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Mulligan's mobilisation with movement: a review of the tenets and prescription of MWMs.

INTRODUCTION

The treatment of musculoskeletal musculoskeletal /mus·cu·lo·skel·e·tal/ (-skel´e-t'l) pertaining to or comprising the skeleton and muscles.

mus·cu·lo·skel·e·tal
adj.
Relating to or involving the muscles and the skeleton.
 joint dysfunction dysfunction /dys·func·tion/ (dis-funk´shun) disturbance, impairment, or abnormality of functioning of an organ.dysfunc´tional

erectile dysfunction  impotence (2).
 may require a physiotherapist physiotherapist /phys·io·ther·a·pist/ (-ther´ah-pist) physical therapist.

physiotherapist

physical therapist.
 to use manual therapy. One of these manual therapy techniques include mobilization with movement mobilization with movement,
n an emerging, manual therapy technique developed by Brian Mulligan, for the treatment of musculoskeletal dysfunction in which the therapist applies a passive glide mobilization to a joint while the patient performs physical
 (MWM MWM,
n See mobilization with movement.
), a type of joint mobilisation n. 1. Mobilization.

Noun 1. mobilisation - act of marshaling and organizing and making ready for use or action; "mobilization of the country's economic resources"
mobilization
 developed by Brian The name Brian (sometimes spelled Bryan) comes from an Irish backround. It is of Celtic origin and its meaning may be "hill" or "strong, noble, and high"[1].  Mulligan (Mulligan 2004, Mulligan 2007); also referred to as a Mulligan mobilisation (Collins et al 2004, Kochar and Dogra The Dogras are a Northern Indo-Aryan ethnic group in South Asia. They live predominantly in the Jammu region of Jammu and Kashmir but also in adjoining areas of Punjab, Himachal Pradesh, other parts of Kashmir, and Northeastern Pakistan.  2002, Teys et al 2006) or a manipulative ma·nip·u·la·tive  
adj.
Serving, tending, or having the power to manipulate.

n.
Any of various objects designed to be moved or arranged by hand as a means of developing motor skills or understanding abstractions, especially in
 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 accessory, in criminal law, a person who, though not present at the commission of a crime, becomes a participator in the crime either before or after the fact of commission.  glide is applied at a peripheral joint, while a normally pain-provoking physiological physiological /phys·i·o·log·i·cal/ (-loj´i-kal) pertaining to physiology; normal; not pathologic.

phys·i·o·log·i·cal or phys·i·o·log·ic
adj. Abbr. phys.
1.
 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 Exelby is a village in the Hambleton district of North Yorkshire, England. It is situated 1 mile south east of Bedale and near the A1 road.  1995, Exelby 1996, Mulligan 2004, Wilson Wilson, city (1990 pop. 36,930), seat of Wilson co., E N.C., in a rich agricultural region; inc. 1849. It is a commercial and industrial center with a large tobacco market. Manufactures include textile goods (especially clothing), metal products, and processed foods.  2001).

[FIGURE 1 OMITTED]

Further gains in pain relief may be attained at·tain  
v. at·tained, at·tain·ing, at·tains

v.tr.
1. To gain as an objective; achieve: attain a diploma by hard work.

2.
 via the application of pain-free passive overpressure overpressure,
n excessive pressure applied at the end of a physiologic joint range to confirm the severity of pain, thus helping determine the manual treatments.
 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 CSOM Carlson School of Management (University of Minnesota, Twin Cities)
CSOM Center for Sex Offender Management
CSOM Computer System Operator's Manual
CSOM Chronic Serous Otitis Media (middle ear infection) 
) as a baseline The horizontal line to which the bottoms of lowercase characters (without descenders) are aligned. See typeface.

baseline - released version
 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 articular /ar·tic·u·lar/ (ahr-tik´u-ler) pertaining to a joint.

ar·tic·u·lar
adj.
Of or relating to a joint or joints.



articular

pertaining to a joint.
 surfaces, thickness thickness (thik´nes) a measurement across the smallest dimension of an object.

triceps skinfold (TSF) thickness
 of cartilage cartilage (kär`təlĭj), flexible semiopaque connective tissue without blood vessels or nerve cells. It forms part of the skeletal system in humans and in other vertebrates, and is also known as gristle. , orientation of fibres of ligaments and capsules, or the direction and pull of muscles and tendons. MWM's correct this by repositioning repositioning Laparoscopic surgery The changing of a Pt's position during a procedure to improve access or visualization of the operative field, which may be linked to complications, as it changes anatomic planes of operation. Cf Laparoscopic surgery.  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 SNS sympathetic nervous system. ) excitation excitation

Addition of a discrete amount of energy to a system that changes it usually from a state of lowest energy (ground state) to one of higher energy (excited state). For example, in a hydrogen atom, an excitation energy of 10.
 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 DeSantis is a common surname. Well-known people with this name include:
  • Mark DeSantis, American politician
  • Tony DeSantis, American entrepreneur
  • Marko DeSantis, American rock guitarist for Sugarcult
  • Dave DeSantis, American bass guitarist for The Secret Syde
 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 Lexico is a Spanish language based object-oriented, educational programming language based on the .NET Framework.

Created to facilitate the programming education, specifically object-oriented programming techniques, Lexico has been shown to be successful in introducing
 Publishing Group Ltd 2007). With respect to MWM prescription, this definition refers to having written guidelines guidelines,
n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks.
 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 hing - (IRC) Fortuitous typo for "hint", now in wide intentional use among players of initgame.

Compare newsfroup, filk.
 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 val·i·date  
tr.v. val·i·dat·ed, val·i·dat·ing, val·i·dates
1. To declare or make legally valid.

2. To mark with an indication of official sanction.

3.
, 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 formulate /for·mu·late/ (for´mu-lat)
1. to state in the form of a formula.

2. to prepare in accordance with a prescribed or specified method.
 guidelines for clinical practice.

METHODS

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 CINAHL Cumulative Index to Nursing and Allied Health Literature  via Ovid Ovid (Publius Ovidius Naso) (ŏv`ĭd), 43 B.C.–A.D. 18, Latin poet, b. Sulmo (present-day Sulmona), in the Apennines. Although trained for the law, he preferred the company of the literary coterie at Rome.  and Ebsco Health Databases, Cochrane For places named Cochrane, see .

Cochrane is a surname of Scottish derivation. Introduction
Cochrane is a Scottish surname that is found throughout the British Isles. The surname Cochrane is the 1,339th most common last name in the United Kingdom. In the U.K.
 via Wiley Wiley may refer to:
  • Wiley, Colorado, a U.S. town
  • Wiley-Kaserne, a district of the city of Neu-Ulm, Germany
  • USS Wiley (DD-597), a U.S. destroyer from the nineteenth century named after William Wiley
  • Wiley College, a college in Texas founded by Isaac Wiley
 and Ovid, AMED AMED Allied and Alternative Medicine (database / base de donnée)
AMED Association for Management Education and Development
AMED Army Medical (US Army)
AMED Army Medical Department
, 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 mobilization

Organization of a nation's armed forces for active military service in time of war or other national emergency. It includes recruiting and training, building military bases and training camps, and procuring and distributing weapons, ammunition, uniforms,
); 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 exclusion criteria AIDS Donor exclusion criteria, see there  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 physiotherapy: see physical therapy. , spinal spinal /spi·nal/ (spi´n'l)
1. pertaining to a spine or to the vertebral column.

2. pertaining to the spinal cord's functioning independently from the brain.


spi·nal
adj.
 manual therapy, chiropractic chiropractic (kīrəprăk`tĭk) [Gr.,=doing by hand], medical practice based on the theory that all disease results from a disruption of the functions of the nerves.  studies, non-original research, cadaver cadaver /ca·dav·er/ (kah-dav´er) a dead body; generally applied to a human body preserved for anatomical study.cadav´ericcadav´erous

ca·dav·er
n.
 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 an·a·lyse  
v. Chiefly British
Variant of analyze.


analyse or US -lyze
Verb

[-lysing, -lysed] or -lyzing,
 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 Hetherington is a surname, derived from a border reiver clan living near the river Hether in Scotland.[1]

Hetherington can refer to: People
  • Janet Hetherington, comic artist
Fictional
Other
 1996, Stephens Ste·phens   , Alexander Hamilton 1812-1883.

American politician who was vice president of the Confederacy (1861-1865) under Jefferson Davis.
 1995, Vicenzino et al 2001).

Review of study characteristics

Using a generic critical appraisal Noun 1. critical appraisal - an appraisal based on careful analytical evaluation
critical analysis

appraisal, assessment - the classification of someone or something with respect to its worth
 checklist, data was extracted from the included 21 articles and information was recorded. Four specific tables relating to relating to relate prepconcernant

relating to relate prepbezüglich +gen, mit Bezug auf +acc 
 MWM prescription were also formed, which included the tenets, pain behaviour analysis, technical parameters, and response parameters (CSOM and the PILL acronym acronym: see abbreviation.


A word typically made up of the first letters of two or more words; for example, BASIC stands for "Beginners All purpose Symbolic Instruction Code.
). Each reviewer re·view·er  
n.
One who reviews, especially one who writes critical reviews, as for a newspaper or magazine.


reviewer
Noun

a person who writes reviews of books, films, etc.

Noun 1.
 analysed all of this data. The content of these tables will be discussed further in the results.

[FIGURE 2 OMITTED]

RESULTS

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 Adj. 1. randomised - set up or distributed in a deliberately random way
randomized

irregular - contrary to rule or accepted order or general practice; "irregular hiring practices"
 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 in·stan·ta·ne·ous  
adj.
1. Occurring or completed without perceptible delay: Relief was instantaneous.

2.
 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 duplication /du·pli·ca·tion/ (doo-pli-ka´shun)
1. the act or process of doubling, or the state of being doubled.

2.
 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 Alt·man   , Robert Born 1925.

American film director and screenwriter whose film credits include M*A*S*H (1970), for which he won an Academy Award, and The Player (1992).
 and Burton Burton can mean: Places
Australia
  • Burton, South Australia, a suburb of Adelaide
Canada
  • Burtonsville, Alberta
  • Burton, British Columbia
  • Burton, New Brunswick
  • Burton, Ontario
  • Burton Brae, New Brunswick
 1999, Backstrom 2002, Bisset Bisset is a surname, and may refer to:
  • Andrew Bisset
  • Baldred Bisset
  • Jacqueline Bisset
  • Murray Bisset
  • Sonia Bisset
See also
  • Bissett

This page or section lists people with the surname 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 Kavanagh or Kavanaugh may refer to:

People with the surname Kavanagh or Kavanaugh:
  • Kavanagh (surname)
In places:
  • Kavanagh, Alberta, a hamlet in Canada
Other:
  • Kavanagh QC, a television series
 1999, Kochar and Dogra 2002, Lexico Publishing Group Ltd 2007, McLean McLean, city (1990 pop. 38,168), Fairfax co., N Va., a suburb of Washington, D.C. Manufacturing includes foods, satellite components, and computer and telecommunications equipment.  et al 2002, Monteiro and Victora 2005, Mulligan 1989, Mulligan 1995, Mulligan 1999, Mulligan 2004, Mulligan 2006, Mulligan 2007, O'Brien O'Bri·en   , Edna Born 1932.

Irish writer whose works, including The Lonely Girl (1962) and Johnny I Hardly Knew You (1977), explore the lives of women in modern-day Ireland.

Noun 1.
 and Vicenzino 1998, Paungmali et al 2003a, Paungmali et al 2004, Paungmali et al 2003b, Roddy Rod´dy

a. 1. Full of rods or twigs.
1. Ruddy.
 et al 2005, Saunders et al 2003, Slater slat·er  
n.
1. One employed to lay slate surfaces, as on roofs.

2. See pill bug.

3. See sow bug.

Noun 1.
 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

Accessory glide

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 epicondylalgia /epi·con·dy·lal·gia/ (-kon?dil-al´jah) pain in the muscles or tendons attached to the epicondyle of the humerus.

ep·i·con·dy·lal·gia
n.
. All studies at the elbow very near; at hand.

See also: Elbow
 applied a lateral glide to the ulna ulna: see arm. . The second most common form of glide was an anterior-posterior mobilisation either directly from mobilising the distal distal /dis·tal/ (-t'l) remote; farther from any point of reference.

dis·tal
adj.
1. Anatomically located far from a point of reference, such as an origin or a point of attachment.
 bone of the joint, or mobilising the proximal proximal /prox·i·mal/ (-mil) nearest to a point of reference, as to a center or median line or to the point of attachment or origin.

prox·i·mal
adj.
 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).

Physiological movement

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 Noun 1. Jensen - modernistic Danish writer (1873-1950)
Johannes Vilhelm 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 dorsiflexion /dor·si·flex·ion/ (dor?si-flek´shun) flexion or bending toward the extensor aspect of a limb, as of the hand or foot.

dor·si·flex·ion
n.
The turning of the foot or the toes upward.
 or inversion inversion /in·ver·sion/ (in-ver´zhun)
1. a turning inward, inside out, or other reversal of the normal relation of a part.

2. a term used by Freud for homosexuality.

3.
 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 scapula /scap·u·la/ (skap´u-lah) pl. scap´ulae   [L.] shoulder blade; the flat, triangular bone in the back of the shoulder. scap´ular

scap·u·la
n. pl.
 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 (1) See Microsoft certification.

(2) (MultiChip Package) A chip package that contains two or more chips. It is essentially a multichip module (MCM) that uses a laminated, printed-circuit-board-like substrate (MCM-L) rather than ceramic (MCM-C).
 flexion flexion /flex·ion/ (flek´shun) the act of bending or the condition of being bent.

flex·ion
n.
1. The act of bending a joint or limb in the body by the action of flexors.

2.
 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 pro·vok·ing  
adj.
Troubling the nerves or peace of mind, as by repeated vexations: a provoking delay at the airport.



pro·vok
 movement, with which the MWM was to eliminate this pain.

'Pain-free' or pain alteration Modification; changing a thing without obliterating it.

An alteration is a variation made in the language or terms of a legal document that affects the rights and obligations of the parties to it.
 (reduction +/- elimination)

Mulligan (2004) states that the MWM technique must be pain-free during its application. This tenet TENET. Which he holds. There are two ways of stating the tenure in an action of waste. The averment is either in the tenet and the tenuit; it has a reference to the time of the waste done, and not to the time of bringing the action.
     2.
 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 con·verse 1  
intr.v. con·versed, con·vers·ing, con·vers·es
1. To engage in a spoken exchange of thoughts, ideas, or feelings; talk. See Synonyms at speak.

2.
 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 PERTINENT, evidence. Those facts which tend to prove the allegations of the party offering them, are called pertinent; those which have no such tendency are called impertinent, 8 Toull. n. 22. By pertinent is also meant that which belongs. Willes, 319.  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 Noun 1. pain threshold - the lowest intensity of stimulation at which pain is experienced; "some people have much higher pain thresholds than do other people"
absolute threshold - the lowest level of stimulation that a person can detect
 (TPT TPT Transport
TPT Trumpet (music scores)
TPT The Physics Teacher
TPT Tara Palmer-Tomkinson (UK celebrity)
TPT Trailer Park Trash
TPT Temporary Part Time
TPT Thermodynamic Perturbation Theory
), 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

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 su·pra·spi·na·tus
n.
A muscle with origin from the supraspinous fossa of the scapula, with insertion into the humerus, with nerve supply from the suprascapular nerve, and whose action abducts the arm.
 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 Grip strength is the force applied by the hand to pull on or suspend from objects. Optimum-sized objects permit the hand to wrap around a cylindrical shape with a diameter from one to three inches.  was applied, overpressure is indirectly incorporated into any of the studies assessing the effects of MWM at the elbow that focused on lateral epicondylalgia.

Repetitions/sets

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 pre·scribe  
v. pre·scribed, pre·scrib·ing, pre·scribes

v.tr.
1. To set down as a rule or guide; enjoin. See Synonyms at dictate.

2. To order the use of (a medicine or other treatment).
 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.

Frequency

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 handheld: see personal digital assistant.  dynamometer dynamometer /dy·na·mom·e·ter/ (di?nah-mom´e-ter) an instrument for measuring the force of muscular contraction.

dy·na·mom·e·ter
n.
An instrument for measuring the degree of muscular power.
, therapists applied a lateral glide to elbows with lateral epicondylalgia at 33%, 50%, 66% or 100% of maximal max·i·mal
adj.
1. Of, relating to, or consisting of a maximum.

2. Being the greatest or highest possible.
 force. The outcome measure was pain-free grip strength (PFGS PFGS Progressive Fine Granularity Scalable Video Coding
PFGS Postgraduate Forum on Genetics and Society
), 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).

Rest periods

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).

Response Parameters

Long-lasting

Effective MWM's should have a long-lasting effect in order for permanent change to occur. This is a further response parameter (1) Any value passed to a program by the user or by another program in order to customize the program for a particular purpose. A parameter may be anything; for example, a file name, a coordinate, a range of values, a money amount or a code of some kind. , as proposed by Vicenzino & Hing (Hing, 2007). Unfortunately this was only investigated in nine of the studies (43%) via follow-up follow-up,
n the process of monitoring the progress of a patient after a period of active treatment.


follow-up

subsequent.


follow-up plan
 assessments to establish deterioration de·te·ri·o·ra·tion
n.
The process or condition of becoming worse.
 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 In human anatomy, the upper limb (also upper extremity) refers to what in common English is known as the arm, that is, the region of the shoulder to the fingertips. It includes the entire limb, and thus, is not synonymous with the term upper arm.  tension tests (ULTT ULTT Upper Limb Tension Test ), 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 induced /in·duced/ (in-dldbomacst´)
1. produced artificially.

2. produced by induction.

induced,
adj artificially caused to occur.


induced

induction.
 condition. All other studies utilised patients with genuine pathologies, whereas this study induced lateral epicondylalgia pain via delayed onset of muscle soreness and hypertonic hypertonic /hy·per·ton·ic/ (-ton´ik)
1. denoting increased tone or tension.

2. denoting a solution having greater osmotic pressure than the solution with which it is compared.
 saline saline /sa·line/ (sa´len) (sa´lin) salty; of the nature of a salt; containing a salt or salts.

normal saline , physiological saline physiologic saline solution.
.

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 naloxone /nal·ox·one/ (nal-ok´son) an opioid antagonist, used as the hydrochloride salt in opioid toxicity, opioid-induced respiratory depression, and hypotension associated with septic shock.  did not have an inhibitory inhibitory /in·hib·i·to·ry/ (-tor?e) restraining or arresting any process; effecting a stay or arrest, partial or complete.

inhibitory

emanating from or pertaining to inhibition.
 effect on the pain relieving effects, therefore suggests that a non-opioid mechanism occurs for the analgesic analgesic (ăn'əljē`zĭk), any of a diverse group of drugs used to relieve pain. Analgesic drugs include the nonsteroidal anti-inflammatory drugs (NSAIDs) such as the salicylates, narcotic drugs such as morphine, and synthetic drugs  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 corticosteroid /cor·ti·co·ster·oid/ (-ster´oid) any of the steroids elaborated by the adrenal cortex (excluding the sex hormones) or any synthetic equivalents; divided into two major groups, the glucocorticoids and  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 flux

In metallurgy, any substance introduced in the smelting of ores to promote fluidity and to remove objectionable impurities in the form of slag. Limestone is commonly used for this purpose in smelting iron ores.
 and skin temperature. These are similar to the effects of spinal manipulation For detail of manipulation in individual synovial joints, see .
Definition
Spinal manipulation is manipulation of synovial joints in the spinal column. The most commonly cited of these are the zygapophysial joints.
 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 magnetic resonance imaging (MRI), noninvasive diagnostic technique that uses nuclear magnetic resonance to produce cross-sectional images of organs and other internal body structures.  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.

DISCUSSION

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.

Tenets

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 sur·round  
tr.v. sur·round·ed, sur·round·ing, sur·rounds
1. To extend on all sides of simultaneously; encircle.

2. To enclose or confine on all sides so as to bar escape or outside communication.

n.
 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).

Technical Parameters

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 A procedure used in a lawsuit by which the court allows a third person who was not originally a party to the suit to become a party, by joining with either the plaintiff or the defendant.  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 This article is about the Elton John box set. For the plot device commonly featuring the phrase "To be continued", see Cliffhanger.

To Be Continued
 with.

Response Parameters

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 analgesia /an·al·ge·sia/ (an?al-je´ze-ah)
1. absence of sensibility to pain.

2. the relief of pain without loss of consciousness.
 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 1. (application) MRI - Magnetic Resonance Imaging.
2. MRI - Measurement Requirements and Interface.
) 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 no·ci·cep·tive
adj.
1. Causing pain. Used of a stimulus.

2. Caused by or responding to a painful stimulus.
 and motor system dysfunction, possibly implying the role of hypoalgesia hy·po·al·ge·sia
n.
Variant of hypalgesia.


hypoalgesia (hī´pōaljē´zē
. 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 algorithm (ăl`gərĭth'əm) or algorism (–rĭz'əm) [for Al-Khowarizmi], a clearly defined procedure for obtaining the solution to a general type of problem, often numerical.  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 irritability /ir·ri·ta·bil·i·ty/ (ir?i-tah-bil´i-te) the quality of being irritable.

myotatic irritability  the ability of a muscle to contract in response to stretching.
.

Future Research

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.

CONCLUSION

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 in·con·sis·tent  
adj.
1. Displaying or marked by a lack of consistency, especially:
a. Not regular or predictable; erratic: inconsistent behavior.

b.
 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 clinician /cli·ni·cian/ (kli-nish´in) an expert clinical physician and teacher.

cli·ni·cian
n.
 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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Altman DG and Burton MJ (1999): The cochrane collaboration The Cochrane Collaboration was developed in response to Archie Cochrane's call for up-to-date, systematic reviews of all relevant randomized controlled trials of health care. . Langenbeck's Archive of Surgery 384: 432-436.

Backstrom KM (2002): Mobilization with movement as an adjunct adjunct (aj´ungkt),
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adjunct 
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Adj. 1. orthopaedic - of or relating to orthopedics; "orthopedic shoes"
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Downs SH and Black N (1998): The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Journal of Epidemiology epidemiology, field of medicine concerned with the study of epidemics, outbreaks of disease that affect large numbers of people. Epidemiologists, using sophisticated statistical analyses, field investigations, and complex laboratory techniques, investigate the cause  and Community Health 52: 377-384.

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adj of, pertaining to, or caused by an injury.

traumatic occlusion,
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traumatic shock,
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Hartling L, Brison RJ, Crumley ET, Klassen Klassen is the surname of:
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  • Cindy Klassen (born 1979), Canadian skater
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Hetherington B (1996): Lateral ligament ligament (lĭg`əmənt), strong band of white fibrous connective tissue that joins bones to other bones or to cartilage in the joint areas. The bundles of collagenous fibers that form ligaments tend to be pliable but not elastic.  strains of the ankle, do they exist? Manual Therapy 1: 274-275.

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Hing W (2007). Personal communication surrounding the concepts of MWM prescription. Vicenzino B. Auckland University of Technology Not to be confused with the University of Auckland.
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Hsieh CY, Vicenzino B, Yang yang (yang) [Chinese] in Chinese philosophy, the active, positive, masculine principle that is complementary to yin; see yin, under principle.  CH, Hu MH and Yang C (2002): Mulligan's mobilization with movement for the thumb: a single case report using magnetic resonance imaging to evaluate the positional fault hypothesis. Manual Therapy 7: 44-49.

Kavanagh J (1999): Is there a positional fault at the inferior INFERIOR. One who in relation to another has less power and is below him; one who is bound to obey another. He who makes the law is the superior; he who is bound to obey it, the inferior. 1 Bouv. Inst. n. 8.  tibiofibular joint Tibiofibular joint may refer to:
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reg·i·men
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McLean S, Naish Naish might refer to:
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  • The Naish District in Afghanistan
  • Robby Naish windsurfer and kitesurfer, also Naish kites, sails and boards
 R, Reed L, Urry Ur´ry

n. 1. A sort of blue or black clay lying near a vein of coal.
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Mulligan B (1989): Manual therapy: "nags", "snags SNAGS,
n.pl See sustained natural apophyseal glides.
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Mulligan B (1995): Manual therapy: "NAGS", "SNAGS", "MWMS MWMS Maintenance Workload Management System
MWMS Maximum Weight Matching Scheduling
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Roddy E, Zhang W, Doherty
for people named Doherty see: Doherty (disambiguation)
The Doherty Clan (Irish: Clann Ua Dochartaigh) is an Irish clan based in County Donegal in the north of the island of Ireland.
 M, Arden Ar·den  

An unincorporated city of north-central California, a residential suburb of Sacramento. Population: 101,400.



Arden, Elizabeth 1884?-1966.
 NK, Barlow bar·low  
n.
An inexpensive, one- or two-bladed pocketknife.



[After Barlow, the family name of its makers, two brothers in Sheffield, England.]
 J, Birrell F, Carr CARR Carrier
CARR Customer Acceptance Readiness Review
CARR Carrollton Railroad
CARR Corrective Action Request and Report
CARR City Area Rural Rides (Texas)
CARR Configuration Audit Readiness Review
CARR Customer Acceptance Requirements Review
 A, Chakravarty K, Dickson Dickson may refer to several placenames: Australia
  • Dickson, Australian Capital Territory in Canberra
  • Dickson Centre, Australian Capital Territory in Canberra
  • Division of Dickson, Electoral Division, Queensland
Malawi
 J, Hay E, Hoise v. t. 1. To hoist.
They . . . hoised up the mainsail to the wind.
- Acts xxvii. 40.
 G, Hurley Hurley has become the English version of at least three distinct original Irish names: the Ó hUirthile, part of the Dál gCais tribal group, based in Clare and North Tipperary; the Ó Muirthile, based around Kilbritain in west Cork; and the OhIarlatha, from the district of  M, Jordan Jordan, country, Asia
Jordan, officially Hashemite Kingdom of Jordan, kingdom (2005 est. pop. 5,760,000), 35,637 sq mi (92,300 sq km), SW Asia. It borders on Israel and the West Bank in the west, on Syria in the north, on Iraq in the northeast, and on Saudi
 K, McCarthy Mc·Car·thy   , Joseph Raymond 1908-1957.

American politician. A U.S. senator from Wisconsin (1947-1957), he presided over the permanent subcommittee on investigations and held public hearings in which he accused army officials, members of the media,
 C, McMurdo McMurdo may refer to:
  • McMurdo Station, a station at the southern tip of Ross Island in Antarctica.
  • McMurdo Sound, a sound about 55 km (35 mi) long and wide, lying at the junction of the Ross Sea.
 M, Mockett S, O'Reilly S, Peat G, Pendleton Pendleton, city (1990 pop. 15,126), seat of Umatilla co., NE Oreg., on the Umatilla River, in the foothills of the Blue Mts.; founded 1869 on the old Oregon Trail, inc. 1889.  A and Richards Rich·ards , Dickinson Woodruff 1895-1973.

American physician. He shared a 1956 Nobel Prize for developing cardiac catheterization.
 S (2005): Evidence-based recommendations for the role of exercise in the management of osteoarthritis osteoarthritis
 or osteoarthrosis or degenerative joint disease

Most common joint disorder, afflicting over 80% of those who reach age 70. It does not involve excessive inflammation and may have no symptoms, especially at first.
 of the hip or knee--the MOVE consensus. Rheumatology rheumatology /rheu·ma·tol·o·gy/ (-tol´ah-je) the branch of medicine dealing with rheumatic disorders, their causes, pathology, diagnosis, treatment, etc.

rheu·ma·tol·o·gy
n.
 44: 67-73.

Saunders LD, Soomro Soomro or Soomra (Urdu: سومرو ) is the name of a Sindhi tribe in Sindh, Pakistan. The Soomra Dynasty ruled Sindh in 1026-1351 CE a period of nearly 300 years.  GM, Buckingham Buck·ing·ham   , First Duke of Originally George Vil·liers 1592-1628.

English courtier and statesman whose military and political policies caused continual friction with Parliament. He was assassinated by a disgruntled naval officer.
 J, Jamtvedt G and Raina P (2003): Assessing the methodological quality of nonrandomized intervention studies intervention studies,
n.pl the epidemiologic investigations designed to test a hypothesized cause and effect relation by modifying the supposed causal factor(s) in the study population.
. Western Journal of Nursing Research 25: 223-237.

Slater H, Arendt-Nielson L, Wright A and Graven grav·en  
v.
A past participle of grave3.

Adj. 1. graven - cut into a desired shape; "graven images"; "sculptured representations"
sculpted, sculptured
 N (2006): Effects of a manual therapy technique in experimental lateral epicondylalgia. Manual Therapy 11: 107-117.

Stephens G (1995): Lateral epicondylitis ep·i·con·dy·li·tis
n.
Infection or inflammation of an epicondyle.


Epicondylitis
A painful and sometimes disabling inflammation of the muscle and surrounding tissues of the elbow caused by repeated stress and strain
. Journal of Manipulative and Manual Therapy 3: 50-58.

Teys P, Bisset L and Vicenzino B (2006): The initial effects of a Mulligan's mobilization with movement technique on range of movement and pressure pain threshold in pain-limited shoulders. Manual Therapy 11: 1-6.

Vicenzino B (2003): Lateral epicondylalgia: a musculoskeletal physiotherapy perspective. Manual Therapy 8: 66-79.

Vicenzino B, Branjerdporn M, Teys P and Jordan K (2006): Initial changes in posterior posterior /pos·ter·i·or/ (pos-ter´e-er) directed toward or situated at the back; opposite of anterior.

pos·te·ri·or
adj.
1. Located behind a part or toward the rear of a structure.
 talar glide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent recurrent /re·cur·rent/ (re-kur´ent) [L. recurrens returning]
1. running back, or toward the source.

2. returning after remissions.


re·cur·rent
adj.
1.
 ankle sprain ankle sprain Orthopedics A stretching of the ankle ligaments and/or muscles with swelling . Journal of Orthopaedic & Sports Physical Therapy 36: 464-471.

Vicenzino B, Paungmali A, Buratowski S and Wright A (2001): Specific manipulative therapy treatment for chronic lateral epicondylalgia produces uniquely characteristic hypolgesia. Manual Therapy 6: 205-212.

Vicenzino B, Paungmali A and Teys P (2007): Mulligan's mobilization-with-movement, positional faults, and pain relief: Current concepts from a critical review of literature. Manual Therapy 12: 98-108.

Vicenzino B and Wright A (1995): Effects of a novel manipulative physiotherapy technique on tennis elbow: a single case study. Manual Therapy 1: 30-35.

Wilson E (2001): The Mulligan concept: NAGS, SNAGS and mobilizations with movement. Journal of Bodywork bodywork /body·work/ (-wurk?) a general term for therapeutic methods that center on the body for the promotion of physical health and emotional and spiritual well-being, including massage, various systems of touch and manipulation,  and Movement Therapies 5: 81-89.

Zhang W, Roddy E, Doherty M, Arden NK, Barlow J, Birrell F, Carr A, Chakravarty K, Dickson J, Hay E, Hoise G and Hurley M (2005): Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee--the MOVE consensus.

Wayne Wayne, city (1990 pop. 19,899), Wayne co., SE Mich., a suburb of Detroit, on the Lower Rouge River; inc. as a village 1869, and with surrounding areas as a city 1960. It has automobile and aircraft industries and other varied manufactures.  Hing PhD

Associate Professor, Health & Rehabilitation rehabilitation: see physical therapy.  Research Centre, AUT AUT n abbr (BRIT) (= Association of University Teachers) → sindicato de profesores de universidad

AUT n abbr (Brit) (= Association of University Teachers) →
 University

Renee Renee is a common female name in the United States and male name in Europe. Pronunciation: rε-'nei The word Renee can mean the following: reborn, born again. There is often an accent over the middle e, as in Renée.  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 School of Physiotherapy is located in Lahore, Punjab, Pakistan. It is located in Mayo Hospital and is affiliated with King Edward Medical College. , Auckland University of Technology

ADDRESS FOR CORESPONDENCE

Associate Professor Wayne Hing, School of Physiotherapy, Health & Rehabilitation Research Centre, AUT University, Private Bag 92006, Auckland Auckland (ôk`lənd), city (1996 pop. 345,768; urban agglomeration pop. 991,796), N North Island, New Zealand. It is situated on an isthmus and is the largest urban region and chief port of the country.  1142, New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. .
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
Article Type:Report
Geographic Code:8NEWZ
Date:Nov 1, 2008
Words:13910
Previous Article:Ethical review of physiotherapy research.
Next Article:Autonomy and the future of speaking about physiotherapy.
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