ML Roberts Prize Winner This literature review won the annual ML Roberts prize awarded for the best 4th year undergraduate research project at AUT University in 2007. NZJP publishes the resulting paper without internal peer review.
Mulligan’s mobilisation with movement: a review of the tenets and prescription of MWMs Wayne Hing PhD Associate Professor, Health & Rehabilitation Research Centre, AUT University Renee Bigelow BHSc (Physiotherapy) Toni Bremner BHSc (Physiotherapy) At the time this paper was written, these authors were 4th year students at the School of of Physiotherapy, Auckland University of Technology
ABSTRACT Introduction: Mulligan’s manual therapy technique at peripheral joints, namely mobilisation with movement (MWM), has been well documented in research for over a decade. The specic parameters of MWM prescription are relativel y variable and generally ill dened. The purpose of this review was to critically evaluate the literature regarding MWM prescription at peripheral joints. Methods: A search was conducted from 1990 to June 2007, to identify all studies pertaining to MWM’s at peripheral joints, using the keywords mobilisation with movement* OR mobilization with movement* OR MWM*; manual therapy AND (mobilisation* OR mobilization); mulligan mobilisation* OR mulligan mobilization* from the following databases: Cinahl, Medline and Amed via Ovid, Pubmed and Medline via Ebsco Health Databases, Cochrane via Wiley and PEDro. Two researchers independently reviewed all papers and cross-examined reference lists for further potential studies. Tables were compiled to determine study content and the specics regarding MWM prescription; including tenets, technical, and response parameters. Results: Twenty-one studies, which have investigated MWM’s at peripheral joints, were included for analysis. This review highlights that specic parameters identied for MWM prescription (tenets, technical and response parameters), are variable and in general inconsistently inconsistentl y implemented and explained. The efcacy of MWM’s at peripheral joints is well established for various joints and pathologies with 20 out of 21 studies (95%) demonstrating positive effects overall. Conclusions: A proposed algorithm algorithm has been formulated formulated for the integration integration into clinical practice to ensure necessary parameters are considered. It would be advisable that future research has more robust methodology metho dology and investigates and/ or implements all necessary established established parameters of MWM prescription. Hing W, Bigelow R, Bremner T (2008): Mulligan’s mobilisation with movement: a review of the tenets and prescription of MWMs. New Zealand Journal of Physiotherapy 36(3): 144-164. Keywords: mobilisation with movement, MWM, manual therapy, mulligan mobilisation, manipulative technique.
InTRODUcTIOn The treatment of musculoskeletal joint dysfunction may require a physiotherapist to use manual therapy. One of these manual therapy techniques include mobilization with movement (MWM), a type of joint mobilisation developed by Brian Mulli Mulligan gan (Mulli (Mulligan gan 2004, Mullig Mulligan an 2007) 2007);; also referred to as a Mulligan mobilisation (Collins et al 2004, Kochar and Dogra 2002, Teys et al 2006) or a manipulative technique (Paungmali et al 2003b, Vicenzino et al 2001). The MWM technique consists of many necessary parameters for prescription, prescriptio n, which are outlined in Figure 1. An accessory glide is applied at a peripheral joint, while a normally pain-provoking physiological physiolo gical movement or action is actively or passivel passively y performed. A key component to MWM is that pain should always be reduced and/or eliminated during the application (Exelby 1995, Exelby 1996, Mulligan 2004, Wilson 2001).
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Parameters
Tenets (Hing 2007, Mulligan 2004) Accessory glide • Physiological movement • Pain-free or pain alteration * • Immediate/instantaneous effect * • Overpressure • ∞
Note: * = Duplication of parameters as defined by different clinicians
∞ ∞ ∞ ∞
Technical Parameters (Hing, 2007) Repetitions • Sets • Frequency • Amount of force • Rest periods • ∞ ∞ ∞ ∞ ∞
Response Parameters (‘PILL’ Acronym) (Hing, 2007) Pain-free or pain alteration * • Immediate/instantaneous effect * • Long-Lasting • Client specific outcome measure (CSOM) • or comparable sign ∞ ∞ ∞ ∞
Figure 1: Key parameters of MWM prescription
Further gains in pain relie may be attained via the application o pain-ree passive overpressure NZ Journal of Physiotherapy – November 2008, Vol. Vol. 36 (3)
at the end o the available range during the MWM (Mulligan, 2004; Wilson, 2001). Adaptation, or ‘tweakanology’ as described by Mulligan, is essential to perorm i the technique does not positively improve pain behaviour (Exelby 1996). Primarily this includes the direction or angle o the accessory glide, and/or the amount o orce. The MWM technique also requires a comparable sign or client specic outcome measure (CSOM) as a baseline measure, to evaluate treatment eectiveness (Exelby 1995, Exelby 1996, Wilson 2001). With respect to the research, the clinical ecacy o Mulligan’s MWM techniques has been established or improving joint unction, with a number o hypotheses or its cause and eect. Mulligan’s original theory or the eectiveness o an MWM is based on the concept concept related to a ‘positional ‘positional ault’ that occur secondary to injury and lead to maltracking o the joint; resulting in symptoms such as pain, stiness or weakness (Mulligan, 2004). The cause o positional aults has been suggested to be due to changes in the shape o articular suraces, thickness o cartilage, orientation o bres o ligaments and capsules, or the direction directio n and pull o muscles and tendons. MWM’s correct this by repositioning repositionin g the joint causing it to track normally (Mulligan, 2004; Wilson, 2001). More recent studies have investigated urther mechanisms that including the hypoalgesic and sympathetic nervous system (SNS) excitation eects (Abbott 2001, Paungmali et al 2003a, Paungmali et al 2004, Teys et al 2006). Further research has established the eectiveness o MWM’s or increasing joint range o motion (ROM), enhancing muscle unction, or more speciically treating particular pathologies patholog ies (Collins et al 2004, DeSantis and Hasson 2006, Exelby 1996, Mulligan 2004, Paungmali et al 2003b, Teys et al 2006, Vicenzino et al 2006). Despite the common use o MWM techniques in clinical practice or many musculoskeletal conditions, the prescription is not clearly dened, although there is common reerence in the literature to Mulligan’s recommendations as outlined in his text (Mulligan 2004). Prescription reers to many parameters within an MWM, including tenets, technical and response parameters, along with a comparable sign or CSOM (reer to Figure 1). Prescription can be dened as ‘a written direction or the preparation, compounding, and administration o a medicine’ (Lexico Publishing Group Ltd 2007). With respect to MWM prescription, this denition reers to having written guidelines that are clearly dened to draw on or the application o this treatment technique. Tenets represent the principles included in an MWM, which have been outlined by Mulligan (Hing 2007, Mulligan 2004) . Both the technical and response parameters are contemporary concepts devised by Vicenzino & Hing (Hing, 2007). To date these aspects o prescript prescription ion have not yet been reviewed or validated, which
may impact on the clinical application o MWM treatment. Thereore Ther eore,, the purp purpose ose was to unde undertak rtake e a revie review w to critically evaluate the literature regarding MWM prescription at peripheral joints and to determine the specic parameters and rationale related to this prescription thus in attempt to ormulate or mulate guidelines or clinical practice.
MeTHODs Litratur sarh stratgy The pur purpos pose e o thi this s rev review iew was to res resear earch ch rel releva evant nt articles in relation to MWM o peripheral joints only. The electr electronic onic datab databases ases in the searc search h rom 1990 to June 2007, 2007, included: CINAHL CINAHL via Ovid and Ebsco Health Databases, Cochrane via Wiley and Ovid, AMED, Medl Medline ine via Ebsc Ebsco o and Pubm Pubmed, ed, and PEDro PEDro.. The rened key key terms, included mobilisation mobilisation with movement* OR mobilization with movement* OR MWM*; manual therapy AND (mobilisation* OR mobilization);; mulligan mobilisation mobilization) mobilisation** OR mulligan mobilization*. These search phrases were adapted or particular databases (Medline via Pubmed and Ebsco, and Ebsco Health Databases), due to the excessive number o results (reer (re er to Figure 2). While perorming peror ming the search, two independent researchers evaluated all titles and abstracts and were obtained obtai ned rom the various databases or rom other sources to determine appropriateness. I this was unclear the ull-text article was obtained to conrm 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 fow chart below (Figure 2). Exclusion criteria which was incorporated during the search included: studies prior to 1990, non-English written articles, studies not relevant to peripheral joint manual therapy/MWM/ physiotherapy, spinal manual therapy, chiropractic studies, non-original research, cadaver or animal studies, and/or i there was no clear indication o the use o MWM. The aim o this review was to obtain every study, which has utilised MWM techniques; thereore no restrictions were placed on study design or methodological quality. All literature needed to be reviewed accurately to analyse the possible variations in its prescription. As papers were examined, examined, reerence reerence lists were cross cross checked checked by both reviewers or citations citations o other potentially potentially relevant studies, and in total three studies were subsequently retrieved rom this process o crossreerencing (Hetherington 1996, Stephens 1995, Vicenzino Vicenzin o et al 2001). 2001). Rviw o study charatriti Using a generic critical appraisal checklist, data was extracted rom the included 21 articles and inormation inormat ion was recorded. Four specic tables relating to MWM prescription were also ormed, which inclu included ded the tenets tenets,, pain behav behaviour iour analys analysis, is, technical parameters, and response parameters (CSOM and the PILL acronym). Each reviewer
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Figure 2: Flow chart outlining research process
Objective: Two independent researchers to obtain relevant articles in relation to mobilisation with movement in peripheral joints only Global search followed by a refined search (exclusion criteria implemented)
Generic search terms for the refined search: KEY: A) mobilization* with movement O R mobilisation* with movement OR MWM* B) manual therapy AND (mobilization* OR mobilisation*) C) mulligan mobilization* OR mulligan mobilisation* Sources:
1)
Amed A) 22 results B) 56 results C) 1 results
2)
3)
4)
Cinahl via Ovid A) 29 results B) 132 results C) 2 results Cochrane via Ovid A) 11 results B) 53 results C) 1 results Cochrane via Wiley A) 84 results B) 1 results C) 4 results
Excluded:
A) 10 B) 51 C) 0
Excluded:
A) 16 B) 126 C) 1
Excluded:
A) 2 B) 50 C) 0
Excluded:
A) 84 B) 1 C) 0
5) Ebsco Health Databases NB: Adapted se arch terms: [A) mobilization* with movement OR mobilisation* with movement ] A) 24 results Excluded: B) 89 results C) 1 results
A) 10 B) 84 C) 1
6) Medline via Ebsco NB: Adapted se arch terms: [A) mobilization* with movement OR mobilisation* with mo vement ] A) 19 results Excluded: B) 68 results C) 0 results
A) 6 B) 63 C) 0
7) Medline via Pubmed NB: Adapted search terms mobilization* with movement OR mobilisation* with movement OR MWM* = 71398 mobilization* with movement OR mobilisation* with movement = 71173 i.e. [A) manual therapy AND (mobilization* with movement OR mobilisation* with movement OR MWM*] manual therapy AND (mobilization* OR mobilisation*) = 28 73 i.e. [B) manual physical therapy AND (mobilization* OR mobilisation*) ]
8)
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A) 333 results B) 111 results C) 634 results
Excluded:
A) 319 B) 110 C) 632
A) 3 results B) 22 results C) 3 results
Excluded:
A) 0 B) 20 C) 0
PEDro
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Figure 2 (continued)
Selected Studies
TOTAL articles identified for analysis in relation to the exclusion criteria: 117 studies Cross matching of search results for repeated articles resulted in: 18 studies Cross-referencing of all articles resulted in: 3 studies
Total: 21 studies to be reviewed 4 True randomised control trials (RCTs) 5 Randomised control trials, participants as own control 1 Quasi-experimental study (no control) 3 Non-experimental studies (2 pretest/posttest, 1 repeated me asures) 3 Case studies
-
5 Case reports
Critiquing method: -
analysed all o this data. The content o these tables will be discussed urther in the results.
ResULTs During the search, articles were excluded on the basis o the strict exclusion criteria previously mentioned. A total o 117 articles were identied rom the stated databases (reer to Figure 2 or details). Once search results were matched or repeated articles between the databases, 18 were included or analysis. An additional three studies were ound by means o urther cross-reerencing by both reviewers (Hetherington 1996, Stephens 1995, Vicenzino et al 2001), increasing the total to 21 studies or analysis - including our true randomised controlled trials (RCT’s), ve RCT’s with par ticip ant s as own control, one quasiexperimental, three non-experimental, three case studies, and ve case reports. Further detail o each o the studies methodological data variation and study design are detailed in Appendix 1. 1) sif paramtr ad Ratioal Rlatd to MWM prritio Within the prescription o MWM’s, there are dierent areas that need investigating. Firstly there are the ve 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 eect, and the use o overpressure, which are outlined in Table 1 (Hing, 2007). Pain behaviour is urther elaborated in Table 2. The second consideration o MWM’s is the technical parameters o prescription, which are: repetitions, sets, requency, amount o orce, and rest periods, which are outlined in Table 3. Vicenzino & Hing have devised a new concept o response parameters, which are the eects that the
Critiquing tool s elected (Downs & Black, 1998) All articles critiqued by both researchers. Simultaneously compared findings
MWM should have on the patient to continue with treatment (Hing, 2007). These are ‘pain-ree’ or pain altering application (reduction + / – elimination), instantaneous and long-lasting eects, namely the ‘PILL’ acronym (reer to Tables 2 and 4). Lastly Vicenzino & Hing have also discussed the use o a comparable sign to determine treatment eectiveness, which is also known as a CSOM, also ound in Table 4 (Hing, 2007). There is a duplication o parameters, such as ‘pain-ree’ or pain altering application and an immediate or instantaneous eect, which are both components o tenets and the PILL acronym. This duplication is secondary to two dierent clinicians dening these parameters o prescription. (Abbott 2001, Abbott et al 2001, Altman and Burton 1999, Backstrom 2002, Bisset et al 2006, Collins et al 2004, DeSantis and Hasson 2006, Downs and Black 1998, Exelby 1995, Exelby 1996, Folk 2001, Hartling et al 2004, Hetherington 1996, Hignett 2003a, Hignett 2003b, Hing 2007, Hsieh et al 2002, Kavanagh 1999, Kochar and Dogra 2002, Lexico Publishing Group Ltd 2007, McLean et al 2002, Monteiro and Victora 2005, Mulligan 1989, Mulligan 1995, Mulligan 1999, Mulligan 2004, Mulligan 2006, Mulligan 2007, O’Brien and Vicenzino 1998, Paungmali et al 2003a, Paungmali et al 2004, Paungmali et al 2003b, Roddy et al 2005, Saunders et al 2003, Slater et al 2006, Stephens 1995, Teys et al 2006, Vicenzino 2003, Vicenzino et al 2006, Vicenzino et al 2001, Vicenzino et al 2007, Vicenzino and Wright 1995, Wilson 2001, Zhang et al 2005) Tt o MWM Accessory glide The accessory glide perormed should either be at a right angle to the joint such as a lateral glide o the elbow, or ollow Kaltenborn’s concave-convex
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rule such as an anterior-posterior glide o the ankle (Exelby 1995). All studies, except Bisset et al. (2006) clearly dened the direction o glide, although reerred to Vicenzino (2003) or the prescription o their MWM, which clearly outlines that the glide should be a lateral glide o the orearm or treatment o lateral epicondylalgia. All studies at the elbow applied a lateral glide to the ulna. The second most common orm o glide was an anterior-posterior mobilisation either directly rom mobilising the distal bone o the joint, or mobilising the proximal bone in the opposite direction, such as a posterioranterior mobilisation (Collins et al., 2004; Vicenzino et al, 2006). The techniques or the wrist and thumb were highly variable (Backstrom, 2002; Folk, 2001; Hsieh et al., 2002).
have reported pain-ree application, conversely three studies in this review did not state whether their MWM technique reduced or eliminated pain (Bisset et al 2006, Slater et al 2006, Stephens 1995). However the study by Bisset et al (2006) reerred to Vicenzino (2003), which states that the application should be ‘pain-ree’. It is pertinent to the application and eectiveness o an MWM that a reduction and/ or an elimination o pain is achieved throughout the technique, with appropriate adaptation o the technique in relation to pain response. Table 2 summarises the analysis o the concept o pain behaviour and alteration with the MWM technique, and urthermore how the adaptation o the MWM in response to pain behaviour changes have occurred in studies.
Physiological movement All studies involved a secondary movement or action to be perormed by the patient during the MWM. Only two studies did not clearly state the movement perormed during the MWM (Abbott, 2001; Bisset et al., 2006). Bisset et al. (2006) once again reerred to Vicenzino (2003), which states that the patient should perorm a pain-ree gripping action. Abbott (2001) stated that the painul movement was perormed, although this was not specied. For the treatment o lateral epicondylalgia the movement was either wrist extension or gripping o the hand (Abbott, Patla & Jensen, 2001; Kochar & Dogra, 2002; McLean et al., 2002; Paungmali et al., 2003a; Paungmali et al., 2003b; Paungmali et al., 2004; Slater et al., 2006; Stephens, 1995; Vicenzino & Wright, 1995; Vicenzino et al., 2001). MWM’s or lateral ankle sprains included either dorsifexion or inversion movements (Collins et al., 2004; Hetherington, 1996; O’Brien & Vicenzino, 1998; Vicenzino et al., 2006). The two studies investigating MWM or treatment o shoulder pain were similar utilising either pure abduction or abduction in the scapula plane (Teys et al., 2006; DeSantis & Hasson, 2006). The movement involved in the treatment o thumb sprains varied between the two studies, either including MCP fexion or extension (Folk, 2001; Hsieh et al., 2002). Only one study to date has investigated the use o MWM’s in de Quervain’s, which employed all wrist movements and thumb abduction (Backstrom, 2002). Overall the rationale or all studies o which physiological movement was perormed during the MWM, was based upon utilising a normally pain provoking movement, with which the MWM was to eliminate this pain.
Immediate / instantaneous eect For an MWM to be deemed eective and progressive, there must be a positive instantaneous or immediate eect during its application. This is determined by the CSOM, which will soon be discussed. All studies that included a CSOM ound a positive instantaneous eect, except Slater et al. (2006), which ound no signicant eects o MWM treatment. Only two studies did not report any immediate/instantaneous eect (Bisset et al 2006, Kochar and Dogra 2002). All the CSOM’s improved post treatment, except temperature pain threshold (TPT), which has not been ound to be aected 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).
‘Pain-ree’ or pain alteration (reduction +/ – elimination) Mulligan (2004) states that the MWM technique must be pain-ree during its application. This tenet o an MWM is questionable, as it is more o an alteration to pain with a reduction and/or elimination, and thus not always ‘pain-ree’ as indicated by Mulligan. Majority o studies (86%),
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Overpressure Overpressure is stated by Mulligan (2004) as been an essential element o MWM prescription, however it was only utilised in ve 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 o which this was applied include the shoulder or supraspinatus tendinopathy (DeSantis and Hasson 2006), the thumb or de Quervain’s (Folk 2001), and also or lateral ankle sprains (Hetherington 1996, O’Brien and Vicenzino 1998, Vicenzino et al 2006). As grip strength was applied, overpressure is indirectly incorporated into any o the studies assessing the eects o MWM at the elbow that ocused on lateral epicondylalgia. Repetitions/sets Although Mulligan recommends ten repetitions and three sets or a typical MWM treatment, there are variations in the literature regarding repetitions and sets o its application. Mulligan (1995) states this prescription in the text, but the rationale is ill NZ Journal of Physiotherapy – November 2008, Vol. 36 (3)
dened. Eighteen out o the 21 articles (86%) stated their repetitions and 11 stated their sets. Majority o studies have ollowed Mulligan’s recommendations and prescribed three sets o ten repetitions. It is evident that this is the only rationale or MWM prescription, in combination with its use in previous studies. Variations o this prescription were utilised, ranging rom two to ten repetitions, with one to our sets.
2001; Vicenzino & Wright, 1995). Most commonly the rest period was 15 seconds between repetitions with these our studies investigating the hypoalgesic eects o a lateral glide perormed 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 ound positive results with increases in PFGS and pressure pain threshold (PPT).
Frequency The requency o treatment varied rom 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 requencies were three or six sessions, which commonly implemented an interval between treatment sessions, varying rom 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 requent treatment carried out two hourly during waking hours, or three weeks (Hsieh et al., 2002), and the less requent was approximately one treatment every ve days (Backstrom, 2002; Bisset et al., 2006).
Ro paramtr Long-lasting Eective MWM’s should have a long-lasting eect in order or permanent change to occur. This is a urther response parameter, as proposed by Vicenzino & Hing (Hing, 2007). Unortunately this was only investigated in nine o the studies (43%) via ollow-up assessments to establish deterioration or improvement rom 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, ve were case studies/reports, which highlights the act that other research designs have not incorporated ollow-up assessment (Backstrom, 2002; Folk, 2001; Hsieh et al., 2002; O’Brien & Vicenzino, 1998; Stephens, 1995). The ollow-up period varied rom one to 52 weeks. The results included reduction in pain levels, increase in participant assessment scores, increase in pain-ree strength, unction and ROM. No studies that investigated this parameter ound any negative long-term eects o MWM treatment when compared to placebo or control.
Amount o orce. The amount o orce recommended or an MWM is not stated in Mulligan’s text (2004), nor was it stated in majority o studies. McLean et al. (2002) is the only study to state the amount o orce used, as this was the aim o their study. Using a handheld dynamometer, therapists applied a lateral glide to elbows with lateral epicondylalgia at 33%, 50%, 66% or 100% o maximal orce. The outcome measure was pain-ree grip strength (PFGS), and the results showed that 66% or 100% o orce resulted in signicant gains. The remainder o the studies either did not state the orce used (13/21, 62%), or distinguished between using body weight or therapist arm orce (7/21, 33%). Thereore the application o orce is an important variable in MWM prescription, or determining treatment eectiveness, and this should be investigated urther (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 rom 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., NZ Journal of Physiotherapy – November 2008, Vol. 36 (3)
Client specifc outcome measure (CSOM) or comparable sign The CSOM or comparable sign is the outcome measure utilised during and immediately ater MWM treatment, to determine its eectiveness, and whether the treatment should be continued with. Vicenzino & Hing have established that this should be carried out ater all MWM applications, and only continued with i 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 decit, and purpose o research. The number o specic CSOM’s also varied between studies, but all included either pain levels, strength, ROM or PPT (Abbott, 2001; Abbott et al., 2001; Collins et al., 2004; DeSantis & Hasson, 2006; Folk, 2001; Hetherington, 1996; McLean et al., 2002; O’Brien & Vicenzino, 1998; Paungmali et al., 2003a; Paungmali et al., 2003b; Paungmali et al., 2004; Slater et al., 2006; Stephens, 1995; Teys et al., 2006; Vicenzino et al., 2001; Vicenzino et al., 2006; Vicenzino & Wright, 1995). Others that were included were TPT, upper limb tension tests (ULTT), sympathetic SNS, joint glides or balance (Collins et al., 2004; Hetherington, 1996; Paungmali et al.,
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; r o i r e r r e o t t a e . t d o l n t n e g p l n e s n r a n a h i e n e u a o / c o t r t c i a e n r m d t t r n r o i i u n s n o l r t o d d i a e o a a t r e z a n a n i n e p p n g l h e n n e e a n m t i i t a h o h e s g t o e o i b j n i m r t v e s o n t n o s r e o e d c i o i s d i a p t v n n e s t u e l M w s o e m e m a n o m r o o = d t i . c t a c l e p m r n n m t h e n r n c l A e i g a o r c a t d r i t o i P o e h i a r u T l ; r o s o a g i a t e c t r s t t o n w y e t . n c r n l s n n o t n i h e o i t d a o n n a t e c n t r i t o i o l o i e u e u t T s a d x i o t a l b t o t r e w e e . n r i i a b e u s c j y e i m l l s i r o a n h a c c h a p e n m s t M x t u a i o u y O g p j o l d e n m l i s i r a w d R r n o e a l o l e r h s i i p a t d r o n g c n t s a e i P e e p a n c s C v t r y o o r n i n n i d a a e e t a a n n o t l e l t i r r l d = u t M t e n n n u M n M p i t m p n s s o o W n m a o i s x s a a i o l a O t P m o a y l t e 1 i j r a m o g t i t r l i s R . M d i s n n . n i e p a n i l m s u d g o g i e P g e o h p n s s n n t n C e n o o s p n t a i a c o l p e i i e i a i t n m d a h t c r ; a t n n M t d s e e a n i r n e i n s r o r o a l c b i s i g i t i e u a s n g a m s m c e u t l l t a o l i a c r i r 1 t e n e l p u a a i p e p c s i a o s c l l h e r p a n a t e o y r t i o e h c i k t t p p u a d c c d p t e n s u M t s l e d s r n o b e e m e a y u r a r a t r l u h s b b t e t e c r r = i o a o e r u n n o c s k e a o o t t r o i s r t s s c c l t h o a i e r e i s t c n n c o d d t t t o s i a o t i t e p a a h t l l t a m e t i v n r u w a u i t o l l e a a e t c e d M m o a a t y a w ; s m w s r m a i u r M t l l e s o a o O d i e r c u e d e l e t e l t e s l e s n s i l c e W d R t t e i r n n n a a . u o d a i t n a s a r i i a n e l M c e w e k l i e e o p n n e d s e e k i a c v n ’ c g o o a t m h m o o e i e s r e i t r s n a M o o d r r t M e i t e v M s o i s g u i h a m r y h v h n l e t n d t p n p l s W m i s r t t t e i o i W W s n r n c n r a a a m = l o m o a r B n M e p p M i P m U o a i a M a a W t d M i s a e c h v e i p s t 0 o ; c ; 6 p n r e n d e f n e a e f e t c a e e w a a h t w t t t t t e s e n e r b t e e m o s g b r n = n m n i t u o s s = P l o s a h t S C e o c p S S S S r S M t N N e s e r N N N N 2 e s N ; ; b r t o n f h m e l i e g e e m c c l u r r o r e e a o r L o v p n o h U p t t m o m i m u t r r h h = a a B a t g r i L i W r d d w d . e e e U S n S S S s d S S ; n h S s n g o N N N a N N U a t N U N i n t i e r a g u s a i n s l e q i i i b r r . b n s s . . u u s o t h n h s s n s d o k m g c i o o h n s i n s n n h e i y e o o o o l = e s t i i i i t s r g w e k k s s s s s s n w n e e u i e s s s s e e e o k 3 M M s s o e e e e = W s h s w m s w s r a o M 2 W 3 B 4 2 1 2 1 2 w ; 5 2 1 M 2 W s ; e n n o i r h i o t o t i t s : f t s o c s . e o d p s n s m p e e e e s t s o e p r n 0 r t h i e r i e o s s e s r a 1 0 t t s = e t - 1 o n 2 e y e s 5 6 g l s h e : . s n . : u n p o c y s e o . s s m . s l x x a e l p s e o s a m p p r s s r a R e e e e t R r t a t p o r 1 i e r r r v e e e = d e ; t a x p l i r l p s r o i 0 m s 0 0 s o e p S n 1 5 0 o m I n M 6 G a 3 1 2 1 1 3 S l N = O a R c N ; i s ; Y n Y Y Y Y N s n h N e o t c y e = w T e . Y Y Y Y Y Y Y ) N ; n = t d n e N e u m ; n i t m t 5 a u , 6 n 9 e 9 n 5 & m r , 0 o 1 , i . t o 9 l 0 t o 9 m x & c 1 , a = 2 g ( s a n 1 o 0 s i , t n i x m 0 r z t i 3 n , t t e n r e R 2 n n o s e 6 = e h h e : h , l a s 2 h g k c i e 2 e x k s c S t i t b p 0 9 0 l e n r a 0 e a e 9 s 0 o a i o a t T S V W B 2 D H F H 1 H 2 N m
2003a; Paungmali et al., 2004; Vicenzino et al., 2006). However specic studies did not use the CSOM immediately ater the rst set to test or an instantaneous/immediate eect (Bisset et al 2006, Kochar and Dogra 2002). 2) Ovrall efay o MWM’ Al l st ud ie s in cl ud ed in th is re vi ew o un d signicant positive results with MWM applications, when compared to placebo or control groups. The only study in which no signicant results were ound with PPT or strength was by Slater et al. (2006), which is also the only study, which investigated the ecacy o MWM’s on an induced condition. All other studies utilised patients with genuine pathologies, whereas this study induced lateral epicondylalgia pain via delayed onset o muscle soreness and hypertonic saline. The most common signiicant results ound were increase in strength, reduction in pain levels, increase in PPT, improved ULTT’s, and overall unction 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 ound at the elbow (Paungmali et al., 2004). Other interesting ndings were that repeated applications o MWM, or MWM with naloxone did not have an inhibitory eect on the pain relieving eects, thereore suggests that a non-opioid mechanism occurs or the analgesic response (Paungmali et al., 2003a; Paungmali et al., 2004). The only study investigating the required orce or optimal eects, demonstrated that best results are gained when an MWM is applied at either 66% or 100% o maximal orce (McLean et al., 2002). MWM treatment was also ound to be superior in the long-term when compared to corticosteroid injection (Bisset et al., 2006). Alterations in SNS unction ollowing an MWM were demonstrated, showing an increase in heart rate, blood pressure, skin conductance, blood fux and skin temperature. These are similar to the eects o spinal manipulation (Paungmali et al., 2003b). MWM applied at the elbow has shown to have benecial eects on shoulder rotation ROM (Abbott, 2001). At the shoulder, wrist, thumb and ankle, similar results were ound. These were decrease in pain, increase in ROM, PPT, strength and joint glides, and improved unction (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 ound at the ankle (Collins et al., 2004). One study investigated MWM under magnetic resonance imaging and ound MWM to correct a position ault at the thumb, although this was not maintained post MWM, although the positive eects were long-lasting (Hsieh et al., 2002).
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) l l r A o e v . e ) e o S c n s A e t V a ( d i h 0 v w 1 e s / o t n i 1 - ( c 0 r a e o e d t y l n 1 a i a t n o p a i t d d c e e c l v n u u o d s r e r e r o n n d i o a a i t h p a c s b i l t m p n u p e h a m t r i t M a / s W p i r T m M i w N
e h t t s o p t e e n e r i t a m p t o e p h t m , y t s n e d e m n i s s a e m s s e a r p d a u - h w e o l l h s o d x r e R a m e y r M 1 W T t n A o c M N
l a g i t i i n n i x e e f h t n e n h i n w o n i t c i a u p d o e r n o d n a h d e e h w s o t h s u n b , b o l i t t m a u u a n h i l t m a t a n h x o i g e i r i I t r R s o e M p h
, s h t n o m 4 x t R a t s d o e s p s r e a s m s e y A y n – 1 o d s r e n T c Y a N
d n a h t n o m 1 t x a R d t e s s o s p e s s s k A e – e w s e 2 T Y 5 N
x R t s o p k e e w 1 d e s s e s s A – s e Y
n o i s n e t x e e g n a r d e n e r u e s e r s e - r n p r i a e p v o – h s t e i Y w
e c n a l a b d n a M O R n i e s a e r c n i – s e Y
n i a p o n o e s i t a a e c i r l c e p d p e a t a M i W d e M m g n m i i – w o l s e l o Y
s e Y
s e Y
s e Y
a L L I P d n a , n g i s e l b a r a p m o c r o ) M O S C ( e r u s a e m e m o c t u o c i c e p s t n e i l C . ) d e u n i t n o c ( 4 e l b a T
e s a e r c n i d n a n i a p n i e s a e r c e d M – O R s e n Y i
s e Y
e s a e r c n i d n a n i a p n i e s a e r c e d M – O R s e n Y i
s e Y . n o i t s t c i r u d w t b a a M O e v R M i t e . O v R c e a i t l c a d g c n a s n a b i r n o S h m u i u d t A t g h V n t S c u n e R d i r d a t n P b P S a N A , m o r t s k c 2 a 0 0 B 2
g n i d n o . n i a s M t n s O e t R g x e l . e e . r n ) ) o d u l P i S s s e S e s A A C s r g n l o V i V ( M e r e s v c ( e p e e n – l g r i s l a a e e n e n c v y c s a r o o c n e s a h i n M n d h n l i i i i a O a n t a a t P B w P R P E w , n , . o l , 1 t a g n 0 s t i n 0 i t o e r 2 n s s e h , a a 6 k 6 i h e 2 S t 0 l 0 e H e 9 0 o 9 s 0 H 1 H 2 D & 2 F
; = n o S i t R o P N m ; t o n e g e n m e a r v = o m M h t O i R w ; n d l i o o t h a s s i e l r i h t b o n m i a = p e r M W u s M s ; e r t s p t e = n T i P o P s n ; e s t m b a r m i g l o r l i e k p = p u s g = k T ; T h L t g U n ; e r m t e s t p s y i r g s s e u e o r v r n e i a n c p i . = t e g n S h t i G a g F p a P m i ; y m t s e n e = c n m S a t n N a e S o r ; s e t d r = l c o i x h t s R e e ; r n g d h a e t t s n m e i = t I t a p o e R n r M ; u l = t a T a r N e e ; p g n d a l m e t t e a a h t s = p t T o o P p n T r a c = ; a n t S i o e N x m ; e e f = l i a s P c r s o C e d M u = ; g F e l o l D a a ; c n g s a n g l i n i a r t a u e a s b r i v t i n = h a g p S i c A e i V w r e : e = m t o B u N W n
The overall ecacy o MWM’s has largely proven to be eective in both reducing pain and improving unction 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’ eects.
DIscUssIOn sif paramtr ad Ratioal Rlatd to MWM prritio As previous ly described, tenets, te chnica l and response parameters, all contribute to the eectiveness o Mulligan’s manual therapy technique. However, a key nding rom this review is that prescription o MWM has been poorly explained or not adequately applied in the literature. This is interesting considering that specic aspects o MWM application have been stated as being necessary components - such as ‘pain-ree’, specic reps and sets, and overpressure. Variations exist in the prescription o MWM not only between studies, but also within individual studies. Tt The tenets o MWM prescription, as described by Mulligan, were generally well incorporated, with the exception o overpressure. All studies clearly dened the accessory glide together with the direction, with the exception o Bisset et al. (2006) who did not state it within the study treatment method, however did reer to Vicenzino (2003). The secondary physiological movement or action perormed 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 perormed (Abbott 2001, Bisset et al 2006), however Bisset et al. (2006) reerred to Vicenzino (2003) or 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 o terminology surrounding the term ‘painree’ as initially stated by Mulligan is controversial. As explained in the results and outlined in Table 2 the alteration o pain that occurs during and ater MWM is not always an elimination o pain or otherwise known as ‘pain-ree’. Majority o studies (86%) documented pain-ree application was utilised, with a minimal number discussing a reduction o pain as also being accepted. This raises the question o why is there is a chosen belie that MWM must be pain-ree to continue wit h treatment? Thus should the ter m ‘painree’ be changed to pain alteration (reduction + / – elimination)? Several studies reerred to the undamental concept o pain-ree application, yet it was not employed in the methods, or i stated it was not clear i pain was altered during or ater the MWM (Abbott 2001, Backstrom 2002, Hsieh et al 2002, O’Brien and Vicenzino 1998, Stephens 1995).
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Figure 3: Algorithm for the prescription MWM techniques
What do I need to e mploy?
Key: ∞ •
CRR* = clinical reasoning required
∞ •
Figure 3: Algorithm for the prescription
Is an MWM appropriate?
∞ •
YES
E.g. Decreased ROM, pain present, positional fault evident, decreased strength, reduced function etc (CRR*)
∞ • ∞ •
of peripheral joint MWM techniques
∞
∞
∞ •
CONTINUE ADAPT as necessary (angle, glide, force, etc) Up to 4 times (CRR*)
THEN if NO improvement
Pain eliminated or reducing during MWM
∞ •
Pain worsening during the MWM
Joint mechanics (CRR*) Accessory glide direction (e.g. lateral/medial, AP/PA) Physiological movement OR action (a normally pain provoking movement e.g. CSOM) Manual contact / belt use Client specific outcome measure/s (relate to presenting problem/s e.g. weakness, pain) Aim for pain alteration (reduction +/– elimination) Number of initial reps (generally 6-10) Force (Note: Irritability) Either 66% or 100% st Rest period after 1 set
First application of MWM:
CSOM is same or improved
STOP
CSOM is worse e.g. pain
AFTER APPLICATION st OF 1 Set - Re-assess CSOM/s Instantaneous effect?
NB: Consider irritability
FINAL COMMENTS: ! !
! !
! !
!
Aim to positively alter pain Overpressure is essential to gain maximum benefit from an MWM Lasting effect with further reps Continuous assessment to assess for long-lasting effects Encourage self-MWMs Consider taping to maintain joint positions Consider muscle strengthening to work concurrently with MWMs
CONTINUE OR PROGRESS
STOP/ ADAPT as necessary (angle, glide, force, etc) Up to 4 times (CRR*)
Further sets - CONSIDER: •∞ ∞ •∞
•∞
Frequency: consider self-MWMs Sets: 3 sets generally Rest period: time for reassessment Constant assessment of CSOM/s
PROGRESSIONS Overpressure Increase force Increase difficulty/level of physiological movement/action Therapist to patient generated Increase frequency/sets (CRR*) ∞ • ∞ • ∞ •
∞ • ∞ •
This also raises the importance o adaptation in response to pain behaviour during the MWM. Only eight studies explained their particular method o adapting the MWM application to alter pain (Abbott 156
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) reerred to Vicenzino (2003) NZ Journal of Physiotherapy – November 2008, Vol. 36 (3)
or MWM prescription, who recommends that an MWM is repeated several times, only i there is a substantial decrease in pain, and i the pain relie has not occurred then glides at dierent angles should be attempted; up to a maximum o our times. Abbott et al. (2001) also states that our attempts o the glide direction are permitted, in order to determine which best eliminates the pain. I the pain was not eliminated or it returned during treatment, no urther repetitions were perormed. Another tenet or response parameter associated with an MWM is the immediate or instantaneous eect, which occurs during and/or ater the application and is determined by the related CSOM/s. Only two studies did not report any immediate or instantaneous eect (Bisset et al 2006, Kochar and Dogra 2002). This aspect o prescription is a necessity in relation to the eectiveness o the MWM, and also adaptation with regards to pain behaviour. Overpressure is considered to be a key component in MWM techniques to produce eective pain relie, either as a progression and/or an adaptation i the patient remains symptomatic ater initial application (Mulligan 2004, Wilson 2001). The literature however does not signicantly refect this, with only ve 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 o overpressure, to urther alter pain behaviour and acquire pain-ree end range (Exelby, 1996; Wilson, 2001). Thial paramtr The documentation o technical parameters was variable throughout the studies. Within this review 18 out o 21 studies (86%) stated the number o repetitions and sets employed. Majority o these studies reerred to Mulligan’s recommendations o three sets o ten repetitions, although no specic research has been undertaken to investigate the ecacy o these parameters (Mulligan 1995). While the rationale or prescription o repetitions and sets is generally ill dened and based on experimentation in clinical practice, Mulligan (2004) does state the importance o perorming an adequate number o repetitions to result in a more lasting eect. In regards to requency o MWM treatment one session was most commonly utilised, which is unlikely in a clinical setting but is oten carried out in research, especially with MWM’s displaying immediate benets (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 requent treatment sessions (n = 19), which may refect the chronicity o lateral epicondylalgia, and may represent the need or intense and regular physiotherapy intervention or e ective treatment outcomes. This is a clear example o how case NZ Journal of Physiotherapy – November 2008, Vol. 36 (3)
studies can be more clinically relevant with greater generalisability o results. The amount o orce applied during an MWM is a parameter o limited research and documentation within studies. McLean et al. (2002) is the only study to date, which has investigated the eects o MWM in relation to varied amounts o orce applied or the accessory glide. The results illustrated that 66% or 100% o maximal orce is superior over less amounts, indicating the amount o orce is pertinent to consider with MWM eectiveness. It is thereore interesting that no other studies to date have detailed this parameter, apart rom seven out o 21 (33%) distinguishing between the use o body weight or therapist arm orce (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 o 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 or treatment eectiveness is advocated (Exelby, 1996; Wilson, 2001). This area was poorly dened with approximately hal o 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 o investigating hypoalgesic eects o a lateral glide perormed 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, o a time that allows re-testing o the CSOM to determine treatment eectiveness, and thereore determine whether the MWM application is to be continued with. Ro paramtr The response parameters as recently dened by Vicenzino & Hing includes the PILL acronym and the CSOM (Hing, 2007). As previously stated the PILL acronym consists o pain alteration, an instantaneous/immediate eect which have bot h been discussed earlier in tenets, along with long-lasting and the CSOM. Long-lasting eects have been investigated via ollow-up assessments in nine studies (43%), all concluding with signicant positive results. Paungmali et al. (2003b) established that hypoalgesic eects did not reduce with repeated treatments, thereore is probable that a non-opioid orm o analgesia is the cause o pain relie. Also, the case report by Hsieh et al. (2002), determined at ollow-up that pain was eliminated via the intervention, however the nal magnetic resonance imaging (MRI) illustrated no change in the initial positional ault o the thumb. 157
The authors thereore suggested that the correction o positional aults during the MWM, as shown by MRI, resulted in immediate eects. The long-term eects, including, pain relie, was hypothesised to be due to changes in nociceptive and motor system dysunction, possibly implying the role o hypoalgesia. Mulligan (2004) also states that the eects o MWM’s can be maintained urther via taping and sel-MWM’s, which may urther enhance the possible long-lasting eects. 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 o CSOM or a comparable sign to be utilised during and/or immediately ater an MWM as a response parameter. The development o the CSOM by Vicenzino & Hing is a new concept, which is related to the requirements o what must occur in order to continue with MWM treatment (Hing, 2007). In general, the choice o 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. prood Guidli or cliial prati Overall, it is apparent that certain parameters o MWM prescription are ill dened, although the ecacy or particular joints is well established. It may be that experimentation or adaptation o the technique is necessary and common in daily practice, however, a review o its necessary components o prescription was timely. The key components o prescribing an MWM technique need to be dened. Thus it is proposed that the ollowing algorithm is utilised or the prescription o MWM’s at peripheral joints in clinical practice (reer to Figure 3). This algorithm is based on the ndings o this systematic review and incorporates all necessary components o MWM prescription. The algorithm encompass es all parameters that have been reviewed in this research and is based upon integration o results. This includes tenets (accessory glide, physiological movement or action, pain alteration (reduction + / – elimination), immediate/instantaneous eect, overpressure), technical parameters (repetitions, sets, requency, amount o orce, rest periods) and response parameters (long-lasting, CSOM). The content o the algorithm aims to allow the practitioner to easily ollow it through in order to apply appropriate MWM prescription. Aspects o the algorithm require clinical reasoning in regards to prescription specics and consideration o irritability. utur Rarh Subsequent to the extensive research and analysis undertaken or this review, there are particular areas within MWM prescription that
158
require urther investigation. This could include research into the eicacy and prescription o MWM’s at joints that have not yet been examined such as the hip and knee. This could also incorporate the consideration o various pathologies as in the clinical setting, MWM’s are utilised or many conditions and in all peripheral joints. It is clear that the specic prescription parameters o the MWM technique have not been consistently employed, nor evaluated. For example the use o overpressure was rarely implemented although it is considered a key component o MWM application, thereore investigation into its additional benets may be necessary. Further parameters o MWM prescription, which were analysed in this review such as the accessory glide, repetitions, sets, requency, rest periods, also warrant speciic comparative research regarding the eects. Once the ecacies o the discussed parameters are urther dened, they need to be prescribed appropriately and more clearly explained in uture research. An example is with the amount o orce used, which has been validated by McLean et al. (2002) although not implemented appropriately in subsequent research to date. The ecacy o the proposed algorithm could be investigated via the comparison o its implementation versus the common clinician’s MWM application. Perhaps common MWM application could be initially identied through a survey with case examples, which will determine a representative norm or everyday clinical practice and MWM prescription. This will overa ll est abl ish the e icacy o the algorithm and the incorporation o all necessary MWM prescription components, with regards to treatment outcomes.
cOncLUsIOn Mulligan’s peripheral MWM techniques are commonly utilised within musculoskeletal physiotherapy. This review o the MWM prescription at peripheral joints highlighted that this area o research has strengths, limitations and inconsistencies. The speciic parameters identiied or MWM prescription in the literature, is variable and in general inconsistently implemented and explained. The ecacy o MWM’s appears to be well established or various joints and pathologies, as shown by previous reviews, however due to the methodological quality o studies, and gaps in particular areas o both prescription and application, it is apparent that urther research is warranted into the specic parameters o MWM’s. The proposed algorithm may be integrated into clinical practice, to aid in the inclusion o all necessary components established rom this review. To conclude, this manual therapy technique is widely used and advocated or many aspects o peripheral joint dysunction. This review has presented an evaluation o MWM prescription, in
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attempt to guide the clinician appropriately, and provide a basis or uture research into this area.
ADDRess OR cORRespOnDence Associate Professor Wayne Hing, School of Physiotherapy, Health & Rehabilitation Research Centre, AUT University, Private Bag 92006, Auckland 1142, New Zealand.
ReeRences
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) J J P l P a d M i n r M d e d a a t e n e a r h h t . : m b h r / o J e n o i m . t P t o I e i . n u n g n s n o S g o h o m e i o r o s A : t i t e : t t r V n s m p c o M c a M i . : u r I p a n x t O O m i i d n R a R e R s r o b y i M P A f ( P a G d C d . , , a , . a t x x / n , / / h o g t R a i n M o s - a s R - n e i r : s e O r 1 t t e 1 R c e . 2 3 t r p g r a s , M : i k k n a k p r I e e n t m O , e p i R r e e e i s R u x W a i M W r d R p d o c P W g
s e i d u t s d e d u l c n i e h t f o s c i t s i r e t c a r a h C . ) d e u n i t n o c ( 1 x i d n e p p A
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b x m n d u a n h l a a t h x e p e h t l d a i n o m s n i x d i o o r n a x e p h e r f h e g t h n g t i n o m i r t g o a i n n s r e M i p u p W u e s b l i M : m h g n u w i M h , o t b W g e m r M e h d l u e t n S o h t u e l s e e g r s n I h i u t R r o d e o u t M d c . a d , r m r e x o i n e r e l t r a o p l p a e a . e p a h b n x t p n e R n s l a a e h t M a p ’ w k s , i a m c M i t M i M x s W t M r W W o r a W a M p w M o P M e l a b m m e u h d t l o t r h g i a r e y h n i t 9 i a 7 w p l b a e s n o m u u i t h i e s M t h e t o p W h M e t t r o d i a n g i I n s a t t R s t c l e e v M u n o a e I t r o p e r e s a C , . l a t e h e 2 i s 0 0 H 2
l ; , n = = s n a o r o J u i n P s u P A x i o I = e v h f ; ; g g = = i B i n n s i t S s r W g s r o A N e a h d V ; t ; = t m ; e l e i g m a F e c n r a i c s D v r t n u i ; g r l r a o a l m o n y i i e l l r i k h a o e a t = n = u s e d r n g a R c a o k i r t H ; m e s o ; i s e n r e = n i t e r i o t T g i u a v t s i s i M m t o t s c p e M = a e p ; I = r e A p t = r h R s P d g M ’ i o ; l L = o ; t s D p n b e w s e e A e i r r y = t ; t ; e d y a g o i p p P m B n b a i t = r ; = n n t h e i e t h a t g ; r p W c t o g n i B = t n e s i r l , m n t r y a a s a c h p e i ; p t s b p r i s - r a = s e t c e g r t T h r a e t e g P i e e ; i m v e r e l i m l a s w n o l i i r s p t e = i m r a r d B a p g = c e o l W l = r = ; o r p e S C m m t v = G ; n o M F o n b c T P C o a R i ; ; d s P s s e e a d m n s ; e s i t e = n x o m t m c a e a o u e r / n d = s i g a n t o ; m = r a n r = o s p x e ; c = s i e t e s o s i y T i n c m ; r p C m a r d e R e o l ; x ; o h d e e e e t h g l e a m r n s e o r m a c a n u t r o i h o q e t h u t o s i v n a = i e = t p r t a c P p C e a e E u c / i = r H c m o O u ; ; t M t = y n t l e O a n e T r c t e r R e a O A m ; e ; p l m s p m i d a s l e x e s o t o e t s r t h = p g s n a s a w e a p l r T a P = = h a = h x 2 t T ; n m x p A o i ; m p a c t e o r . r t t p / n p s a n e W e p i c r y o a j m ; s a t t ; z u l s e s a t h r t e u m a r h e e s e o g t r v = g n r n = a p e r P l a = e t x g n C s e T a R c P h i ; m p M t t i ; P p e r n ; 6 l g h e = s 3 z s t = m a p m a e H e p S r r n v M c m o a o ; e G r a y ; o t m d t s d r s n h e h o e e = t t m i u l o a c S t s = w s s N s a = J n r u S t 6 P t o l m ; o i t M u t n n 3 a e ; o i t = F = z s t i l S n o i i S o S ; n o b m N r o U d o j l ; ; i e e y o g r m l e a e n t = a i a e g r c l g s n s e a o M d n a e p l a W e r b a r u = o h M g = t i S h : o r r g t e l e p M M i t e e O o a O n t n n N a D R w a i NZ Journal of Physiotherapy – November 2008, Vol. 36 (3)
