Mulligan's mobilisation with movement: a review of the tenets and prescription of MWMs.
The treatment of musculoskeletal joint dysfunction may require a physiotherapist to use manual therapy. One of these manual therapy techniques include mobilization with movement (MWM), a type of joint mobilisation developed by Brian Mulligan (Mulligan 2004, Mulligan 2007); also referred to as a Mulligan mobilisation (Collins et al 2004, Kochar and Dogra 2002, Teys et al 2006) or a manipulative technique (Paungmali et al 2003b, Vicenzino et al 2001). The MWM technique consists of many necessary parameters for prescription, which are outlined in Figure 1. An accessory glide is applied at a peripheral joint, while a normally pain-provoking physiological movement or action is actively or passively performed. A key component to MWM is that pain should always be reduced and/or eliminated during the application (Exelby 1995, Exelby 1996, Mulligan 2004, Wilson 2001).
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Further gains in pain relief may be attained via the application of pain-free passive overpressure at the end of the available range during the MWM (Mulligan, 2004; Wilson, 2001). Adaptation, or 'tweakanology' as described by Mulligan, is essential to perform if the technique does not positively improve pain behaviour (Exelby 1996). Primarily this includes the direction or angle of the accessory glide, and/or the amount of force. The MWM technique also requires a comparable sign or client specific outcome measure (CSOM) as a baseline measure, to evaluate treatment effectiveness (Exelby 1995, Exelby 1996, Wilson 2001).
With respect to the research, the clinical efficacy of Mulligan's MWM techniques has been established for improving joint function, with a number of hypotheses for its cause and effect. Mulligan's original theory for the effectiveness of an MWM is based on the concept related to a 'positional fault' that occur secondary to injury and lead to maltracking of the joint; resulting in symptoms such as pain, stiffness or weakness (Mulligan, 2004). The cause of positional faults has been suggested to be due to changes in the shape of articular surfaces, thickness of cartilage, orientation of fibres of ligaments and capsules, or the direction and pull of muscles and tendons. MWM's correct this by repositioning the joint causing it to track normally (Mulligan, 2004; Wilson, 2001).
More recent studies have investigated further mechanisms that including the hypoalgesic and sympathetic nervous system (SNS) excitation effects (Abbott 2001, Paungmali et al 2003a, Paungmali et al 2004, Teys et al 2006). Further research has established the effectiveness of MWM's for increasing joint range of motion (ROM), enhancing muscle function, or more specifically treating particular pathologies (Collins et al 2004, DeSantis and Hasson 2006, Exelby 1996, Mulligan 2004, Paungmali et al 2003b, Teys et al 2006, Vicenzino et al 2006).
Despite the common use of MWM techniques in clinical practice for many musculoskeletal conditions, the prescription is not clearly defined, although there is common reference in the literature to Mulligan's recommendations as outlined in his text (Mulligan 2004). Prescription refers to many parameters within an MWM, including tenets, technical and response parameters, along with a comparable sign or CSOM (refer to Figure 1). Prescription can be defined as 'a written direction for the preparation, compounding, and administration of a medicine' (Lexico Publishing Group Ltd 2007). With respect to MWM prescription, this definition refers to having written guidelines that are clearly defined to draw on for the application of this treatment technique. Tenets represent the principles included in an MWM, which have been outlined by Mulligan (Hing 2007, Mulligan 2004). Both the technical and response parameters are contemporary concepts devised by Vicenzino & Hing (Hing, 2007). To date these aspects of prescription have not yet been reviewed or validated, which may impact on the clinical application of MWM treatment.
Therefore, the purpose was to undertake a review to critically evaluate the literature regarding MWM prescription at peripheral joints and to determine the specific parameters and rationale related to this prescription thus in attempt to formulate guidelines for clinical practice.
Literature search strategy
The purpose of this review was to research relevant articles in relation to MWM of peripheral joints only. The electronic databases in the search from 1990 to June 2007, included: CINAHL via Ovid and Ebsco Health Databases, Cochrane via Wiley and Ovid, AMED, Medline via Ebsco and Pubmed, and PEDro. The refined key terms, included mobilisation with movement* OR mobilization with movement* OR MWM*; manual therapy AND (mobilisation* OR mobilization); mulligan mobilisation* OR mulligan mobilization*. These search phrases were adapted for particular databases (Medline via Pubmed and Ebsco, and Ebsco Health Databases), due to the excessive number of results (refer to Figure 2). While performing the search, two independent researchers evaluated all titles and abstracts and were obtained from the various databases or from other sources to determine appropriateness. If this was unclear the full-text article was obtained to confirm whether MWM at peripheral joints was employed. All articles to be included in this review were obtained in hard copy. For more detail on this search strategy see the flow chart below (Figure 2).
Exclusion criteria which was incorporated during the search included: studies prior to 1990, non-English written articles, studies not relevant to peripheral joint manual therapy/MWM/ physiotherapy, spinal manual therapy, chiropractic studies, non-original research, cadaver or animal studies, and/or if there was no clear indication of the use of MWM. The aim of this review was to obtain every study, which has utilised MWM techniques; therefore no restrictions were placed on study design or methodological quality. All literature needed to be reviewed accurately to analyse the possible variations in its prescription. As papers were examined, reference lists were cross checked by both reviewers for citations of other potentially relevant studies, and in total three studies were subsequently retrieved from this process of cross-referencing (Hetherington 1996, Stephens 1995, Vicenzino et al 2001).
Review of study characteristics
Using a generic critical appraisal checklist, data was extracted from the included 21 articles and information was recorded. Four specific tables relating to MWM prescription were also formed, which included the tenets, pain behaviour analysis, technical parameters, and response parameters (CSOM and the PILL acronym). Each reviewer analysed all of this data. The content of these tables will be discussed further in the results.
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During the search, articles were excluded on the basis of the strict exclusion criteria previously mentioned. A total of 117 articles were identified from the stated databases (refer to Figure 2 for details). Once search results were matched for repeated articles between the databases, 18 were included for analysis. An additional three studies were found by means of further cross-referencing by both reviewers (Hetherington 1996, Stephens 1995, Vicenzino et al 2001), increasing the total to 21 studies for analysis--including four true randomised controlled trials (RCT's), five RCT's with participants as own control, one quasi-experimental, three non-experimental, three case studies, and five case reports. Further detail of each of the studies methodological data variation and study design are detailed in Appendix 1.
1) Specific Parameters and Rationale Related to MWM Prescription
Within the prescription of MWM's, there are different areas that need investigating. Firstly there are the five tenets, described by Mulligan, which should be considered with all MWM's. These are: the accessory glide generated by the therapist, the physiological movement or action, pain reduction or elimination, an immediate effect, and the use of overpressure, which are outlined in Table 1 (Hing, 2007). Pain behaviour is further elaborated in Table 2. The second consideration of MWM's is the technical parameters of prescription, which are: repetitions, sets, frequency, amount of force, and rest periods, which are outlined in Table 3. Vicenzino & Hing have devised a new concept of response parameters, which are the effects that the MWM should have on the patient to continue with treatment (Hing, 2007). These are 'pain-free' or pain altering application (reduction + / - elimination), instantaneous and long-lasting effects, namely the 'PILL' acronym (refer to Tables 2 and 4). Lastly Vicenzino & Hing have also discussed the use of a comparable sign to determine treatment effectiveness, which is also known as a CSOM, also found in Table 4 (Hing, 2007). There is a duplication of parameters, such as 'pain-free' or pain altering application and an immediate or instantaneous effect, which are both components of tenets and the PILL acronym. This duplication is secondary to two different clinicians defining these parameters of prescription.
(Abbott 2001, Abbott et al 2001, Altman and Burton 1999, Backstrom 2002, Bisset et al 2006, Collins et al 2004, DeSantis and Hasson 2006, Downs and Black 1998, Exelby 1995, Exelby 1996, Folk 2001, Hartling et al 2004, Hetherington 1996, Hignett 2003a, Hignett 2003b, Hing 2007, Hsieh et al 2002, Kavanagh 1999, Kochar and Dogra 2002, Lexico Publishing Group Ltd 2007, McLean et al 2002, Monteiro and Victora 2005, Mulligan 1989, Mulligan 1995, Mulligan 1999, Mulligan 2004, Mulligan 2006, Mulligan 2007, O'Brien and Vicenzino 1998, Paungmali et al 2003a, Paungmali et al 2004, Paungmali et al 2003b, Roddy et al 2005, Saunders et al 2003, Slater et al 2006, Stephens 1995, Teys et al 2006, Vicenzino 2003, Vicenzino et al 2006, Vicenzino et al 2001, Vicenzino et al 2007, Vicenzino and Wright 1995, Wilson 2001, Zhang et al 2005)
Tenets of MWM
The accessory glide performed should either be at a right angle to the joint such as a lateral glide of the elbow, or follow Kaltenborn's concave-convex rule such as an anterior-posterior glide of the ankle (Exelby 1995). All studies, except Bisset et al. (2006) clearly defined the direction of glide, although referred to Vicenzino (2003) for the prescription of their MWM, which clearly outlines that the glide should be a lateral glide of the forearm for treatment of lateral epicondylalgia. All studies at the elbow applied a lateral glide to the ulna. The second most common form of glide was an anterior-posterior mobilisation either directly from mobilising the distal bone of the joint, or mobilising the proximal bone in the opposite direction, such as a posterior-anterior mobilisation (Collins et al., 2004; Vicenzino et al, 2006). The techniques for the wrist and thumb were highly variable (Backstrom, 2002; Folk, 2001; Hsieh et al., 2002).
All studies involved a secondary movement or action to be performed by the patient during the MWM. Only two studies did not clearly state the movement performed during the MWM (Abbott, 2001; Bisset et al., 2006). Bisset et al. (2006) once again referred to Vicenzino (2003), which states that the patient should perform a pain-free gripping action. Abbott (2001) stated that the painful movement was performed, although this was not specified. For the treatment of lateral epicondylalgia the movement was either wrist extension or gripping of the hand (Abbott, Patla & Jensen, 2001; Kochar & Dogra, 2002; McLean et al., 2002; Paungmali et al., 2003a; Paungmali et al., 2003b; Paungmali et al., 2004; Slater et al., 2006; Stephens, 1995; Vicenzino & Wright, 1995; Vicenzino et al., 2001). MWM's for lateral ankle sprains included either dorsiflexion or inversion movements (Collins et al., 2004; Hetherington, 1996; O'Brien & Vicenzino, 1998; Vicenzino et al., 2006). The two studies investigating MWM for treatment of shoulder pain were similar utilising either pure abduction or abduction in the scapula plane (Teys et al., 2006; DeSantis & Hasson, 2006). The movement involved in the treatment of thumb sprains varied between the two studies, either including MCP flexion or extension (Folk, 2001; Hsieh et al., 2002). Only one study to date has investigated the use of MWM's in de Quervain's, which employed all wrist movements and thumb abduction (Backstrom, 2002). Overall the rationale for all studies of which physiological movement was performed during the MWM, was based upon utilising a normally pain provoking movement, with which the MWM was to eliminate this pain.
'Pain-free' or pain alteration (reduction +/- elimination)
Mulligan (2004) states that the MWM technique must be pain-free during its application. This tenet of an MWM is questionable, as it is more of an alteration to pain with a reduction and/or elimination, and thus not always 'pain-free' as indicated by Mulligan. Majority of studies (86%), have reported pain-free application, conversely three studies in this review did not state whether their MWM technique reduced or eliminated pain (Bisset et al 2006, Slater et al 2006, Stephens 1995). However the study by Bisset et al (2006) referred to Vicenzino (2003), which states that the application should be 'pain-free'. It is pertinent to the application and effectiveness of an MWM that a reduction and/ or an elimination of pain is achieved throughout the technique, with appropriate adaptation of the technique in relation to pain response. Table 2 summarises the analysis of the concept of pain behaviour and alteration with the MWM technique, and furthermore how the adaptation of the MWM in response to pain behaviour changes have occurred in studies.
Immediate / instantaneous effect
For an MWM to be deemed effective and progressive, there must be a positive instantaneous or immediate effect during its application. This is determined by the CSOM, which will soon be discussed. All studies that included a CSOM found a positive instantaneous effect, except Slater et al. (2006), which found no significant effects of MWM treatment. Only two studies did not report any immediate/instantaneous effect (Bisset et al 2006, Kochar and Dogra 2002). All the CSOM's improved post treatment, except temperature pain threshold (TPT), which has not been found to be affected by MWM's in any studies to date (Abbott, 2001; Abbott et al., 2001; Collins et al., 2004; DeSantis & Hasson, 2006; Folk, 2001; Hetherington, 1996; McLean et al., 2002; O'Brien & Vicenzino, 1998; Paungmali et al., 2003a; Paungmali et al., 2003b; Paungmali et al., 2004; Slater et al., 2006; Stephens, 1995; Teys et al., 2006; Vicenzino et al., 2001; Vicenzino et al., 2006; Vicenzino & Wright, 1995).
Overpressure is stated by Mulligan (2004) as been an essential element of MWM prescription, however it was only utilised in five studies (24%) within this review (DeSantis and Hasson 2006, Folk 2001, Hetherington 1996, O'Brien and Vicenzino 1998, Vicenzino et al 2006). The particular joints and pathologies of which this was applied include the shoulder for supraspinatus tendinopathy (DeSantis and Hasson 2006), the thumb for de Quervain's (Folk 2001), and also for lateral ankle sprains (Hetherington 1996, O'Brien and Vicenzino 1998, Vicenzino et al 2006). As grip strength was applied, overpressure is indirectly incorporated into any of the studies assessing the effects of MWM at the elbow that focused on lateral epicondylalgia.
Although Mulligan recommends ten repetitions and three sets for a typical MWM treatment, there are variations in the literature regarding repetitions and sets of its application. Mulligan (1995) states this prescription in the text, but the rationale is ill defined. Eighteen out of the 21 articles (86%) stated their repetitions and 11 stated their sets. Majority of studies have followed Mulligan's recommendations and prescribed three sets of ten repetitions. It is evident that this is the only rationale for MWM prescription, in combination with its use in previous studies. Variations of this prescription were utilised, ranging from two to ten repetitions, with one to four sets.
The frequency of treatment varied from one to 19, with one session most commonly utilised (Abbott, 2001; Abbott et al., 2001; Folk, 2001; Hetherington, 1996; McLean et al., 2002; Paungmali et al., 2003a; Slater et al., 2006; Stephens, 1995; Vicenzino et al., 2001; Vicenzino et al., 2006). The other two most common frequencies were three or six sessions, which commonly implemented an interval between treatment sessions, varying from 24 to 48 hours (Collins et al., 2004; DeSantis & Hasson, 2006; Kochar & Dogra, 2002; O'Brien & Vicenzino, 1998; Paungmali et al., 2003b; Paungmali et al., 2004; Teys et al., 2006; Vicenzino & Wright, 1995). The most frequent treatment carried out two hourly during waking hours, for three weeks (Hsieh et al., 2002), and the less frequent was approximately one treatment every five days (Backstrom, 2002; Bisset et al., 2006).
Amount of force.
The amount of force recommended for an MWM is not stated in Mulligan's text (2004), nor was it stated in majority of studies. McLean et al. (2002) is the only study to state the amount of force used, as this was the aim of their study. Using a handheld dynamometer, therapists applied a lateral glide to elbows with lateral epicondylalgia at 33%, 50%, 66% or 100% of maximal force. The outcome measure was pain-free grip strength (PFGS), and the results showed that 66% or 100% of force resulted in significant gains. The remainder of the studies either did not state the force used (13/21, 62%), or distinguished between using body weight or therapist arm force (7/21, 33%). Therefore the application of force is an important variable in MWM prescription, for determining treatment effectiveness, and this should be investigated further (Backstrom 2002, Collins et al 2004, DeSantis and Hasson 2006, Kochar and Dogra 2002, Paungmali et al 2003a, Slater et al 2006, Vicenzino et al 2006).
There is large variation in rest periods among the studies reviewed and it has only been stated in 11 studies (52%) ranging from 30 seconds to two hours between sets (Collins et al 2004, Hsieh et al 2002, McLean et al 2002, Slater et al 2006, Teys et al 2006, Vicenzino et al 2006), and 15 to 60 seconds between repetitions (Paungmali et al., 2003a; Paungmali et al. 2003b; Paungmali et al., 2004; Vicenzino et al., 2001; Vicenzino & Wright, 1995). Most commonly the rest period was 15 seconds between repetitions with these four studies investigating the hypoalgesic effects of a lateral glide performed at the elbow in patients with lateral epicondylalgia (Paungmali et al., 2003a; Paungmali et al. 2003b; Paungmali et al., 2004; Vicenzino et al., 2001). These studies found positive results with increases in PFGS and pressure pain threshold (PPT).
Effective MWM's should have a long-lasting effect in order for permanent change to occur. This is a further response parameter, as proposed by Vicenzino & Hing (Hing, 2007). Unfortunately this was only investigated in nine of the studies (43%) via follow-up assessments to establish deterioration or improvement from treatment (Backstrom 2002, Bisset et al 2006, Folk 2001, Hsieh et al 2002, Kochar and Dogra 2002, O'Brien and Vicenzino 1998, Paungmali et al 2003b, Stephens 1995, Vicenzino and Wright 1995). Interestingly, five were case studies/reports, which highlights the fact that other research designs have not incorporated follow-up assessment (Backstrom, 2002; Folk, 2001; Hsieh et al., 2002; O'Brien & Vicenzino, 1998; Stephens, 1995). The follow-up period varied from one to 52 weeks. The results included reduction in pain levels, increase in participant assessment scores, increase in pain-free strength, function and ROM. No studies that investigated this parameter found any negative long-term effects of MWM treatment when compared to placebo or control.
Client specific outcome measure (CSOM) or comparable sign
The CSOM or comparable sign is the outcome measure utilised during and immediately after MWM treatment, to determine its effectiveness, and whether the treatment should be continued with. Vicenzino & Hing have established that this should be carried out after all MWM applications, and only continued with if the CSOM has improved (Hing, 2007). It determines whether adaptation in relation to pain response needs to be applied. All studies incorporated a CSOM in their MWM application, which varied in relation to the joint, main problem or deficit, and purpose of research. The number of specific CSOM's also varied between studies, but all included either pain levels, strength, ROM or PPT (Abbott, 2001; Abbott et al., 2001; Collins et al., 2004; DeSantis & Hasson, 2006; Folk, 2001; Hetherington, 1996; McLean et al., 2002; O'Brien & Vicenzino, 1998; Paungmali et al., 2003a; Paungmali et al., 2003b; Paungmali et al., 2004; Slater et al., 2006; Stephens, 1995; Teys et al., 2006; Vicenzino et al., 2001; Vicenzino et al., 2006; Vicenzino & Wright, 1995). Others that were included were TPT, upper limb tension tests (ULTT), sympathetic SNS, joint glides or balance (Collins et al., 2004; Hetherington, 1996; Paungmali et al., 2003a; Paungmali et al., 2004; Vicenzino et al., 2006). However specific studies did not use the CSOM immediately after the first set to test for an instantaneous/immediate effect (Bisset et al 2006, Kochar and Dogra 2002).
2) Overall Efficacy of MWM's
All studies included in this review found significant positive results with MWM applications, when compared to placebo or control groups. The only study in which no significant results were found with PPT or strength was by Slater et al. (2006), which is also the only study, which investigated the efficacy of MWM's on an induced condition. All other studies utilised patients with genuine pathologies, whereas this study induced lateral epicondylalgia pain via delayed onset of muscle soreness and hypertonic saline.
The most common significant results found were increase in strength, reduction in pain levels, increase in PPT, improved ULTT's, and overall function improvements when compared with placebo or control, mainly in lateral epicondylalgia (Abbott et al., 2001; Bisset et al., 2006; Kochar & Dogra, 2002; McLean et al., 2002; Paungmali et al., 2003a; Paungmali et al., 2003b; Paungmali et al., 2004; Stephens, 1995; Vicenzino et al., 2001;Vicenzino & Wright, 1995). No change in TPT has been found at the elbow (Paungmali et al., 2004). Other interesting findings were that repeated applications of MWM, or MWM with naloxone did not have an inhibitory effect on the pain relieving effects, therefore suggests that a non-opioid mechanism occurs for the analgesic response (Paungmali et al., 2003a; Paungmali et al., 2004). The only study investigating the required force for optimal effects, demonstrated that best results are gained when an MWM is applied at either 66% or 100% of maximal force (McLean et al., 2002). MWM treatment was also found to be superior in the long-term when compared to corticosteroid injection (Bisset et al., 2006). Alterations in SNS function following an MWM were demonstrated, showing an increase in heart rate, blood pressure, skin conductance, blood flux and skin temperature. These are similar to the effects of spinal manipulation Paungmali et al., 2003b). MWM applied at the elbow has shown to have beneficial effects on shoulder rotation ROM (Abbott, 2001).
At the shoulder, wrist, thumb and ankle, similar results were found. These were decrease in pain, increase in ROM, PPT, strength and joint glides, and improved function (Backstrom, 2002; Collins et al., 2004; DeSantis & Hasson, 2006; Folk, 2001; Hetherington, 1996; Hsieh et al., 2002; O'Brien & Vicenzino, 1998; Teys et al., 2006; Vicenzino et al., 2006). Again no change in TPT was found at the ankle (Collins et al., 2004). One study investigated MWM under magnetic resonance imaging and found MWM to correct a position fault at the thumb, although this was not maintained post MWM, although the positive effects were long-lasting Hsieh et al., 2002).
The overall efficacy of MWM's has largely proven to be effective in both reducing pain and improving function in conditions such as lateral epicondylalgia, shoulder pain, de Quervain's, thumb and ankle sprains. The long-term results are discussed above, within 'long-lasting' effects.
Specific Parameters and Rationale Related to MWM Prescription
As previously described, tenets, technical and response parameters, all contribute to the effectiveness of Mulligan's manual therapy technique. However, a key finding from this review is that prescription of MWM has been poorly explained or not adequately applied in the literature. This is interesting considering that specific aspects of MWM application have been stated as being necessary components--such as 'pain-free', specific reps and sets, and overpressure. Variations exist in the prescription of MWM not only between studies, but also within individual studies.
The tenets of MWM prescription, as described by Mulligan, were generally well incorporated, with the exception of overpressure. All studies clearly defined the accessory glide together with the direction, with the exception of Bisset et al. (2006) who did not state it within the study treatment method, however did refer to Vicenzino (2003).
The secondary physiological movement or action performed by the patient is important to ensure a normally pain provoking movement can be altered with the MWM technique. All studies involved this tenet, with only two not clearly stating the movement or action performed (Abbott 2001, Bisset et al 2006), however Bisset et al. (2006) referred to Vicenzino (2003) for its prescription. The secondary physiological movement closely relates to pain behaviour and how the pain associated with this movement or action should be reduced or eliminated with an MWM. However the concept of terminology surrounding the term 'pain-free' as initially stated by Mulligan is controversial. As explained in the results and outlined in Table 2 the alteration of pain that occurs during and after MWM is not always an elimination of pain or otherwise known as 'pain-free'. Majority of studies (86%) documented pain-free application was utilised, with a minimal number discussing a reduction of pain as also being accepted. This raises the question of why is there is a chosen belief that MWM must be pain-free to continue with treatment? Thus should the term 'pain-free' be changed to pain alteration (reduction + / - elimination)? Several studies referred to the fundamental concept of pain-free application, yet it was not employed in the methods, or if stated it was not clear if pain was altered during or after the MWM (Abbott 2001, Backstrom 2002, Hsieh et al 2002, O'Brien and Vicenzino 1998, Stephens 1995). This also raises the importance of adaptation in response to pain behaviour during the MWM. Only eight studies explained their particular method of adapting the MWM application to alter pain (Abbott 2001, Abbott et al 2001, Backstrom 2002, Bisset et al 2006, Collins et al 2004, Folk 2001, Teys et al 2006, Vicenzino and Wright 1995). For example Bisset et al (2006) referred to Vicenzino (2003) for MWM prescription, who recommends that an MWM is repeated several times, only if there is a substantial decrease in pain, and if the pain relief has not occurred then glides at different angles should be attempted; up to a maximum of four times. Abbott et al. (2001) also states that four attempts of the glide direction are permitted, in order to determine which best eliminates the pain. If the pain was not eliminated or it returned during treatment, no further repetitions were performed.
[FIGURE 3 OMITTED]
Another tenet or response parameter associated with an MWM is the immediate or instantaneous effect, which occurs during and/or after the application and is determined by the related CSOM/s. Only two studies did not report any immediate or instantaneous effect (Bisset et al 2006, Kochar and Dogra 2002). This aspect of prescription is a necessity in relation to the effectiveness of the MWM, and also adaptation with regards to pain behaviour.
Overpressure is considered to be a key component in MWM techniques to produce effective pain relief, either as a progression and/or an adaptation if the patient remains symptomatic after initial application (Mulligan 2004, Wilson 2001). The literature however does not significantly reflect this, with only five studies (24%) incorporating this parameter (DeSantis and Hasson 2006, Folk 2001, Hetherington 1996, O'Brien and Vicenzino 1998, Vicenzino et al 2006). Several reviews have discussed the use of overpressure, to further alter pain behaviour and acquire pain-free end range (Exelby, 1996; Wilson, 2001).
The documentation of technical parameters was variable throughout the studies. Within this review 18 out of 21 studies (86%) stated the number of repetitions and sets employed. Majority of these studies referred to Mulligan's recommendations of three sets of ten repetitions, although no specific research has been undertaken to investigate the efficacy of these parameters (Mulligan 1995). While the rationale for prescription of repetitions and sets is generally ill defined and based on experimentation in clinical practice, Mulligan (2004) does state the importance of performing an adequate number of repetitions to result in a more lasting effect.
In regards to frequency of MWM treatment one session was most commonly utilised, which is unlikely in a clinical setting but is often carried out in research, especially with MWM's displaying immediate benefits (Abbott, 2001; Abbott et al., 2001; Folk, 2001; Hetherington, 1996; McLean et al., 2002; Paungmali et al., 2003a; Slater et al., 2006; Vicenzino et al., 2001; Vicenzino et al., 2006). A case study by Stephens (1995) utilised the most frequent treatment sessions (n = 19), which may reflect the chronicity of lateral epicondylalgia, and may represent the need for intense and regular physiotherapy intervention for effective treatment outcomes. This is a clear example of how case studies can be more clinically relevant with greater generalisability of results.
The amount of force applied during an MWM is a parameter of limited research and documentation within studies. McLean et al. (2002) is the only study to date, which has investigated the effects of MWM in relation to varied amounts of force applied for the accessory glide. The results illustrated that 66% or 100% of maximal force is superior over less amounts, indicating the amount of force is pertinent to consider with MWM effectiveness. It is therefore interesting that no other studies to date have detailed this parameter, apart from seven out of 21 (33%) distinguishing between the use of body weight or therapist arm force (Backstrom 2002, Collins et al 2004, DeSantis and Hasson 2006, Kochar and Dogra 2002, Paungmali et al 2003a, Slater et al 2006, Vicenzino et al 2006).
The rest period between sets of MWM's, has not been stated by Mulligan (1995), nor is it clearly outlined in any review articles (Exelby, 1995; Exelby, 1996; Vicenzino, 2003; Wilson, 2001), although retesting between each set for treatment effectiveness is advocated (Exelby, 1996; Wilson, 2001). This area was poorly defined with approximately half of studies (52%) stating the rest periods, with large variations evident. Most commonly employed was a 15 second rest period between repetitions, which was unique to a research purpose of investigating hypoalgesic effects of a lateral glide performed at the elbow in patients with lateral epicondylalgia (Paungmali et al., 2003a; Paungmali et al. 2003b; Paungmali et al., 2004; Vicenzino et al., 2001). To date there are no consistencies within the literature to guide the rest periods between sets (Collins et al 2004, Hsieh et al 2002, McLean et al 2002, Slater et al 2006, Teys et al 2006, Vicenzino et al 2006). In the clinical setting it is probably most appropriate to have a rest period between sets, of a time that allows re-testing of the CSOM to determine treatment effectiveness, and therefore determine whether the MWM application is to be continued with.
The response parameters as recently defined by Vicenzino & Hing includes the PILL acronym and the CSOM (Hing, 2007). As previously stated the PILL acronym consists of pain alteration, an instantaneous/immediate effect which have both been discussed earlier in tenets, along with long-lasting and the CSOM. Long-lasting effects have been investigated via follow-up assessments in nine studies (43%), all concluding with significant positive results. Paungmali et al. (2003b) established that hypoalgesic effects did not reduce with repeated treatments, therefore is probable that a non-opioid form of analgesia is the cause of pain relief. Also, the case report by Hsieh et al. (2002), determined at follow-up that pain was eliminated via the intervention, however the final magnetic resonance imaging (MRI) illustrated no change in the initial positional fault of the thumb. The authors therefore suggested that the correction of positional faults during the MWM, as shown by MRI, resulted in immediate effects. The long-term effects, including, pain relief, was hypothesised to be due to changes in nociceptive and motor system dysfunction, possibly implying the role of hypoalgesia. Mulligan (2004) also states that the effects of MWM's can be maintained further via taping and self-MWM's, which may further enhance the possible long-lasting effects. This was included in several studies within this review (Backstrom 2002, Hetherington 1996, Hsieh et al 2002, O'Brien and Vicenzino 1998, Stephens 1995, Vicenzino and Wright 1995).
All studies in this review have incorporated the use of CSOM or a comparable sign to be utilised during and/or immediately after an MWM as a response parameter. The development of the CSOM by Vicenzino & Hing is a new concept, which is related to the requirements of what must occur in order to continue with MWM treatment (Hing, 2007). In general, the choice of the CSOM within the literature was variable but very consistent in relation to employing a normally provoking movement or action, with which the MWM is aimed to improve.
Proposed Guidelines for Clinical Practice
Overall, it is apparent that certain parameters of MWM prescription are ill defined, although the efficacy for particular joints is well established. It may be that experimentation or adaptation of the technique is necessary and common in daily practice, however, a review of its necessary components of prescription was timely. The key components of prescribing an MWM technique need to be defined. Thus it is proposed that the following algorithm is utilised for the prescription of MWM's at peripheral joints in clinical practice (refer to Figure 3). This algorithm is based on the findings of this systematic review and incorporates all necessary components of MWM prescription.
The algorithm encompasses all parameters that have been reviewed in this research and is based upon integration of results. This includes tenets (accessory glide, physiological movement or action, pain alteration (reduction + / - elimination), immediate/instantaneous effect, overpressure), technical parameters (repetitions, sets, frequency, amount of force, rest periods) and response parameters (long-lasting, CSOM). The content of the algorithm aims to allow the practitioner to easily follow it through in order to apply appropriate MWM prescription. Aspects of the algorithm require clinical reasoning in regards to prescription specifics and consideration of irritability.
Subsequent to the extensive research and analysis undertaken for this review, there are particular areas within MWM prescription that require further investigation. This could include research into the efficacy and prescription of MWM's at joints that have not yet been examined such as the hip and knee. This could also incorporate the consideration of various pathologies as in the clinical setting, MWM's are utilised for many conditions and in all peripheral joints. It is clear that the specific prescription parameters of the MWM technique have not been consistently employed, nor evaluated. For example the use of overpressure was rarely implemented although it is considered a key component of MWM application, therefore investigation into its additional benefits may be necessary. Further parameters of MWM prescription, which were analysed in this review such as the accessory glide, repetitions, sets, frequency, rest periods, also warrant specific comparative research regarding the effects. Once the efficacies of the discussed parameters are further defined, they need to be prescribed appropriately and more clearly explained in future research. An example is with the amount of force used, which has been validated by McLean et al. (2002) although not implemented appropriately in subsequent research to date.
The efficacy of the proposed algorithm could be investigated via the comparison of its implementation versus the common clinician's MWM application. Perhaps common MWM application could be initially identified through a survey with case examples, which will determine a representative norm for everyday clinical practice and MWM prescription. This will overall establish the efficacy of the algorithm and the incorporation of all necessary MWM prescription components, with regards to treatment outcomes.
Mulligan's peripheral MWM techniques are commonly utilised within musculoskeletal physiotherapy. This review of the MWM prescription at peripheral joints highlighted that this area of research has strengths, limitations and inconsistencies.
The specific parameters identified for MWM prescription in the literature, is variable and in general inconsistently implemented and explained. The efficacy of MWM's appears to be well established for various joints and pathologies, as shown by previous reviews, however due to the methodological quality of studies, and gaps in particular areas of both prescription and application, it is apparent that further research is warranted into the specific parameters of MWM's. The proposed algorithm may be integrated into clinical practice, to aid in the inclusion of all necessary components established from this review.
To conclude, this manual therapy technique is widely used and advocated for many aspects of peripheral joint dysfunction. This review has presented an evaluation of MWM prescription, in attempt to guide the clinician appropriately, and provide a basis for future research into this area.
Appendix 1. Characteristics of the included studies Author Design Purpose Bisset et al., True RCT To investigate the efficacy 2006 of PT intervention compared with corticosteroid injection and wait and see for lateral epicondylalgia Kochar & True RCT To compare the effects of a Dogra, 2002 combination of MWM and US versus US alone, followed by an exercise programme, for lateral epicondylalgia Slater et al., True RCT To examine the effects of a 2006 lateral glide MWM in healthy subjects with induced lateral epicondylalgia pain Teys et al., True RCT Examine the effect of MWM of 2006 the shoulder in relation to ROM and PPT Collins et al., RCT with Evaluate the effect of MWM 2004 participants for lateral ankle sprains on as own control ROM and hypoalgesia (repeated measures, crossover) Paungmali et RCT with To determine whether an MWM al., 2003a participants technique at the elbow as own control produces physiological (repeated measures) effects such as hypoalgesia and SNS function in patients with lateral epicondylalgia Paungmali et RCT with Evaluate the effect of al., 2004 participants as own naloxone on pain relief from control (repeated an MWM applied to lateral measures crossover) epicondylalgia Vicenzino et RCT with Determine whether MWM for al., 2001 participants lateral epicondylalgia as own control produced hypoalgesia and to (repeated measures) compare effects on the affected and non-affected arms Vicenzino et RCT with To explore the deficits in al., 2006 participants ankle ROM in patients with as own control recurrent ankle sprains, and (repeated investigate the effect of a measures, posterior glide MWM applied crossover) in NWB and WB on talocrural DF McLean et al., Quasi-experimental To assess different manual 2002 --repeated forces used in a MWM measures technique for lateral elbow (randomisa-tion, epicondylalgia and its no control) effects on hypoalgesia Abbott, 2001 Non-experimental To investigate the effects of --pre/post test a single intervention of MWM (randomisa-tion) at the elbow on shoulder ROM for patients with lateral epicondylalgia Abbott et al., Non-experimental Determine what proportion of 2001 --pre/post test pts respond to MWM for (randomisa-tion) lateral epicondylalgia, whether PGFS and maximum GS increases after 1 Rx of MWM, and determinants of responsiveness Paungmali et Non-experimental Examine whether initial al., 2003b --repeated measures hypoalgesia effects from MWM applied to lateral epicondylalgia were maintained after repeated applications O'Brien & Case study To determine the Vincenzino, effectiveness of MWM applied 1998 at the ankle for acute lateral ankle pain Stephens, Case study NS 1995 Vincenzino & Case study To investigate effects of a Wright, 1995 manipulative PT technique on pain and dysfunction of a patient with tennis elbow Backstrom, Case report Introduce MWM in the 2002 treatment of de Quervain's tenosynovitis DeSantis & Case report To describe the effects of an Hasson, 2006 MWM treatment regime for shoulder impingement Folk, 2001 Case report To describe the differential diagnosis and treatment techniques for strained 1st MCP joint Hetherington, Case report NS. 1996 People with ankle injuries were examined to detect a positional fault and managed using MWM and taping methods Hsieh et al., Case report Investigate the use of MRI 2002 for positional fault and MWM effects in the thumb Author Participants Intervention Bisset et al., 198 participants. Group 1: 8 sessions of PT. 2006 128 males, 70 Group 2: corticosteroid females. injection. Mean age: 48 Group 3: wait and see Kochar & 66 participants. Group 1: combination of US Dogra, 2002 36 males, 30 and MWM on 10 sessions females. (different Rx on alternate Mean age: 41 days) completed in 3 weeks and an exercise programme (9 weeks). Group 2: US only on 10 sessions completed in 3 weeks and an exercise programme (9 weeks). Group 3 (control): no treatment Slater et al., 24 participants. Day 0--induced DOMS 2006 11 males, 13 (eccentric exercises on females. non-dominant arm). Mean age: 23 Day 1--injected hypertonic saline (24hrs post exercise) to mimic tennis elbow symptoms (pain duration 10 mins), then applied MWM or placebo Rx Teys et al., 24 participants. Group 1: MWM Rx. 2006 11 males, 13 Group 2: placebo. females Group 3: control Mean age: 46 Collins et al., 16 participants. Group 1: MWM. 2004 8 males, 8 females. Group 2: placebo. Mean age: 28 Group 3: control Paungmali et 24 participants. Each participant completed al., 2003a 17 males, 7 the 3 randomised Rx groups females. (Rx, placebo, control), at Mean age: 49 same time of day. 48 hrs in between each session Paungmali et 18 participants. All participants received al., 2004 14 male, 4 female. intravenously naloxone, Mean age: 49 saline or no-substance control on 3 different occasions, then a MWM was applied to the elbow Vicenzino et 24 participants. Participants received either al., 2001 14 male, 10 female. MWM Rx, placebo or control on Mean age: 46 affected and un-affected arm. They received all 3 intervention levels on different days Vicenzino et 16 participants. Group 1: WB MWM. al., 2006 8 males, 8 females. Group 2: NWB MWM. Mean age: 20 Group 3: control. All participants experienced 1 of the 3 conditions in a randomised sequence on 3 separate days (at least 48 hours apart) McLean et al., 6 participants. MWM force levels were 2002 2 males, 4 females. determined for 33%, 50%, Mean age: 49 66% and maximum. All participants received applications of the MWM technique comprising of the 4 force levels in a random order Abbott, 2001 23 patients. Random assignment of left or 18 male, 5 female. right arm to be Ax and Rx Mean age: NS (MWM) first Abbott et al., 25 participants. All participants received 2001 17 males, 8 MWM to unaffected and females. affected arm (randomised Mean age: 46 order), in 1 Rx session. If participants pain could not be eliminated Rx was stopped Paungmali et 24 participants. All participants received al., 2003b 19 males, 5 lateral glide MWM. females. Applied on 6 occasions, Mean age: 50 approx 48 hours apart O'Brien & 2 male participants To determine the Vincenzino, with recent (2-3 effectiveness of MWM applied 1998 days) lateral ankle at the ankle for acute sprains. Aged 17 lateral ankle pain and 18 Stephens, 43 year old female Rx: 3 times a week for 1st 4 1995 with left sided weeks, then once a week for chronic lateral the following 4 weeks, then epicondylitis once every 2 weeks for the last 6 weeks. Rx: MWM's, ice, US, transverse frictions, exercises began after MWM Rx, massage, stretching, HEP Vincenzino & 39 year old female PT for 6 sessions over 5 Wright, 1995 with right tennis weeks. Included 2 weeks Ax, 2 elbow weeks Rx (4 sessions), and 6 weeks HEP Backstrom, 61 year old female Rx: Manipulation of capitate 2002 with de Quervain's on first session only, MWM, tenosyno-vitis of elastic splint with horseshoe the right wrist type insert (introduced on session 6), eccentric and concentric strengthening, AROM, tendon gliding, transverse friction, anti- inflammatories and HEP CAROM, strengthening, tendon gliding, frictions, self MWM) DeSantis & 27 year old male Physiotherapy 3 times a week Hasson, 2006 with left shoulder for 30 mins with a total of supra-spinatus 12 sessions tendinopathy Folk, 2001 39 years old Received OT (7 sessions in 6 female, 4.5 weeks weeks), then referred for after strain to trigger thumb release 1st MCP, with surgery, then back to OT, diagnosis of de which then referred to PT. OT Quervain's of the evaluation/Rx performed 3 left hand weeks later Hetherington, NS. Majority of patients were 1996 Patients post ankle treated only with MWM's and sprain with limited taping. and painful ROM No electro-physical therapies were used Hsieh et al., 79 year old female MWM was applied to the 2002 with right thumb proximal phalanx. MRI was pain taken before, during MWM, then after a course of MWM Rx. Participant performed self MWM's Author Prescription of MWM/other Rx Bisset et al., PT: 8 sessions for 30 mins over 6 weeks. 2006 Included MWM, theraband exercises and stretching. Corticosteriod injection: 1 injection, and a 2nd one if necessary after 2 weeks. Wait and see: advice, education on modifications to ADL's, encourage activity, using analgesic drugs, heat, cold and braces Kochar & US: 3 MHz, 1.5 W/cm2, pulsed 1:5, 5 mins. Dogra, 2002 MWM: elbow extended, forearm pronated, 10 reps, no pain, glide sustained while participant lifted weight that previously produced pain, for 3 sets, 10 sessions. Progressed MWM by increasing weights by 0.5kg. Exercise: stretching, PRT, concentric/ eccentric exercises Slater et al., Exercises to induce DOMS: repeated eccentric 2006 wrist extension contractions--5 sets of 60 reps, with 1 min rest interval between sets. MWM: sustained lateral glide, with PT's hand against participants ulna. Participant supine, shoulder abducted 20[degrees], elbow extended and forearm pronated. Placebo: application of a firm constant manual contact around the medial and lateral aspects of the elbow Teys et al., MWM: posterolateral glide with patient seated. 2006 PT placed hands over posterior scapula and thenar eminence of other hand over anterior aspect of head of humerus. Posterior glide applied to Numeral head. Participant actively abducted arm. Placebo: a/a, but hands of PT were anteriorly on the clavicle and sternum, and an anterior glide with minimal force was applied Control: no manual contact of PT Collins et al., MWM: at talocrural joint. Participant WB in 2004 stance position with affected leg forward. Belt around PT pelvis and distal tibia and fibula. Pt leaned back to create PA glide, with talus and forefoot stabilised by PTs hand and other hand over proximal tibia and fibula to maintain leg alignment. Placebo: a/a with belt over calcaneum and minimal force, with stabilising hand over metatarsals. Control: pt in stance position for 5 mins with no manual contact of PT Paungmali et Rx group: lateral glide MWM with pain-free al., 2003a dynamometer gripping. Participant supine, with shoulder internally rotated, elbow extended, forearm pronation. 10 reps, for 6 sets, 15 sec rest period. Placebo: PT applied a firm manual contact with both hands over the elbow joint whilst the participant gripped the dynamometer pain-free. Control: involved the pain gripping action only (no manual force applied) Paungmali et MWM: participant in supine position. Rx al., 2004 applied immediately after the injection. One hand stabilised the distal humerus on the lateral aspect, and the other hand applied a lateral glide to the proximal radius and ulna Vicenzino et MWM: lateral glide of the elbow. One al., 2001 hand gliding the proximal forearm, and other stabilising the distal humerus, while participant performed pain-free gripping. Placebo: firm manual contact over elbow joint. Control: no manual contact of PT Vicenzino et WB MWM: in standing with therapist al., 2006 manually stabilising the foot on the plinth, using belt to apply force and participant moving into DF. NWB MWM: applied with the participant in supine lying, tibia resting on plinth and ankle on the edge. Control group: no manual contact or movement. The participant stood for a similar period of time similar to the treatment time for the other two groups McLean et al., MWM: directed towards the medial aspect 2002 of the ulna. Duration of each Rx technique was no more than 10 sets. 3 applications with contraction for baseline measure. 2 applications of the 4 force levels, with 2 min rest intervals Abbott, 2001 MWM: participant in supine, and performed the normally provoking movement on the left and right side Abbott et al., MWM: lateral glide of proximal medial forearm 2001 with the distal humerus stabilised, whilst participant performed previously painful movement (fist, gripping, wrist extension, 3rd finger extension). Either of the following glides were performed depending on participants pain response: directly lateral or approx 5[degrees] posterior, anterior or caudal of lateral Paungmali et MWM: patient supine with shoulder in al., 2003b internal rotation, elbow extended and supinated. Therapist stabilised the humerus and applied lateral glide at forearm. Technique performed was pain-free with participants maintaining a grip for approx 6 sets and repeated 10 times with 15 sets rest intervals O'Brien & MWM Rx: posterior glide of distal fibula Vincenzino, while participant inverted the ankle. Passive 1998 overpressure was applied. Repeated 4 times. Rx1: 6 sessions over 2 weeks. Rx2: 3 sessions over 1 week. No Rx1: 3 sessions over 1 week. No Rx2: 5 measurement sessions over 1 week. Strapping tape was applied to maintain the posterior glide after every Rx session Stephens, MWM: lateral mobilisation of the forearm 1995 at the elbow during active wrist extension, forearm supination and gripping. Dorsal glide of the hand applied at the wrist during radial deviation and the metacarpal of the thumb was mobilised palmerly at the CMC during thumb opposition. Elbow was taped into a lateral glide. Self mobilizations were performed against a doorway to provide pain relief Vincenzino & Initial physio Rx: deep and painful massage, Wright, 1995 ice, laser, some form of sensory stimulation. Exercises--stretching and gripping exercises. Experimental Rx: MWM--lateral glide applied at the proximal part of the forearm whilst stabilising the lateral aspect of the distal humerus (participant in supine, shoulder internal rotation, elbow extended, forearm pronated). Participant was taught self mobilisation and taping (taping was used to replicate the lateral force applied at the elbow by the MWM) Backstrom, MWM: radial glide of proximal row of carpal 2002 bones. 3 sets of 10 reps of each of the movements (wrist flexion, extension, ulna and radial deviation, and thumb radial or palmer abduction) (pain-free). Done at all Rx sessions. WB technique--participant WB through the hand and the same radial glide was performed as participant progressively WB through the right upper limb. Ulna glide of trapezium and trapezoid for thumb radial abduction. Self-MWM--WB of upper limb. Participant applied ulna glide on forearm (therefore radial glide of carpal bones), shifted BW (wrist flexion/extension) with thumb abducted DeSantis & Warm-up: 5 min warm up on cycle ergometer Hasson, 2006 prior to each session. Phase 1: focused on decreasing pain (education on rest, cryotherapy, restoring ROM with MWM) MWM: AP glide with abduction movement (guiding movement of the scapular and humerus with both hands). Phase 2: focused on strengthening rotator cuff, scapular stabilising muscles, improving function, education regarding posture. Each session ended with 10 mins of cryotherapy Folk, 2001 2 cortisone injections for de Quervain's. OT Rx: splint and gutter use, active ROM exercises. Operation: trigger thumb release. PT Rx: MWM at 1st MCP with sustained pain-free internal axial rotation, with overpressure at the end Hetherington, MWM: lateral malleous of fibula glided 1996 posteriorly with active inversion (with and without a belt). Taping: two strips of 25mm tape approx 15cm in length. Posterior glide applied and then tape applied over the lateral malleolus and travelled around the lower leg (taping changed after 24 hrs) Hsieh et al., Self MWM: supinating the proximal phalanx 2002 of the thumb using other hands index and thumb, while performing flexion of the thumb undergoing MWM Author Times of Ax O/C measures Bisset et al., 6 weeks and Global improvement. 2006 52 weeks Grip force. Assessors rating of severity. Pain (VAS). Elbow disability (pain-free function questionnaire) Kochar & Week 1, 2 and 3. Pain--VAS scale. Dogra, 2002 Follow-up at Ability to lift 0-3kg weights 4 months with no pain, 24hrs after Rx. Grip Strength. Weight test Slater et al., Before exercise, PPT. 2006 injection and McGill pain questionnaire. MWM. Muscle force. After Rx. Maximal grip force Follow-up at day 7 (dynamometer). Maximal wrist extension force (force transducer) Teys et al., Before and after AROM (active pain-free 2006 Rx, on 3 sessions shoulder elevation). PPT Collins et al., Before and after Rx Weight-bearing DF ROM. 2004 PPT. TPT Paungmali et Before, during and PFGS. al., 2003a after Rx PPT. TPT. Cuteneous blood flux. Skin conductance. Skin temperature. BP. HR Paungmali et Before infection PFGS. al., 2004 and Rx, and after PPT. Rx TPT. Upper limb neural test provocation (radial nerve) Vicenzino et Before and after PFGS. al., 2001 each Rx session. PPT PFGS also measured during Rx Vicenzino et Before and after Posterior talar glide. al., 2006 Rx, on 3 sessions WB ankle DF (a WB lunge measured with a tape measure) McLean et al., Before and after Rx PFGS. 2002 Muscle force: measured with a flexible pressure sensing mat between hand and elbow Abbott, 2001 Before and after Rx Passive ROM (goniometer): in particular internal and external rotation Abbott et al., Before and after PFGS. 2001 Rx, on each arm Maximal grip strength Paungmali et Before and after PFGS. al., 2003b every Rx PPT O'Brien & Before, during Pain: VAS. Vincenzino, (pain, inversion ROM: inversion and DF (WB). 1998 ROM) and after Functional performance each Rx (Kaikkonen scale). Function: VAS Stephens, NS Pain: VAS. 1995 AROM: shoulder, elbow and thumb. Strength: shoulder, elbow, wrist and grip. Sensation: dermatomes. Special test: resisted wrist ext with elbow at 45[degrees]. Palpation Vincenzino & Before Rx, during 2 VAS. Wright, 1995 week Ax phase, and PPT. at 6 weeks Grip strength. following Rx Function VAS. Pain-free function questionnaire Backstrom, At each session. Pain (VAS). 2002 Follow-up at Observation. 4 months and 12 ROM (goniometer). Wrist months post Rx flexion, extension, radial and ulna deviation. Thumb palmer and radial abduction. Strength -isometric and MMT. Accessory motion testing. Palpation. Finklestein test DeSantis & Measurement AROM (goniometer)--abduction Hasson, 2006 of pain and AROM mainly. at every PT session MMT. Impingement tests (Neer, Hawkins Kennedy, empty can, apprehension). Functional status: shoulder pain and disability index. SF-36 (global self-report questionnaire). Pain (VAS) Folk, 2001 Measurement taken Pain (MCP ext). throughout Rx. Swelling. Follow-up at 2 ROM (MCP ext). months and 1 year MMT. post Rx Grip strength. Upper limb tension tests. Cervical spine Ax. De Quervain's tests (finkelsteins, pincer strength, palpation) Hetherington, Before, during and Pain on inversion. 1996 after Rx ROM. One leg standing test (balance--eyes closed). Swelling. Gait Patterns Hsieh et al., MRI: pre Rx, MRI. 2002 during 1st Pain: VAS. Rx, after Rx. AROM: goniometer Week 1: (flexion of IPJ and MPJ) pain, ROM, PROM: thumb radial abduction. distraction/ Grip strength: hand compression, PROM. dynamometer. Week 2--a/a. Compression/distraction Week 3--a/a, of the MPJ grip strength Note: MWM = mobilization with movement; Rx =treatment; Ax = assessment; O/C = outcome; RCT = randomised controlled trial; PT = physiotherapy; ADL's = activities of daily living; UAS = visual analogue scale; US = ultrasound; MHz = mega hertz; W/[cm.sup.2] = watts per centimetre squared; mins = minutes; PRT = progressive resistant training; reps = repetitions; kg = kilogram; hrs = hours; DOMS = delayed onset muscle soreness; PPT = pressure pain threshold; AROM = active range of motion; a/a = as above; WB = weight-bearing; pt = patient; PA = posterior-anterior; DF = dors flexion, ROM = range of motion; SNS = sympathetic nervous system; TPT = temperature pain threshold; secs = seconds; PFGS = pain free grip strength; BP = blood pressure; HR = heart rate; NWB = non weight-bearing; NS = not stated; GS = grip strength; approx = approximately; HEP = home exercise programme; CMC = carpometacarpal, BW = body weight; MMT = manual muscle testing; AP = anterior posterior; SF-36 = short form 36; MCP = metacarpophaiangeal; OT = occupational therapy; ext = extension; mm = millimetres; cm =centimetres; MRI = magnetic resonance imaging; IPJ = interphaiangeal jolnt; MPJ = metacarpal phaiangeal joint.
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Wayne Hing PhD
Associate Professor, Health & Rehabilitation Research Centre, AUT University
Renee Bigelow BHSc (Physiotherapy)
Toni Bremner BHSc (Physiotherapy)
At the time this paper was written, these authors were 4th year students at the School of Physiotherapy, Auckland University of Technology
ADDRESS FOR CORESPONDENCE
Associate Professor Wayne Hing, School of Physiotherapy, Health & Rehabilitation Research Centre, AUT University, Private Bag 92006, Auckland 1142, New Zealand.
Table 1. Tenets of MWM application Physiological Author Accessory glide movement Bisset et al., 2006 NS NS Kochar & Dogra, 2002 Lateral glide Wrist extension with weights Slater et al., 2006 Lateral glide Gripping Teys et al., 2006 Posterolateral glide Patient actively to humeral head. At elevated arm in right angle to scapula plane shoulder elevation Collins et al., 2004 PA glide of tibia DF in WB Paungmali et al., Lateral glide Gripping a 2003a dynamometer for approx 6 seconds Paungmali et al., Lateral glide Gripping 2004 Vicenzino et al., Lateral glide Gripping 2001 Vicenzino et al., 1) PA force applied Patient actively 2006 at the tibia with a moving into the belt, therefore a onset of pain or posterior glide of end range DF the talus. 2) AP force applied to glide the talus McLean et al., 2002 Lateral glide Gripping a dynamometer Abbott, 2001 Lateral glide Specific combined movement NS. Only states that patient performed the normally pain provoking movement up to 10 times Abbott et al., 2001 Either direct lateral Gripping action, glide of the proximal combine with wrist forearm or 5[degrees] extension or 3~d posterior, anterior finger extension or caudal of lateral Paungmali et al., Lateral glide Gripping for approx 2003b 6 seconds O'Brien & Vicenzino, Posterior glide of Active inversion 1998 distal fibula Stephens, 1995 Elbow: lateral glide. Wrist extension, Wrist: dorsal glide. forearm supination, Thumb: palmar glide gripping, radial deviation, thumb oposition Vicenzino & Wright, Lateral glide Gripping a weight 1995 wring the MWM Backstrom, 2002 Radial glide of Wrist flexion, proximal row of extension, ulna and carpal bones. radial deviation, and Ulna glide of thumb radial or trapezium and palmer abduction trapezoid for thumb radial abduction. Self MWM: Patient applied ulna glide on forearm with UL WB (i.e. radial glide of carpal bones), shifted BW DeSantis & Hasson, Right angle to Abduction movement 2006 glenohumeral joint (externally rotated; open can position) Folk, 2001 Glides at the MCP extension proximal end of the proximal phalanx: medial, lateral, axial IR and ER. IR proved to be effective in decreasing pain and improving ROM Hetherington, 1996 Posterior glide of Patient performed the distal fibula at active inversion with the lateral malleolus and without a belt and then released Hsieh et al., 2002 Supination of the Thumb flexion proximal phalanx of the thumb Pain alteration (Reduction +/- Author elimination) Immediate effect Bisset et al., 2006 NS NT Kochar & Dogra, 2002 Yes NT Slater et al., 2006 NS No Teys et al., 2006 Yes Yes Collins et al., 2004 Yes Yes Paungmali et al., Yes Yes 2003a Paungmali et al., Yes Yes 2004 Vicenzino et al., Yes Yes 2001 Vicenzino et al., 1) Yes Yes 2006 2) NS McLean et al., 2002 Yes Yes Abbott, 2001 Yes Yes Abbott et al., 2001 Yes Yes Paungmali et al., Yes Yes 2003b O'Brien & Vicenzino, Yes Yes 1998 Stephens, 1995 NS Yes Vicenzino & Wright, Yes Yes 1995 Backstrom, 2002 Yes Yes DeSantis & Hasson, Yes Yes 2006 Folk, 2001 Yes Yes Hetherington, 1996 Yes Yes Hsieh et al., 2002 Yes Yes Author Overpressure Bisset et al., 2006 NS Kochar & Dogra, 2002 NS Slater et al., 2006 NA Teys et al., 2006 NS Collins et al., 2004 NS Paungmali et al., NA 2003a Paungmali et al., NA 2004 Vicenzino et al., NA 2001 Vicenzino et al., Overpressure if no 2006 pain after active movement McLean et al., 2002 NA Abbott, 2001 NA Abbott et al., 2001 NS Paungmali et al., NA 2003b O'Brien & Vicenzino, Passive overpressure 1998 Stephens, 1995 NS Vicenzino & Wright, NA 1995 Backstrom, 2002 NS DeSantis & Hasson, Pain-free passive 2006 overpressure Folk, 2001 Passive overpressure Hetherington, 1996 Passive overpressure Hsieh et al., 2002 NS Note: NS = not stated; NA = Not applicable; NT = not tested; PA = posterior-anterior; DF = dorsiflexion; WB = weight bearing; AP = anterior-posterior; approx = approximately; MWM = mobilisation with movement; UL = upper limb; BW = body weight; IR = internal rotation; ER = external rotation; ROM = range of motion; MCP = metacarpophalangeal. Table 2. Pain behaviour explanation for application and technique adaptation Pain alteration (reduction elimination): Stated Details regarding classification Author (Yes / No) of pain behaviour Bisset et al., No--referred to Vicenzino (2003) states the 2006 Vicenzino gripping action performed during (2003) the MWM should be to the onset of pain and no more Kochar & Dogra, Yes States that MWM's are pain-free 2002 with a correct glide, although they noted that pain was only diminished during their MWM application Slater et al., No--referred to NS (Mulligan 1999) 2006 Mulligan (1999), Vicenzino & Wright (1995), Abbott et al. (2001), Vicenzino et al. (2001), & Paungmali et al. (2003a) Teys et al., Yes Pain-free arm elevation during 2006 the glide Collins Yes MWM was applied to the end of the et al., 2004 pain-free range Paungmali Yes The glide was painlessly applied, et al., 2003a and the patient performed a pain- free gripping action Paungmali Yes The glide was painlessly applied, et al., 2004 and a pain-free gripping action was performed Vicenzino Yes The glide was performed whilst et al., 2001 the patient performed a pain-free gripping action Vicenzino Yes It was stated in the text that et al., 2006 the essential parameter of an MWM is that they do not inflict any pain but rather alleviate pain during normally painful actions McLean Yes Pain-free grip strength test et al., 2002 performed while the glide was sustained Abbott, 2001 Yes It is stated that the normally pain provoking movement is performed during the MWM (it is unclear whether this was pain- free during the treatment) Abbott Yes Stated that the aim for the MWM et al., 2001 was an elimination of pain with the comparable sign (normally pain provoking action) that was particular to the patient Paungmali Yes The glide was painlessly applied, et al., 2003b and a pain-free gripping action was performed O'Brien & Yes Stated that MWM success is based Vicenzino, 1998 on an immediate relief of symptoms during its application. MWM, which consisted of inversion to the end of pain free range. It was stated that the MWM reduced pain overall (unclear whether this was during or after the MWM application) Stephens, 1995 No The elimination of pain was stated, but was unclear whether this was during or after the MWM application Vicenzino & Yes Glide was performed whilst a Wright, 1995 pain-free gripping action was performed. Stated that the pain-free application was fundamental Backstrom, 2002 Yes Pain-free glides were applied. Chosen MWM resulted in immediate elimination of painful action however was not clear if this was during or after the application DeSantis & Yes The physiological movement Hasson, 2006 performed during the MWM (shoulder abduction), must be pain-free Folk, 2001 Yes The patient was instructed that the MWM with overpressure used must be pain-free Hetherington, Yes The MWM application was only 1996 continued with if the application of the glide and the active movement of ankle inversion was pain-free Hsieh et al., Yes Patient performed self MWM's, and 2002 their was an emphasis on pain- free application. In the discussion it was stated that pain alleviation is important with MWM application Author Adaptation of MWM in response to pain behaviour Bisset et al., Vicenzino (2003) states to repeat the MWM several 2006 times, only if there is a substantial decrease in pain. If the pain relief has not occurred then glides at different angles should be attempted, up to a maximum of 4 Kochar & Dogra, NS 2002 Slater et al., NS 2006 Teys et al., The MWM was ceased immediately if any pain was 2006 experienced Collins If pain was experienced during the MWM the treatment et al., 2004 was ceased, and the participant was excluded from the study Paungmali NS. Although no patients reported pain with et al., 2003a treatment Paungmali NS et al., 2004 Vicenzino NS. Although no patients reported pain with et al., 2001 treatment Vicenzino NS et al., 2006 McLean NS--The force was changed in relation to the study et al., 2002 intervention, not the pain response Abbott, 2001 If pain returned, no further repetitions were performed Abbott Four attempts of the direction of manual pressure et al., 2001 were allowed to determine which eliminated the pain. If there pain was not eliminated or it returned during treatment, no further repetitions were performed Paungmali NS et al., 2003b O'Brien & NS Vicenzino, 1998 Stephens, 1995 NS. Within the literature review of the case study they state that if the MWM application is painful, an alternative painless angle of mobilization is utilised Vicenzino & After the first treatment session causing an Wright, 1995 exacerbation of pain, the patient was encouraged to perform the gripping action well below their pain threshold during the MWM Backstrom, 2002 Continued directional modification of the imposed glide was applied throughout Rx to achieve a pain free DeSantis & NS Hasson, 2006 Folk, 2001 Constant repositioning of the joint with alteration of the glide, positioning, force, overpressure, and therapist to patient generated movement, abolished the pain Hetherington, NS 1996 Hsieh et al., NS 2002 Note: NIWM = mobilization with movement; NS = not stated. Technical Parameters of NIWM Table 3. Technical parameters of the MWM technique and rationale for treatment effectiveness Reps/Sets Y/N Author Reps Sets Number Bisset et al., Referred to Vicenzino (2003) for 2006 MWM prescription. Not stated in the study itself Kochar & Y Y 10 reps. Dogra, 2002 3 sets. 10 sessions Slater et al., Y Y 6 reps 2006 (30 sets). 3 sets. Total duration = 2.5 mins approx Teys et al., Y Y 10 reps. 2006 3 sets Collins et al., Y Y 10 reps. 2004 3 sets Paungmali et Y N 10 reps applied al., 2003a for approx 6 sets Paungmali et Y N 6 reps al., 2004 Vicenzino Y N 6 reps et al., 2001 Vicenzino Y Y 1 &2) 4 reps et al., 2006 of glides. Each glide maintained for 10 sets at end range or at the onset of pain. 4 sets per Rx. McLean et al., Y Y 2 reps each 2002 force. 4 force levels (sets) Abbott, 2001 N N Performed the provoking movement 10 times. Total time for both sides and measuring = approx 15 mins Abbott et al., Y N Up to 10 times 2001 Paungmali et Y N 10 reps al., 2003b O'Brien & Y N 4 reps Vincenzino, 1998 Stephens, 1995 N N NS Vincenzino & Y Y 6 reps. Wright, 1995 Glide sustained for approx 5-10 sets Backstrom, Y Y 3 sets of 10 2002 reps for each of the movements DeSantis & Y Y Initially: Hasson, 2006 10 reps. 2 sets. 5 more sessions: 10 x 1 only Folk, 2001 Y Y 2 sets. 10 reps Hetherington, Y Y 10 reps. 1996 3 sets Hsieh et al., Y N Self Rx: 6 reps 2002 Author Frequency Force Rest period Bisset et al., 8 sessions. NS NS 2006 6 weeks Kochar & 10 sessions. NS. NS Dogra, 2002 3 weeks Used body weight (belt) Slater et al., 1 session NS. 30 sets between 2006 Used arm force sets Teys et al., 3 sessions. NS 30 sets between 2006 24 hours apart sets Collins et al., 3 sessions. NS. 1 min between 2004 24 hours apart Use of body sets weight Paungmali et 1 session NS. 15 sets in al., 2003a Used arm force between reps. Sets not stated Paungmali et 3 sessions. NS 15 sets between al., 2004 48 hours apart reps Vicenzino 1 session NS 15 sets between et al., 2001 reps Vicenzino 1 session NS. 1) 20 sets. et al., 2006 Used a belt and 2) NS bodyweight to produce PA force McLean et al., 1 session Mean % of max 2 mins between 2002 force: each Rx 100% =113.2N 66% = 74.5N 50% = 55.6N 33% = 36.8N Abbott, 2001 1 session NS NS Abbott et al., 1 session NS NS 2001 Paungmali et 6 sessions. NS 15 sets in al., 2003b 48 hours apart between reps. Approx 48 hours between each session O'Brien & Subject 1: 6 NS NS Vincenzino, sessions over 1998 2 weeks, and 3 sessions over 1 week (with 1 week between). Subject 2: 6 sessions over 2 weeks Stephens, 1995 23 sessions NS NS Vincenzino & 4 sessions. NS No longer than Wright, 1995 2 weeks 60 sets in between reps Backstrom, 12 sessions. NS. NS 2002 2 months Used arm force and WB through the right UL DeSantis & 5 sessions. NS NS Hasson, 2006 2 weeks Used arm force Folk, 2001 1 session NS NS Hetherington, 1 session NS NS 1996 Hsieh et al., 2 hourly during NS 2 hours between 2002 waking hours sets for 3 weeks Author Bisset et al., NS 2006 Kochar & Pain relief due to sensory gating and positional Dogra, 2002 fault correction. Increased tensile strength of tissue Slater et al., To exert rapid pain relieving effects associated 2006 with sympathoexcitation mechanisms that would be likely to occur in actual tennis elbow pain Teys et al., Changes to joint or muscle structures and 2006 positional fault correction Collins et al., MWM has a mechanical effect rather than a 2004 hypoalgesic. After ankle sprain anterior displacement of the talus may occur, and MWM may correct this positional fault Paungmali et Positional fault correction has been researched, al., 2003a however physiological effects have not been. Hypoalgesic effects of MWM treatment Paungmali et Non-opioid and possible a noradrenergic endogenous al., 2004 pain modulation mechanisms Vicenzino Hypoalgesic/physiological mechanisms of pain relief et al., 2001 versus mechanical joint correction/positional fault mechanism Vicenzino Use of MWM indicated as evidence shows that people et al., 2006 with recurrent ankle sprains have common physical impairments being a lack of posterior talar glide and WB dorsiflexion. Based on the arthrokinematic principle of that the talus glides posteriorly during dorsiflexion. To improve the coupling joint motion at the talocrural joint, not just simple posterior talar glide McLean et al., Specific force needs to be applied for sufficient 2002 pain relief Abbott, 2001 People with lateral epicondylalgia have reduced shoulder rotation. A change in shoulder ROM with manual therapy at the elbow suggests that the pre intervention limitation was neurophysiologic in nature, not mechanical Abbott et al., Correcting the joint malalignment with MWM 2001 techniques has an effect on increasing muscle strength and relieving associated pain with normally provokin actions Paungmali et Yain relie due to descending pain inhibition, not al., 2003b due to endogenous opioid mediators O'Brien & Positional fault. Post ankle sprain there may be Vincenzino, antero-inferior subluxation of the distal fibula 1998 and MWM may correct this resulting in increased ROM and decreased pain Stephens, 1995 Minor positional fault occurring from an injury or strain. Mobilization perpendicular to the dysfunctional plane of motion corrects joints positional fault Vincenzino & MWM effect was to decrease pain and increase Wright, 1995 function during and immediately after its application. Positional fault correction Backstrom, Positional fault of carpal bones. MWM realigns 2002 bones allowing pain-free movement with correct alignment DeSantis & Use of MWM versus Maitland sustained glides without Hasson, 2006 movement to not only decrease pain but increase ROM and function. To restore normal arthrokinematics by decreasing dysfunctional joint alignment and then in turn allow more uniform tensile stress applied at the tendon during activities Folk, 2001 MWM was used to reposition the 1st MCP with extension movement and therefore decrease pain and improve ROM. To normalise the arthrokinematics of the 1st MCP joint Hetherington, With a lateral ankle sprain the ligament remains 1996 intact and the forces are transmitted to the fibula gliding it anteriorly creating a positional fault. Balance deficits at ankle are commonly associated with mechanoreceptor damage in relation to the malposition of the fibula Hsieh et al., MWM's used to correct positional fault and 2002 therefore decrease pain and improve ROM Note: Rx = treatment; Y = yes; N = no; Reps = repetitions; MWM = mobilisation with movement; NS = not stated;; secs = seconds; mins = minutes; approx = approximately; PA = posterior/anterior; max = maximum; N = newtons; ROM = range of motion; WB = weight bearing; UL = upper limb; MCP = metacarpophaiangeal. Table 4. Client specific outcome measure (CSOM) or comparable sign, and PILL acronym Client specific outcome Pain alteration measure (CSOM) or (Reduction +/- Author comparable sign Elimination) Bisset et al., Grip force. NS 2006 Pain VAS scale Kochar & PFGS. Yes Dogra, 2002 Pain VAS scale. Ability to lift 0-3 kgs Slater et al., PPT. NS 2006 Maximal grip and wrist extension force Teys et al., Pain-free ROM in the scapula Yes 2006 plane. PPT Collins et al., WB DF ROM. Yes 2004 PPT. TPT Paungmali et PFGS. Yes al., 2003a PPT. TPT. SNS parameters Paungmali et PFGS. Yes al., 2004 PPT. TPT. ULTT Vicenzino et PFGS. Yes al., 2001 PPT Vicenzino et Posterior talar glide. 1) Yes al., 2006 WB ankle DF ROM 2) NS McLean et PFGS Yes al., 2002 Abbott, 2001 Passive shoulder internal and Yes external ROM Abbott et al., PFGS. Yes 2001 Maximal grip strength Paungmali et PFGS. Yes al., 2003b PPT O'Brien & VAS. Yes Vicenzino, Inversion and WB DF ROM 1998 Stephens, 1995 Pain scale (VAS) during active NS and resisted wrist extension, forearm supination, and hand grip Vicenzino & PFGS Yes Wright, 1995 Backstrom, Pain VAS scale. Yes 2002 Strength and ROM at wrist and thumb DeSantis NPRS during active abduction. Yes & Hasson, 2006 Abduction active ROM Folk, 2001 Pain scale (VAS). Yes End range MCP extension with overpressure Hetherington, Pain on inversion ROM. Yes 1996 Balance--single leg standing with eyes closed Hsieh et al., Pain scale (VAS). Yes 2002 ROM Author Instantaneous effect Bisset et al., NT 2006 Kochar & NT Dogra, 2002 Slater et al., Yes--No significant effects 2006 Teys et al., Yes--significant increases in ROM 2006 and pressure pain threshold Collins et al., Yes--increase in ROM and pressure 2004 pain threshold Paungmali et Yes--increase in pain-free grip al., 2003a strength and pressure pain threshold. SNS activation Paungmali et Yes--increase in pain-free grip al., 2004 strength, pressure pain threshold and ULTT Vicenzino et Yes--increase in PFGS and PPT al., 2001 Vicenzino et Yes--increase in posterior talar glide al., 2006 and ROM McLean et Yes--increase in PFGS (only with 66% al., 2002 or 100% force) Abbott, 2001 Yes--increase in ROM Abbott et al., Yes--increase in pain-free and 2001 maximal grip strength Paungmali et Yes--increase in PFGS and PPT al., 2003b O'Brien & Yes--decrease in pain and increase in Vicenzino, ROM (inversion and DF) 1998 Stephens, 1995 Yes--decrease in pain with all hand and arm motions Vicenzino & Yes--increase in PFGS during and Wright, 1995 after application Backstrom, Yes--decrease in pain and increase 2002 in ROM DeSantis Yes--decrease in pain and increase & Hasson, 2006 in ROM Folk, 2001 Yes--pain-free end range extension with overpressure Hetherington, Yes--increase in ROM and balance 1996 Hsieh et al., Yes--immediate decrease of pain 2002 following MWM application Author Assessment of 'Long-Lasting' Bisset et al., Yes--Assessed at week 6 and 2006 52 post Rx Kochar & Yes--Assessed at 1, 2, 3 & 12 Dogra, 2002 weeks post Rx Slater et al., NT 2006 Teys et al., NT 2006 Collins et al., NT 2004 Paungmali et NT al., 2003a Paungmali et NT al., 2004 Vicenzino et NT al., 2001 Vicenzino et NT al., 2006 McLean et NT al., 2002 Abbott, 2001 NT Abbott et al., NT 2001 Paungmali et Yes--Assessed at final (6th) al., 2003b session (48 hours in between sessions) O'Brien & Yes--Assessed 3 times. 1 week Vicenzino, post Rx phase = phase C 1998 Stephens, 1995 Yes--Assessed at each session and at the end of 23 treatments Vicenzino & Yes--Assessed at 6 weeks post Wright, 1995 Rx Backstrom, Yes--Assessed at 4 months, 2002 and 1 year post Rx DeSantis NT & Hasson, 2006 Folk, 2001 Yes--Assessed at 1 month and 52 weeks post Rx Hetherington, NT 1996 Hsieh et al., Yes--Assessed 1 week post Rx 2002 Long-lasting affects stated at follow-up Author assessment Bisset et al., Physiotherapy Rx was superior to wait and see and 2006 corticosteroid injections at 6 weeks, however at 52 weeks there was no difference between physio and wait and see Kochar & Significant reductions in pain, improvements in Dogra, 2002 grip strength and lifting strength in the intervention group Slater et al., NT 2006 Teys et al., NT 2006 Collins et al., NT 2004 Paungmali et NT al., 2003a Paungmali et NT al., 2004 Vicenzino et NT al., 2001 Vicenzino et NT al., 2006 McLean et NT al., 2002 Abbott, 2001 NT Abbott et al., NT 2001 Paungmali et Hypoalgesic effect of MWM did not reduce with al., 2003b repeated applications. All treatments resulted in increased PFGS (significant) and PPT O'Brien & Reduction in pain, improved inversion and DF ROM, Vicenzino, improved functional performance at the ankle. No 1998 deterioration. Stephens, 1995 Elimination of pain would continue for 1-2 days however pain would eventually re-occur. Self-MWM would eliminate the pain again. At discharge, MWMs were still effective at decreasing pain if needed Vicenzino & Patient had no pain and had returned to full Wright, 1995 function. Strong correlation between pain reduction and increased function Backstrom, MWM application reduced pain to 0-1 / 10 (VAS). All 2002 impairments had resolved at 1 year (no evidence of wrist/thumb pain or functional deficits whatsoever) DeSantis NT & Hasson, 2006 Folk, 2001 At lyear follow-up assessment, the patient confirmed she had remained symptom free post the MWM Rx Hetherington, NT 1996 Hsieh et al., MRI examination showed no reduction in the initial 2002 positional fault, but she had no pain when flexing her right thumb Note: VAS = visual analogue scale; NS = not stated; NT = not tested; Rx = treatment; PFGS = pain free grip strength; kgs = kilograms; PPT = pressure pain threshold; ROM = range of motion; WB = weight bearing; DF = dorsiflexion; TPT = temperature pain threshold; SNS = sympathetic nervous system; ULTT = upper limb tension test; MWM = mobilisation with movement; NPRS = numeric pain rating scale; MCP = metacarpophalangeal; MRI = magnetic resonance imaging.
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|Title Annotation:||ML Roberts Prize Winner; mobilization with movement|
|Author:||Hing, Wayne; Bigelow, Renee; Bremner, Toni|
|Publication:||New Zealand Journal of Physiotherapy|
|Date:||Nov 1, 2008|
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