 10.6 AP glide on the talus with active dorsiflexion.


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treatment table with the ankle joint placed levelwith the end of the bed. A pillow placed under theknee will take the gastrocnemius off stretch.A sustained AP glide to the talus is applied by thetherapist while the patient actively dorsiflexes

the ankle. If the range of pain-free movementimproves, the MWMs are repeated. Overpressuremay be applied if pain-free end range is achieved(Fig. 10.6).

Mulligan (1995) has found that applying anAP/cephalad glide to the distal end of the fibulawith active inversion often results in a dramaticimprovement of inversion. This suggests that thedysfunction is more likely to be a joint surfaceproblem rather than ligamentous in nature. In thiscase the talocrural or inferior tibiofibular joints are

implicated. If the gliding of the talus relative to themortise formed by the tibia and fibula doesnot result in pain-free inversion the inferiortibiofibular joint is implicated. There may be ahistory of previous inversion sprains and thepatient may present to physiotherapy in the acuteor chronic stage. Mulligan (1995) suggests thatwhen the foot is inverted beyond the expectedrange the fibula is wrenched forward on the tibiawith a positional fault occurring at the inferiortibiofibular joint. In that case the anteriortalofibular ligament may remain virtuallyundamaged. Taping applied to the fibula whilstthe therapist holds the AP glide can complementthe treatment effects (Fig. 10.7).

In the post-acute stage of ankle sprain theresidual functional disability may be an inabilityfor the patient to lower himself downstairs on theinjured ankle. MWMs can be performed with thismovement by applying a PA glide on the tibiaand fibula and a counter AP/cephalad glide on

the talus applied with the therapists web space,while the patient lowers himself down a step. Theuse of a belt to glide the tibia and fibula will helpthe therapist perform a stronger PA glide. If painrelief is not achieved with this, MWMs can beperformed on the inferior tibiofibular joint anAP/PA direction (Fig. 10.8). The normal move-ment of the fibula with dorsiflexion is a cephaladglide and lateral rotation. This movement can befacilitated by angling the AP on the fibula cor-rectly. It is important for the therapist to keep an

open mind: the direction of the MWM on the tibiaand fibula is that which enables the patient toachieve pain-free movement.

NEURAL INVOLVEMENT INSPRAINED ANKLES

Restoration of more normal articular bio-mechanics can permit greater mobility of theadjacent neural tissue (Butler 1991). This can also

be applied in the periphery using MWM whenadverse neurodynamics is a component of therestricted movement. By using MWMs theinterface is moved actively relative to neuraltissue in varying degrees of tension. The abovetechniques often improve signs and symptomsmore rapidly than passive joint movement alone.The reasons for this are as yet unclear;theories hypothesizing why MWMs may have anormalizing effect on neurodynamics arediscussed by Wilson (1994, 1995).

Figure 10.7 Corrective taping on fibula to maintain APglide.


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136 GENERAL

Figure 10.8 Gliding tibia and fibula with active end-range dorsiflexion. (Reproduced with kind permission fromPhysiotherapy 1995 81(12): 726729.)


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If, on assessment, inversion and plantarflexionare the symptomatic movements, and the symp-toms are worsened by the addition of passivestraight leg raise, the differential diagnosis indicatesabnormal superficial peroneal nerve dynamics.

Active inversion with a glide on the distal fibula inthis same position of tension may result in themovement becoming symptom-free. The approachis to use the symptom-reducing glide as the treat-ment with the leg positioned in the same degree ofstraight leg raise. If a glide performed on the fibu-la in this position of tension can eliminate symp-toms it is chosen as a treatment to be repeated withactive inversion (Fig. 10.9). The head of the fibulais a bony interface of the common peroneal nerveand a potential tension site (Butler 1991). Aglide on

the head of the fibula may also be considered as atreatment option because the injury may havealtered the position of the neck of the fibula relativeto the common peroneal nerve. If there is no imme-diate change in symptoms it suggests that the nerveinterface pathology may be soft tissue and moreappropriate treatment must be given.

SHOULDER PATHOLOGY

The integrity of the shoulder complex is reliantlargely on its ligamentous and muscularcomponents (Hawkins et al 1991). Incorrect

movement patterns can result in alterations ofa joints centre of rotation, which may causecumulative microtrauma to the joint and itssurrounding structures (Grant 1994). Commonmovement dysfunctions are frequently a result ofincorrect scapula and rotator cuff musculaturerecruitment, a resulting downward-facing glenoidcavity and anterior or superior migration of thehead of the humerus (Margery & Jones 1992; Jobe& Pink 1993).

Mobilizations with movements integrate well

with muscle imbalance correction of thesemovement abnormalities. If the patientsproblematic movement is abduction a correctiveAP or longitudinal caudad glide on the headof the humerus can be sustained while thepatient actively abducts the arm. The therapistsopposite hand fixates the scapula so that the

Figure 10.9 Glide of fibula with inversion in straight leg raise.


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glide of the humerus is relative to the scapula. Itis important to ensure that the AP glide is appliedat right angles to the plane of the glenohumeral

joint. The resulting movement must be pain-free.The patient can also be encouraged to activate

specific muscles. For example, once a patient hasbeen taught to activate a weak trapezius in isola-tion, the abduction MWM can be performedwhile encouraging correct recruitment of thismuscle through the movement pattern (Fig.10.10). Pain-free repetitions ensure sufficient cor-rective afferent input from the joint receptors andresulting reflex changes in muscle recruitment. Ahome programme of appropriate correct move-ment patterns (Sahrmann SA 2002) with the addi-tion of taping will ensure prolonged and

automatic pattern correction.Similar glides can be applied if glenohumeral

flexion is the symptomatic movement. A beltis usually used to glide the humeral head back-ward in the treatment plane, as the use of the ther-

apists hand over the anterior aspect of thehead of the humerus will block the movement.A counter pressure is applied to the scapulafrom behind. It is essential that the belt is main-tained at right angles to the plane of the joint. The

belt position on the therapist should be lower thanthe glenohumeral joint; this ensures that the

belt does not elevate the humeral head andimpinge on superior structures. The belt and ther-apist position must be altered so that whenthe glide is applied the flexion is facilitated(Fig. 10.11).

CONCLUSION

The above clinical examples serve to illustratethe flexibility of this approach, which makesit highly suitable for integration into anytherapists favoured treatment regime, whatevertheir speciality.

138 GENERAL

Figure 10.10 AP glide on humerus with active abduction and lower trapezius activation.


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Mobilization with movements enable thetherapist to perform treatments in more dynamic,weight-bearing, functional positions. As theaggravating movement is used, treatment is

specific and the results are often dramatic(Mulligan 1995). A single case study design by

Vicenzino and Wright (1995) using this approachdemonstrated improvement in a patient withtennis elbow. As this concept becomes establishedit is hoped that further research will be under-

taken to substantiate the claims of immediatedramatic results.

Figure 10.11 MWM with shoulder flexion.

REFERENCES

Baxendale RH, Ferrell WR 1981 The effect of knee jointdischarge on transmission in flexion pathways indecerebrate cats. Journal of Physiology315: 231242

Butler DS 1991 Mobilisation of the Nervous SystemChurchill Livingstone, Edinburgh, pp42, 185210

Cobb CR, De Vries HE, Urban RT, Lcukens CA, Bugg RJ1975 Electrical activity in muscle pain. AmericanJournal of Physical Medicine 54: 8087

Gerrard B, Matyas TA 1980 The electromyographicevaluation of an intervertebral mobilisation technique oncases presenting with acute paraspinal spasm in thelumbar spine. In: Proceedings of the SecondManipulative Therapists Association of AustraliaConference, Adelaide pp 3555

Grant R 1994 Physical Therapy of the Cervical andThoracic Spine, 2nd edn. Churchill Livingstone,Edinburgh, p. 339


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Hawkins RJ, Mohtadi GH 1991 Controversy in anteriorshoulder instability. Clinical Orthopaedics and RelatedResearch 272: 152161

Jobe FW, Pink M 1993 Classification and treatment ofshoulder dysfunction in the overhead athlete. Journal ofOrthopaedic and Sports Physical Therapy 18(2): 427432

Kaltenborn FM 1989 Manual Mobilisation of the Extremity

Joints, 4th edn. Orthopaedic Physical Therapy Products,USA, pp11, 20

Lewit K 1985 The muscular and articular factor inmovement restriction. Manual Medicine 1: 8385

Lundberg A, Malmgren K, Schonberg ED 1978 Role of thejoint afferents in motor control exemplified by effects onreflex pathways from 1b afferents. Journal of Physiology284: 327343

Maitland GD 1991 Peripheral Manipulation, 2nd edn.Butterworths, London, p. 23

Margery M, Jones M 1992 Clinical diagnosis andmanagement of minor shoulder instability. AustralianJournal of Physiotherapy 38(4): 269280

Mulligan BR 1993 Mobilisations with movement. Journal of

Manual and Manipulative Therapy 1(4): 154156Mulligan BR 1995 Manual Therapy Nags, Snags, PRPs

etc., 3rd edn Plane View Services, Wellington, NewZealand

Murphy BA, Dawson NJ, Slack JR 1995 Sacroiliac jointmanipulation decreases the H-reflex. Electromyographyand Clinical Neurophysiology 35: 8794

Sahrmann SA 2002 Diagnosis and Treatment of MovementImpairment Syndromes. Mosby, St Louis, USA

Schaible H, Grubb B 1993 Afferent and spinal mechanismsof joint pain. Pain 55: 554

Stokes M, Young A 1984 The contribution of reflexinhibition to arthrogenous muscle weakness. ClinicalScience 67: 714

Taylor M, Suvinen T, Rheade P 1994 The effect ofGrade 4 distraction mobilisation on patients withtemporomandibular pain-dysfunction disorder.Physiotherapy Theory and Practice 10:129136

Thabe H 1986 EMG as a tool to document diagnosticfindings and therapeutic results associated with somaticdysfunctions in the upper cervical spinal joints andsacroiliac joints. Manual Medicine 2: 5358

Vicenzino B, Wright A 1995 Effects of a novelmanipulative physiotherapy technique on tenniselbow: a single case study. Manual Therapy 1(1):3035

Williams P, (ed) 1995 Grays Anatomy, 38th edn. Churchill

Livingstone, Edinburgh, pp505510Wilson E 1994 Peripheral joint mobilisation with movement

and its effects on adverse neural tension. ManipulativePhysiotherapist 26(2): 3540

Wilson E 1995 Mobilisation with movement and adverseneural tension: an exploration of possible links.Manipulative Physiotherapist 27(1): 4046

140 GENERAL


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A number of articles on peripheral MWM have

been published since 1996. These encompass casereports (Backstrom 2002; Folk 2001), single casestudy designs (Vicenzino & Wright 1995; OBrien& Vicenzino 1998), research investigating possibleneurophysiological and mechanical effects(Kavanagh 1999; Vicenzino et al 2001; Abbott et al2001a; Abbott et al 2001b; Hsieh et al 2002) and arandomized controlled trial (Kochar & Dogra2002).

Using the Mulligan Concept a single casestudy design by Vicenzino and Wright (1995)

demonstrated a long-term beneficial effect on apatient with tennis elbow. O Brien andVicenzinos study (1998) involved treating twopatients with acute ankle sprains using a posteri-or glide to the distal end of the fibula with activeankle inversion. The results for both these subjectsindicated that the MWM intervention producedan improvement in excess of that attributable tothe natural history of a sprained ankle over a 5-week period.

Mulligan (1999) proposes that minorpositional faults may result in movementrestriction. Folks case study (2001) of a patientwith a diagnosis that varied from a sprainedmetacarpal joint of the thumb to De Quervainstendinitis and finally to trigger thumb of theflexor sheath, seems to support this theory.Treatment included use of a splint, steroidinjections into various tendon sheaths, surgicalexploration and various electrotherapy modali-ties, but all these interventions were unsuccessful.

The patient was finally referred to a manual ther-apist, who performed one treatment session ofMWMs. This restored pain-free range of move-ment and function, which was maintained over a1-year follow-up period.

The following two papers attempted tomeasure the positional fault. Using a potentio-meter and strain gauge, Kavanagh (1999)measured AP excursion and force applied to thedistal end of the fibula in 25 normal ankles and6 acute sprained ankles. The sample size was too

small to come to any definitive conclusions;however, nearly twice the AP force could beapplied to the normal ankles compared with theankle-sprain subjects. Pain was the limiting factor,however, thus questioning the ability to test a

positional fault by measuring the amount ofmovement per unit of force. This method may bemore applicable in less acute conditions. In thesecond paper Hsieh et al (2002) used magneticresonance imaging (MRI) to measure the effect ofMWM on thumb metacarpophalangeal (MCP)

joint position. The pretreatment MRIs from theleft and right MCP joints demonstrated a posi-tional fault on the symptomatic side. An MRItaken while applying passive supination to theproximal phalanx demonstrated that the posi-

tional fault could be corrected. The patient wasinstructed to perform self MWMs for 3 weeks,which was reviewed on a weekly basis. The post-treatment MRI demonstrated that the positionalfault was similar to that before treatment, eventhough the patient was pain-free and fully func-tional. This implies that the MWM produced itsclinical effects through mechanisms more complexthan long-term restoration of bony alignment.

Two papers that apply MWMs to a group ofpatients with tennis elbow may provide someclues to the neurophysiological responses (Abbottet al 2001a; Vicenzino et al 2001). The tennis elbowtechnique involves a sustained lateral glide to theelbow joint while contracting the extensor musclesof the forearm (Mulligan 1999). The results of thesepapers cannot be automatically extrapolated to themore traditional MWM, which involves applyinga pain-free accessory glide to the actively moving

joint. The sustained lateral elbow glide with grip-ping resulted in immediate significant changes in

pain-free grip strength (Abbott et al 2001a).Vicenzino et al (2001) undertook a randomized,double-blind controlled study on tennis elbowpatients and evaluated the effects of the sameelbow lateral glide technique on pain-free gripstrength (PFGS) and pressure pain threshold(PPT). This study demonstrated an immediate 50%increase in PFGS, with only a 10% increase in PPT.Of particular interest in these studies is that sig-nificant modulatory changes occurred in the motorneurone pool. However, the results of these papers

POSTSCRIPT


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Abbott JH, Patla CE, Jenson RH 2001a The initial effects ofan elbow mobilisation with movement technique on gripstrength in subjects with lateral epicondylalgia. ManualTherapy 6(3): 163169

Abbott JH, Patla CE, Jenson RH 2001b Mobilisation withmovement applied to the elbow affects shoulder rangeof motion in subjects with lateral epicondylalgia. ManualTherapy 6(3): 170177

Backstrom KM 2002 Mobilisation with movement as anadjunct intervention in a patient with complicated DeQuervains tenosynovitis: A case report. Journal ofOrthopaedic & Sports Therapy 32(3): 8697

Folk B 2001Traumatic thumb injury management usingmobilization with movement. Manual Therapy 6(3):178182

Hsieh CY, Vicenzino B, Yang CH, Hu MH, Yang C 2002Mulligan mobilisation with movement for the thumb: asingle case report using magnetic resonance imaging toevaluate the positional fault hypothesis. Manual Therapy7(1): 4449

Kavanagh J 1999 Is there a positional fault at the inferiortibiofibular joint in patients with acute or chronic sprainscompared to normals? Manual Therapy 4(1): 1924

Khan KM, Cook JL, Maffulli N, Kannus P 2000 Where is thepain coming from in tendinopathy? It may bebiochemical, not only structural, in origin. British Journalof Sports Medicine 34: 8184

Kochar M, Dogra A 2002 Effectiveness of a specificphysiotherapy regimen on patients with tennis elbow.Physiotherapy 88(6): 333341

Mulligan BR 1999 Manual Therapy Nags, Snags,MWMs etc 4th edn Plane View Services, Wellington.New Zealand

OBrien T, Vicenzino B 1998 A study of the effects ofMulligans mobilisation with movement treatment oflateral ankle pain using a case study design. ManualTherapy 3(2): 7884

Peinimaki T, Tarvainen TK, Sura PT, Vanharanta H 1996Progressive strengthening and stretching exercisesand ultrasound for chronic lateral epicondylitis.Physiotherapy 82(9): 522530

Peinimaki T, Karinen P, Koivukangas P, Vanharanta H 1998Long term follow-up of conservatively treated chronictennis elbow patients: A prospective and retrospectiveanalysis. Scandinavian Journal of RehabilitationMedicine 30: 159166

Vicenzino B, Paungmali A, Buratowski S, Wright A 2001Specific manipulative therapy treatment for chroniclateral epicondylalgia produces uniquely characteristichypoalgesia. Manual Therapy 6(4): 205212

Vicenzino B, Wright A 1995 Effects of a novel manipulativephysiotherapy technique on tennis elbow: a single casestudy. Manual Therapy 1(1): 3035

only reflect immediate responses and are of limitedclinical value when considered in isolation.

The clinical study by Kochar and Dogra (2002)provides some support to the laboratory findings.Their study randomized tennis elbow patients into

two groups: one receiving ultrasound (US) and agraduated exercise programme and the othergroup receiving the elbow MWM technique andthe same graduated exercise programme. A thirdgroup (control) received no treatment and did notattend the department on a regular basis. Thetreatment was administered for 10 sessions over 3weeks. The graduated exercise regime was start-ed after this 3-week period and continued foranother 9 weeks. Outcome measures includedpain assessed on a visual analogue scale, status of

pain over the 24-hour period prior to assessment,grip strength and a weight test that assessed theamount of weight the patient could lift free of painwith active wrist extension. At 3 weeks the MWMgroup were markedly better than the US groupand control group in all parameters. After dis-charge, recovery continued over the 9 weeks

of exercise with the MWM group showingsignificantly greater improvement in all parame-ters. Pienimaki et al (1996, 1998) demonstrated theshort- and long-term benefits of progressivestrengthening and stretching exercises only when

compared with ultrasound. Recent literature pro-poses that the majority of tendinopathies are morelikely to be degenerative than inflammatoryin nature and that an important componentto their treatment is progressive strengtheningincorporating eccentric loading (Khan et al 2000).The improvements in the objective tests ofthe MWM group may provide support to theproposal that there is a modulatory effect on themotor neurone pool, allowing faster progress withan exercise regime that may now be less inhibited

by pain.The greater part of the literature on this concept

to date has been concerned with tennis elbow;hopefully the future will see more research onMWM intervention in other peripheral joints inorder to establish the clinical efficacy of this valu-able adjunct to manual therapy.

142 GENERAL

REFERENCES

mulligan artigo em inglês - fácil de ler

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