Upload
phamanh
View
234
Download
0
Embed Size (px)
Citation preview
“EFFECTIVE OF MULLIGAN MOBILISATION
AND TAPING IN LATERAL EPICONDYLITIS”
Submitted by:
POOJA KALARIA
(12SPTPT11039)
DHARA KAPURIYA
(12SPTPT11040)
BPT 6th semester, JULY-2015
Guided by:
Dr NAMRATA CHANDRALA
Assistant professor, School of physiotherapy, RK University
II
CERTIFICATE
This is to certify that the project work entitled “Effect of Mulligan mobilization and
tapingin lateral epicondylitis”has been undertaken and written under my supervision and it
describes the original research work carried out by Ms. Pooja Kalaria and Ms. Dhara
Kapuriya registered at RK University in 6th semester Bachelors of Physiotherapy.
I
Signature of Guide
Name: Dr Namrata Chandrala
Degree: MPT ORTHO
Designation: Assistant professor
III
DECLARATION
We hereby certify that we are the authors of this project work. We certify to the best of
our knowledge, our project does not infringe upon anyone’s copyright nor violate any
proprietary rights and that any ideas, techniques, quotations, or any other material from the
work of other people included in our project published or otherwise, are fully acknowledged
in accordance with the standard referencing practices. We declare that this is a true copy of
our project, including any final revisions, as approved by my project review committee.
Signature.of candidate: Signature.of candidate:
Pooja kalaria Dhara Kapuriya
Enrolment no.: 12sptpt11039 Enrolment no.: 12sptpt11040
Date: 16th july 2015 Date: 16th july 2015
Place: Rajkot Place: Rajkot
IV
ACKNOWLEGEMENT
First and foremost we would like to thank our parents Lalitbhai Kalaria, Jagrutiben Kalaria and
Vinodbhai Kapuriya, Sarojben Kapuriya who are my living Gods and our brothers Arjun Kalaria
and Neel Kapuriya for their valuable support and encouragement, blessing and love which has
always been a source of inspiration and strength in accomplishing this academic task.
Our heartfelt gratitude to almighty God who has guided us this far and to whom goes all the honor
and glory for the successful completion of this study.
We wish to express our regards to our Director Dr Priyanshu Rathod School of Physiotherapy,
RK.University for his whole hearted guidance and meticulous suggestions in the completion of this
work and for all the facilities and support extended to me during this study. We are extremely thankful
for his constant encouragement and inspiration during the course of this study.
With due respect, we would like to express our sincere thanks to our guide Dr Namrata Chandrala
Senior lecturer of School of Physiotherapy, RK.University, for her judicious information, expert
suggestions, valuable guidance, continuous support, incessant reassurance during every stage of this
work and interest shown in this dissertation without which this work would not have been possible.
we would like to extend our heartfelt thanks to assistant lecturer, Dr Ankur Parekh, Dr Kajal
Anadkat and Dr Vaibhavi Ved for their valuable guidance, constant help and support throughout this
study and all the lecturers of my college who have taught me and gave their valuable suggestions
during the course of the study.
We shall fail our duties if we don’t acknowledge my Colleagues and Friends for their suggestions and
criticism while assisting us in this study.
Last but not the least we would like to thanks all the Individuals in our study without whom this task
would not have been possible.
Our sincere thanks to all the contributors whose names we might have missed but who truly deserve
our gratitude.
We would like to thank once again to all who have helped us all the while.
Signature: Signature:
Name: Pooja kalaria Name: Dhara Kapuriya
V
V
LIST OF ABBREVIATIONS
1. MWM: Mulligan’s Mobilization with Movement
2. US: Ultrasound
3. PRTEE: Patient Rated Tennis Elbow Evaluation
4. ECRB: Extensor Carpi Radialis Brevis.
V
VI
ABSTRACT
BACKGROUND:
Lateral epicondylitis is a painful musculoskeletal condition which is considered to be due to
over use, over stress or over exertion of wrist extensors(mainly ECRB) of the forearm with
production of pain around the common extensor origin. The study is to evaluate the efficacy
of taping and Mulligan mobilization in improving the functional ability and reduction of pain in
tennis elbow.
AIM:
1 To evaluate the effectiveness of taping, US and stretching exercise on pain and disability
of patient with lateral epicondylitis. 2 To evaluate the effectiveness of MWM, US and
stretching exercise on pain and disability of patient with lateral epicondylitis. 3 To compare
the effectiveness of taping and Mulligan mobilization technique on lateral epicondylitis.
METHODOLOGY:
1 Study design: Experimental study(pre test and post test). 2 Inclusion criteria: Age of 30-
60 years with symptomatic lateral epicondylitis on side, males and females, positive Cozens
test or Mills test confirming lateral epicondylitis. 3 Exclusion criteria: Patient having history
of trauma,surgery , acute infection, fractures around elbow complex, Patient who have
received steroids injection within last 30 days in elbow joint. 4 Sample size: 30 subjects. 5
sampling: Simple random sampling. 6 Study setting: Various physiotherapy clinics in
Rajkot.
RESULTS:
The result of this study indicate that the mean improvement in hand grip strength when
compared in pre and post treatment did not show significant improvement with in the groups
with p<0.05.
The result of this study indicate that the mean improvement in PRTEE when compared in pre
and post treatment shows significant improvement with in and between the groups with
p<0.05.
VII
CONCLUSION:
Mulligan mobilization was more effective than taping technique in reducing pain and
functional performance.
KEY WORDS:
Lateral epicondylitis, Mulligan mobilization (MWM), Hand Grip Strength, Patient Rated
Tennis Elbow Evaluation (PRTEE).
VIII
TABLE OF CONTENTS
Sr. No. TITLE Page No.
1. INTRODUCTION 1
2. AIMS & OBJECTIVES 6
3. REVIEW OF LITERATURE 10
4. METHODOLOGY 14
5. RESULTS 23
6. DISCUSSION 29
7. CONCLUSION 32
8. SUMMARY 34
9. BIBLIOGRAPHY 36
10. ANNEXURES 40
IX
LIST OF TABLES
Sr. No. TABLES Page No.
5.1 Comparison of PRTEE in group A and B(within group) 25
5.2 Comparison of Hand Grip Strength in group A and
B(within group)
26
5.3 Comparison of PRTEE between group A and B 27
5.4 Comparison of Hand Grip Strength between group A
and B
28
X
LIST OF GRAPHS
SR.
No.
GRAPHS PAGE
NO.
5.1 Comparison of PRTEE in group A and B 25
5.2 Comparison of Hand Grip Strength in group A and B 26
5.3 Comparison of PRTEE between group A and B 27
5.4
Comparison of Hand Grip Strength between group A and
B
28
XI
LIST OF FIGURES
SR. NO. FIGURES PAGE NO.
4.1 Lateral epicondylitis 2
4.2 Tapping applying method 16
4.3 Mulligan applying method 18
4.4 Grip strength measurement 17
4.5 Material used in study 20
XII
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 1
INTRODUCTION
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 2
INTRODUCTION
Tennis elbow or lateral epicondylitis is one of the most common lesions of the
forearm. It is a lesion affecting the origin of the tendons of the muscles that extend the wrist
joint mainly Extensor Carpi RadialisBrevis (ECRB) 1. The dominant arm is commonly
affected among both men and women with prevalence of 1-3 % 2 and in the age group of
30- 60 years3.
Fig 4.1
The commonest causative factor is present at elbow over-use or repetitive concentric
and eccentric contractions of the extensor muscles (mainly ECRB) which stabilizes the wrist.
These repetitive stresses (heavy lifting, repetitive hammering, scissoring, twisting, and in
tennis players with backhand stroke & inadequate forearm extensor power and endurance)
produces chronic overload due to biomechanical positional fault resulting in micro tearing &
fibrosis of the common wrist extensor origin. This presents as pain on gripping activities,
decreased grip strength and tenderness over the outer edge of the elbow 3, 4.
The Repeated tensile stress created at the origin of the ECRB may cause microscopic
tears at the musculotendinous junction and Angio-fibroblastic hyperplasia response may
follow. This leads to inflammation &mucinoid degeneration of the Extensor origin and
subsequent changes within the inelastic tendon such as thickening of the tendon’s sheath,
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 3
nodule formation & adhesions. Additional changes seen microscopically include a reduction
in vascularity ,fraying & splitting of collagen fibers and an increase in the amount of type III
collagen within a tendon which further weakens the tendon causing more microtears and
prolong the degeneration process5, 6.
Numerous manual therapy procedures have been developed to assist in the
management of Tennis elbow Indications and applications of these numerous manual
therapy procedures varies with each author, but the biomechanical effect of radio-humeral
gapping remains consistent with each technique8
A) Mulligan’s Mobilization with Movement (MWM): It is a class of manual therapy
technique (based on the principle of Kaltenborn i.e. passive accessory mobilization
technique applied parallel or perpendicular to the joint plane) that is widely used in the
management of musculoskeletal pain. It involves the manual application of a sustained glide
by a therapist to a joint, while a concurrent physiological movement of the joint is actively
performed by the patient7.MWM techniques are applied in case of positional fault of the
elbow joint Complex & they help to restore normal tracking of the radius on the capitulum. It
also prevents the contractile element pathology of the common extensor bundle so that
strengthening the forearm muscles can be done without painful symptoms8.
Several researchers have reported decrease in pain and increase in grip strength
during or shortly after MWM at the elbow13.
B)Taping: It is a cost effective treatment alternative for many common injuries &
overuse syndromes (hillfrank, 1991). Tape is applied across the joint in several layers and is
positioned to provide outside support and restrict forces that would apply stress on an
injured part.
Mulligan taping mainly aims to mainly, to reduce pain, improve function &
biomechanics12. It taping aim to control the fascia directly, establish proper structural
alignment, improve muscular recruitment & also increase proprioception stimulation
enhancing static & dynamic neuro-muscular retraining by balancing the tissue length/tension
relationship &motor control12, 14.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 4
NEED OF THE STUDY
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 5
NEED OF THE STUDY
Mulligan mobilization is the commonest manual therapy procedures used in the
treatment of lateral epicondylitis. These techniques help in reduction of pain immediately
after the technique is applied for short period8, 9,10,11,15,16,17. Taping has been found effective
in decreasing the pain & restoring the joint play by maintaining & establishes proper
structural alignment by balancing the tissue length/tension relationship for prolonged
period12, 14.
There are many studies on the effects of Mulligan mobilization in the management of
lateral epicondylitis. However not many studies have evaluated the efficacy of using taping
technique as an adjunct to manual therapy approach. This study is an attempt to evaluate
the efficacy of taping as an adjunct to Mulligan mobilization in improving the functional
ability and reduction of pain in lateral epicondylitis. Therapeutic ultrasound and stretching
exercises are used to deal with the bio-chemical changes of the condition.
This study is to evaluate the efficiency of taping and Mulligan mobilisation in improving
the functional ability and reduction of pain in lateral epicondylitis.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 6
AIM AND OBJECTIVES
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 7
AIM & OBJECTIVES
AIM :
1. To compare the effectiveness of taping and Mulligan technique on lateral epicondylitis
OBJECTIVES:
1. To evaluate the effectiveness of taping, US and stretching on pain and disability of patient
with lateral epicondylitis.
2. To evaluate the effectiveness of MWM, US and stretching on pain and disability of patient
with lateral epicondylitis.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 8
HYPOTHESIS
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 9
HYPOTHESIS
ALTERNATIVE HYPOTHESIS:
Treatment using Mulligan mobilization and taping shows significant difference in pain and
disability in patients with lateral epicondylitis.
NULL HYPOTHESIS:
Treatment using Mulligan mobilization and taping does not show any significant difference in
pain and disability in patients with lateral epicondylitis.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 10
REVIEW OF LITERATURE
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 11
REVIEW OF LITERATURE
1)Bryan Chung, J ability due Wiley.et.al (2010): Studied the validity of PRTEE. The
PRTEE had questionable discriminant ability due to its moderate test-retest reliability and
possibly due to low convergent validity with other measures of similar constructs. The
PRTEE appears to be sensitive to change, but the margin of difference between a clinically
relevant change and no change is very small.23
2)Tom J. Overend,Jennifer C, Wuori-Fearn, John .F. Kramer .et. at. (1999): Studied the
reliability of a questionnaire designs to assess forearm pain function in patient with lateral
epicondylitis. The PRTEE or PRFEQ has been found to effective in providing simple, quick
and reliable estimations of arm pain functions in patients with lateral epicondylitis.24
3) Bryan chung, J Preston wileyet. al. (2010): studied validity, responsiveness and
reliability of PRTEE .they conclude that it is having questionable discriminant ability due to
its moderate test-retest reliability and possibility due to low convergent validity with other
measures of similar constructs.14
4) Won-Hwee Lee, Oh et.at. (2011): Studied the effect of taping on wrist extensor force
reproduction and wrist joint position reproduction with or without lateral epicondylitis. The
lateral epicondylitis group had a significantly higher FR and JPR errors. Taping significantly
improved force reproduction and joint position reproduction error.16
5) AlirzaShamsoddini, Mohammad TaghiHollisaz, et.al. (2010) studied the initial
effect oftaping techniques in subjects with tennis elbow by testing grip strength, wrist
extensionmuscleforce and range of motion wrist extension immediately after the
application of tapingtechniques. Results showed impressive effect on wrist extension,
grip strength and pain. 17
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 12
6) Stasinopoulos, K Stasinopoulu, M I Johanson et. al (2012): Studied the exercise
program for the management of tennis elbow. Study described the use and effects of
strengthening and stretching exercise program in the treatment of tennis elbow. They
concluded that the well designed trial is needed to study the effectiveness of supervised
exercise program for tennis elbow consisting of eccentric and static stretching exercise. 19
7) Magnus Peterson, Stephen butler, et. al. (2011): studied randomized controlled clinical
trial on the effect of exercise versus expectation on pain, muscle strength, function and
quality of life in patients with long standing lateral epicondylosis. They found that exercise
group had greater and faster regression of pain, both during muscle contraction and muscle
elongation than the reference group. 20
8)MoneetKochar and AnkitDogra(2002): conducted a clinical study on Effectiveness of a
specific physiotherapy regimen on patients with Tennis Elbow on 66 patients who were
randomized into 3 groups, The first (MM) group was treated with a combination of
ultrasound therapy and Mulligan mobilization while the second group was treated with
ultrasound therapy alone for ten sessions (completed within three weeks). Both groups
followed a progressive exercise regime for a further nine weeks, third group as control
group. They were evaluated at weekly intervals from the time of selection until the third
week and finally at the 12th week with four outcome measures: visual analogue scale
(VAS), isometric grip strength, weight test and patient assessment test. The results
conclude that the MM group showed improvement on most parameters than other groups
and found that the addition of Mulligan mobilization to a regimen comprising ultrasound
therapy and progressive exercises brings about increased and faster recovery in patients
with tennis elbow15.
9)A Binder, G Hodge, A M Greenwood, B L Hazleman, and D P Page
Thomas(1985):Conducted a randomized study to determine the effectiveness of
therapeutic ultrasound in treatment of soft tissue lesions. They included 76 patients with
lateral epicondylitis, 38 were randomly allocated to receive ultrasound treatment and 38
placebo. The conditions of 24 patients (63%) treated with ultrasound and 11 (29%) given
placebo improved, the difference being significant at the 1%. Improvement in particular
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 13
clinical variables (pain score, weight lifting, grip strength) also showed an advantage for the
patients given ultrasound treatment and the result concluded that Ultrasound enhances
recovery in most patients with lateral epicondylitis18.
10)Pienimaki, Tuomo, Tarvainen .et.al. (2002), Studied the association between changes
in pain and grip strength and manual tests among patients with chronic tennis elbow. Pain
thresholds at the lateral epicondyle are strongly associated with pain on palpation and with a
positive Mill’s test. Resisted extension test results reflect decreased grip strength.25
11)OritShechtman, Lisa Gestewitz and Christine Kimble have done a study to examine
the reliability and validity of the digital DynEx dynamometer. Grip strength testing was
conducted on 100 healthy subjects (aged 20–40 years) using both the Jamar and DynEx
dynamometers in the second handle position.The results of this study indicate that
concurrent validity between the two instruments was excellent21.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 14
METHODOLOGY
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 15
METHODOLOGY
Study Design: Experimental study (pre test and post test).
Study Setting: Various physiotherapy centres in Rajkot.
Sampling Technique: Convenient sampling technique
Study Population: Male and Female
Study Sample: 30 subjects
Study Duration: Training duration: Daily one session
Total Study duration - 2 weeks.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 16
Fig 4.2: Mulligan Tapping
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 17
Fig 4.3:Hand grip strength
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 18
Fig 4.4: Mulligan Mobilisation
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 19
CRITERIA FOR SELECTION
INCLUSION CRITERIA
Age group of 30-60 years with symptomatic lateral epicondylitis on either side.
Both males and females.
Positive Cozens test or Mills test confirming lateral epicondylitis22, 24, 25.
EXCLUSION CRITERIA
Patient having history of trauma, surgery, acute infections.
Patient who have received steroid injections within last 30 days in elbow joint.
Severe neck or shoulder problems with radiating pain to upper limb.
Fractures around elbow complex.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 20
MATERIALS USED IN THE STUDY Mulligan belt
Hand held dynamometer
Ultrasound machine frequency 1MHZ
Ultrasonic gel
couch
stool
Mulligan elastic adhesive tape
pen
paper
data collection sheet.
Patient rated tennis elbow evaluation.
Scissors
Fig 4.5
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 21
METHOD
Patients will be included in the study after the initial assessment and informed consent
will be taken. Subjects who fulfil the inclusion criteria will be assigned into two groups based
on convenient random sampling. Pre test evaluation will be done before starting treatment
which includes pain assessment using PRTEE and pain free grip strength by hand held
dynamometer.
Group A (n=15) will be given Mulligan’s Mobilization With movement on the involved
elbow joint, with patient lying in supine position having their elbow extended and forearm
pronated. The mulligan belt is kept around the therapist’s shoulder and a lateral glide will be
given to the proximal part of the patient’s elbow joint. During the lateral glide, the patient is
asked to perform the pain producing movement (such as gripping or resisted isometric
contraction wrist extensor). If the glide is applied correctly then the patient will not feel any
pain on Lateral Glide Produced Via The Mobilization Belt Concurrent With Strong Resisted
Isometric Wrist Extension. The dosages are 3 sets of 10 pain free mobilizations in each set
with one minute rest time between each set7, 8.
Group B (n=15) Mulligan taping: The subjects will be asked to rest the elbow in
supported position with the elbow is slightly flexion and pronated and wrist in extended
position to contract the ERCB. The tape will be placed on the proximal forearm, starting
medially and laterally parallel to the wrist line. This will be repeated 2 or 3 times. The tape is
tightened until the subject agrees that it snugs during a contraction of the wrist extensors,
but not impending blood flow. The tape should be comfortable when the wrist extensors are
relaxed.2
Both the groups received Pulsed Ultrasound therapy (UST) with a Frequency of 1
MHz & Intensity of 0.5w/cm2 for 5 min at the musculo-tendinous junction of ECRB on the
affected elbow 26, 27.
In addition, both the groups will be given stretching exercises. The stretching will be
given by flexion of the wrist with forearm pronated and elbow extended. This is held for few
seconds and then released. A total of 10 stretches will be given on session per day 20, 28.
Each group will be receiving the interventions one session per day up to 2 weeks.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 22
At the end of 2nd week post test evaluation comprising of PRTEE& Pain free grip
strength will be conducted for both the groups. The result of pre &post test values of each
group is compared & differences in pre &post test values between groups will also be
compared.
30 subjects with pre diagnosed tennis
elbow will be taken.
Consent form will be taken.
2 groups: A and B
Pre & post assessment of PRTEE and
hand grip strength.
Group A :
Mulligan mobilization
Ultrasound
Stretching exercise
Group B:
Taping
Ultrasound
Stretching exercise
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 23
RESULTS
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 24
Result
A study was performed in which PRTEE and Hand grip strength was assessed in both
groups.
The pre and post values for PRTEE and Hand grip strength were collected for both the
groups.
Statistics was performed using unpaired t test and paired t test for Hand grip strength within
and between the groups respectively, whereas Wilcoxson test and Mann Whitney U test was
used for PRTEE within and between the groups respectively.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 25
Table 5.1 Comparison of PRTEE in group A and B(within group)
variable mean
s.d.
W value P value
Result
PRTEE pre post Pre Post
pre post
Group A 52.1 46.53 14.92 14.39 120 <0.0001 0.0007 Significant
Group B 50.83 47.47 13.14 11.82 120 <0.0001 0.0007 Significant
Graph 5.1
The PRTEE comparison within group A and B with pre mean of group A being 52.10
and post mean being 46.53, whereas for group B pre= 50.83 and post=47.47.
The s.d. pre and post value for group A is 14.92 and 14.39 respectively. The s.d. pre
and post value for group B is 13.14 and 11.82 respectively.
The pre and post P value for both the groups being p<0.0001 and p=0.0007
respectively therefore the result is significant.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 26
Table 5.2
Graph 5.2
The Hand grip stremgth comparison within group A and B with pre mean of group A
being 15.37and post mean being 15.99, whereas for group B pre= 14.56 and
post=14.95.
The s.d. pre and post value for group A is 4.931 and 5.099 respectively. The s.d. pre
and post value for group B is 6.054 and 6.054 respectively.
The p value=0.7375 for group A and 0.8624 for group B, therefore the result is not
significant.
Comparison of Hand grip strength in Group A and B(within group)
variable mean
s.d.
t value p value Result
Hand grip strength Pre post pre post
Group A 15.37 15.99 4.931 5.099 0.3385 0.7375 Not significant
Group B 14.56 14.95 6.054 6.054 0.1749 0.8624 Not significant
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 27
Table 5.3
Graph 5.3
The PRTEE between group A and B with pre mean difference of 5.567 and post
mean difference of 3.367.
The pre s.d. difference being 2.809 and post s.d. difference being 2.985.
The p value=0.0156, therefore the result is significant.
Comparison of PRTEE between Group A and B
variable mean
s.d.
U
value p value Result
PRTEE Pre-post pre-post Pre-post Pre-post
5.567 3.367 2.809 2.985 54 0.0156 Significant
Group A:
Group B:
Group A:
Group B:
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 28
Table 5.4
Graph 5.4
0
0.5
1
Hand grip strength Pre-post
Pre-post
Variable
mean
0.62
0.3867
comparison of hand grip strength between group A &
B
Group A:
Group B:
The Hand grip strength between group A and B with pre mean difference of 0.6200
and post mean difference of 0.3867.
The pre s.d. difference being 0.5158 and post s.d. difference being 0.2850.
The p value=0.1615, therefore the result is not significant.
Comparison of hand grip strength between group A and B
Variable mean
s.d.
t
value
p
value Result
Hand grip
strength Pre-post Pre-post Pre-post
Pre-post
0.62 0.3867 0.5158 0.285 1.478 0.1615
Not
significant
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 29
DISCUSSION
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 30
DISCUSSION
The present clinical trial was conducted to compare the effectiveness of Mulligan
moblisation and taping technique with common treatment of therapeutic ultrasound and
stretching exercise in subjects with lateral epicondyitis.
Result of the study were focused on improvement of grip strength was measured with
the help of hand dynamometer and reduction in function actually improvement scored based
on PRTEE for lateral epicondylitis. It was noticed that there was improvement in the above
parameters in both groups.
AlirzaShamsoddini, Mohammad TaghiHollisaz, et.al. (2010):Studied the initial
effect of taping techniques in subjects with tennis elbow by testing grip strength,wrist
extensionmuscleforce and range of motion wrist extension immediately after the
application of taping techniques.Results showed impressive effect on wrist extension,
grip strength and pain. 17
MoneetKochar and Ankit Dogra(2002): conducted a clinical study on Effectiveness
of a specific physiotherapy regimen on patients with Tennis Elbow on 66 patients who were
randomized into 3 groups, The first (MM) group was treated with a combination of
ultrasound therapy and Mulligan mobilization while the second group was treated with
ultrasound therapy alone for ten sessions (completed within three weeks). Both groups
followed a progressive exercise regime for a further nine weeks, third group as control
group. They were evaluated at weekly intervals from the time of selection until the third
week and finally at the 12th week with four outcome measures: visual analogue scale
(VAS), isometric grip strength, weight test and patient assessment test. The results
conclude that the MM group showed improvement on most parameters than other groups
and found that the addition of Mulligan mobilization to a regimen comprising ultrasound
therapy and progressive exercises brings about increased and faster recovery in patients
with tennis elbow15.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 31
Mulligan mobilization is the commonest manual therapy procedures used in the
treatment of lateral epicondylitis. These techniques help in reduction of pain immediately
after the technique is applied for short period8, 9,10,11,15,16,17. Taping has been found effective
in decreasing the pain & restoring the joint play by maintaining & establishes proper
structural alignment by balancing the tissue length/tension relationship for prolonged
period12, 14.
LIMITATIONS OF THE STUDY
Subjects could not be followed up for longer period of time, to see long term
benefit.
Small sample size was used.
Majority of the subjects were females.
FURTHER RECOMMENDATION
longer duration are recommended with longer follow-up period to assess long
term benefits.
Conduct the study with larger sample size.
Further study should be carried out with acute or chronic injury subjects.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 32
CONCLUSION
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 33
CONCLUSION
The present randomized clinical trial provided evidence to support the use of Mulligan
mobilization and taping techniques in relieving pain, improving grip strength and improve
functional performance in subject with tennis elbow.
In addition, results supported that Mulligan mobilization was more effective than taping
technique in reducing pain and functional performance.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 34
SUMMARY
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 35
SUMMARY
The purpose of this study is to determine the effectiveness of Mulligan mobilization
and taping in lateral epicondylitis.
Individuals (N= 15) were randomly assigned into a group containing 13 females and 2
males in group A and group B containing 12 females and 3 males. Group A was treated with
Mulligan mobilization, US and stretching where as group B was treated with Mulligan taping,
US and stretching.
The measurement used are hand dynamometer and PRTEE. Each subject was
measured before and after 2 weeks of treatment.
The result of this study indicate that the mean improvement in hand grip strength
when compared in pre and post treatment did not show significant improvement within and
between the groups with p>0.05.
The result of this study indicate that the mean improvement in PRTEE when
compared in pre and post treatment shows significant improvement within and between the
groups with p<0.05.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 36
BIBLIOGRAPHY
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 37
BIBLIOGRAPHY
1) Robert A. Donatelli , Michael J. Wooden. Orthopaedic Physical Therapy. 2nd edition ,
Churchill Livingstone Inc publications,1994,pp-188-189
2) D Stasinopulos, M I Johnson, Cyriax Physiotherapy for tennis elbow, Br J of sports
medicine. 2004;38;675-677
3) S.BrantBrotzman, Kevin. E. Wilk, Clinical Orthopaedic Rehabilitation. 2nd edition, Mosby
pub, 2003.
4) Ched Starkey, Jeff Ryan. Evaluation of Orthopaedic and Athletic Injuries. 2nded, F A
Davis company, 2002.
5) Pamela K Levangie, Cynthia. C Norkin. Joint Structure & Function, A Comprehensive
analysis. 3rded, Jaypee pub. 2001.
6) Peggy.A.Houglum, Therapeutic Exercise for musculo skeletal injuries. 2ndedition..Human
Kinetics Publications,2004
7) Brian R Mulligan. Manual Therapy- ‘’NAGS’’, ‘’SNAGS’’, ‘’MWMS’’ etc. 4thed, Plane view
press, Welligton, 1995.
8) Jack miller ,Case study: mulligan management of “Tennis elbow”, published orthpaedic
Division Review May/June 2000
9) James H Cyriax, The Text book of Orthopedic Medicine, Diagnosis of soft tissue lesion,
volume one, 8th edition, A.I.T.B.S Pub. 2002.
10) Rene cailliet. Soft tissue pain & disability, 3rd edition, F.A.Davis Company, 1996.
11) James. H Cyriax, The text book orthopedic medicine, Treatment by manipulation,
massage and injection, 11th edition, Vol 2, A.I.T.B.S PUB.2002.
12) Mary Lynn Jocobs, Noelle Austin. Splinting the hand & upper extremity principles &
process, 2003, Lippincott Williams &wilkins pub.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 38
13) Carolyn kisner, Lynn Allen Colby. Therapeutic exercises: foundations and technique.
4thed. Jaypee publications.2003.
14) Bill Vicenzino, Jane Brooks bank, Joanne Minto, Sonia offord, Aatitpaungmali, Initial
effects of elbow taping on pain free grip strength and pressure pain threshold,, Journal of
orthopedic & sports Physical therapy,2003;33: 400-407
15) Moneet, Kocher Dograankit . Effectiveness of specific physiotherapy regimen on patients
with tennis elbow: Clinical Study, Physiotherapy, 2002 , vol.88,333-341.
16) AatitPaungmali, Shaun O'Leary, Tina Souvlis and Bill Vicenzino.“Hypoalgesic and
Sympatho excitatory Effects of Mobilization with Movement for Lateral Epicondylalgia”.
Physther 2003; 83:374-383.
17) D Stasinopulos, M I Johnson, Cyriax Physiotherapy for tennis elbow, Br J of sports
medicine. 2004; 38; 675-677.
18) A Binder, G Hodge, A M Greenwood, B L Hazleman, and D P Page Thomas, Is
therapeutic ultrasound effective in treating soft tissue lesions.Br Med J (Clin Res Ed).
1985 February 16; 290(6467): 512–514.
19) Williamson A, Hoggart B, Pain: A review of three commonly used pain rating scales. J
Clin. Nurs. 2005, Aug; 14(7):798-804.
20) D Stasinopoulos, P Manias, A controlled clinical pilot trial to study the effectiveness of ice
as a supplement to the exercise programme for the management of lateral elbow
tendinopathy,Br J Sports Med. 2006 January; 40(1): 81–85.
21) Orit Shechtman , Lisa Gestewitz and Christine Kimble, Reliability and Validity of the
DynEx Dynamometer, Journal of Hand TherapyVolume 18, Issue 3, July-September
2005, 339-347.
22) Pienimaki, tuomo et al,The clinical journal of pain, Association between pain,grip strength
and manual tests in the treatment evaluation of chronic tennis elbow.May/June
2002,vol.18,issue 3,pp 164-170.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 39
23) Won- Hwee Lee, Oh-Yun Kwon, Chung-Hwi Yi, Hye-SeonJeon, Sung-Min Ha. Effects of
Taping on Wrist Extensor Force and Joint Position Reproduction Sense of Subjects With
and Without Lateral Epicondylitis. Journal .Physiotherapy Therapeutics. Science 2011;
(23):629-624.
24) David J.Magee, Orthopedic Physical Assessment, 4th edition, Saunders,2002.pp 379
25) Ronald C.Evans , Illustrated orthopedic physical assessment , 2nd edition,pp316
26) John Low and Reed .Electrotherapy Explained: principles and practice. 3rd ed.
Buttersworth-Heinemann, 1999,
27) Sheila kitchen, Electrotherapy: Evidence Based Practice, 11th ed. Churchill Livingstone,
2002.
28) Hillel M. finestone, Deborah L. robinovitch. Tennis elbow no more, practical eccentric and
concentric exercises to heal the pain; Can Fam Physician, 2008 Aug; 54(8):1115-1116.
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 40
ANNEXURE
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 41
ANNEXURE 10.1
CONSENT FORM
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 42
ETHICAL INFORMED CONSENT FORM
Study title: “ EFFECTIVENESS OF MULLIGAN MOBILIZATION AND TAPING IN LATERAL
EPICONDYLITIS.”
Subject’s Name:
Age : ____________Years Sex:___________
Address of the Subject___________________________________________________
___________________________________________________________
I have been explained in details about the various questions/tests that will be asked/performed is to
assess my functional capacity & health status etc. I have also been explained that all the tests are non-
invasive and without any side effect.
I understand that my participation in the study is voluntary and that I am free to withdraw at any time,
without giving any reason, without my medical care or legal right being affected.
I understand that the data obtained through the study may be used for research paper publication and I
also understand that my identity will not be revealed at any cost. I agree to give my consent for
taking my photograph and have no objection against it.
I agree to take part in the above study
Signature / Thumb impression of the subject ------------------
Date:
Name of Witness:___________________________________________
Signature of the Witness: ____________
Signature of Investigator --------------------
Date:
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 43
ANNEXURE 10.2
DATA COLLECTION FORM
Name:
Age: Gender:
Occupation: Contact no:
Address:
Chief complain:
Provisional diagnosis:
Pain history:
Site: Type:
Frequency: Duration:
Aggravating factors: Relieving factors:
Outcome measures:
PRTEE: Pre score Post score
Hand grip strength:
Pre score Post score
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 44
ANNEXURE 10.3
MEASUREMENT TOOL
Patient rated tennis elbow evaluation (PRTEE)
Clinical test: Cozen’s test
Mill’s test
Hand dynamometer
“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 45
ANNEXURE 10.4
SCALES USED IN OUTCOME MEASURES
PATIENT-RATED TENNIS ELBOW EVALUATION
Name _______________________________ Date______________
Instruction: Please rate the activities in each category according to your difficulty.
Circle one for each activity.
1. PAIN in your affected arm
Rate the average amount of pain in your arm over the past week by circling the number
that best describes your pain on a scale from 0-10. A zero (0) means that you did not have any
pain and a ten (10) means that you had the worst pain imaginable.
RATE YOUR PAIN: Worst
No Pain Imaginable
When your are at rest 0 1 2 3 4 5 6 7 8 9 10
When doing a task with repeated arm 0 1 2 3 4 5 6 7 8 9 10
Movement
When carrying a plastic bag of groceries 0 1 2 3 4 5 6 7 8 9 10
When your pain was at its least 0 1 2 3 4 5 6 7 8 9 10
When your pain was at its worst 0 1 2 3 4 5 6 7 8 9 10
Pain score = ( ) = /50
EFFECT OF MULLIGAN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 46
2. FUNCTIONAL DISABILITY
A. SPECIFIC ACTIVITIES Rate the amount of difficulty you experienced performing each of the tasks listed
below, over the past week, by circling the number that best describes your difficulty on
a scale of 0-10. A zero (0) means you did not experience any difficulty and a ten (10)
means it was so difficultyou were unable to do it at all.
No Unable
Difficulty To Do
Turn a doorknob or key 0 1 2 3 4 5 6 7 8 9 10
Carry a grocery bag or briefcase by the handle 0 1 2 3 4 5 6 7 8 9 10
Lift a full coffee cup or glass of milk to your 0 1 2 3 4 5 6 7 8 9 10
Mouth
Open a jar 0 1 2 3 4 5 6 7 8 9 10
Pull up pants 0 1 2 3 4 5 6 7 8 9 10
Wring out a washcloth or wet towel 0 1 2 3 4 5 6 7 8 9 10
B. USUAL ACTIVITIES Rate the amount of difficulty you experienced performing your usual activities in
each of the areas listed below, over the past week, by circling the number that best
describes your difficulty on a scale of 0-10. By “usual activities”, we mean the
activities that you performed before you started having a problem with your arm. A
zero (0) means you did not experience any difficulty and a ten (10) means it was so
difficulty you were unable to do any of your usual activities.
1. Personal activities (dressing, washing) 0 1 2 3 4 5 6 7 8 9 10
2. Household work (cleaning, maintenance) 0 1 2 3 4 5 6 7 8 9 10
3. Work (your job or everyday work) 0 1 2 3 4 5 6 7 8 9 10
4. Recreational or sporting activities 0 1 2 3 4 5 6 7 8 9 10
Functional score= ( )/2= /50 Total score= = /100
EFFECTIVE OF MULLIGAN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 47
ANNEXURE 10.5
MASTER CHART
GROUP A
MULLIGAN MOBILISTAION, STRETCHING, ULTRASOUND
SR
NO
AGE GENDER PRTEE HAND GRIP
STRENGTH(kgs)
PRE
SCORE
POST
SCORE
PRE
SCORE
POST
SCORE
1 55 F 44 39.5 13.6 14
2 49 M 39.5 32.5 24 26.2
3 34 F 35 29.5 12 12.8
4 54 M 60 55 17.2 17.8
5 36 F 30 26 10.3 11.2
6 42 F 54.5 43 12.4 12.8
7 33 F 52.5 45.5 21.3 21.8
8 38 F 37.5 32 20.4 21
9 46 F 58 58 20.3 20.3
10 51 F 81 73 12 13
11 31 F 73 68.5 19.5 20
12 35 F 73.5 64 11.3 12
13 46 F 46 42.5 6.7 7
14 44 F 48 45.5 16.8 17
15 42 F 49 43.5 12.8 13
EFFECTIVE OF MULLIGAN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 47
GROUP B
TAPPING,STRETCHING,ULTRASOUND
SR
NO
AGE GENDER PRTEE HAND GRIP
STRENGTH
PRE
SCORE
POST
SCORE
PRE
SCORE
POST
SCORE
1 55 F 52 49.5 6.5 7
2 44 F 42 42 11.4 11.4
3 50 F 45.5 43 22.1 23
4 38 F 28 26 22 22.5
5 47 M 35 33 26.7 27
6 52 M 79 68 8.2 9
7 60 F 40 32 7.6 8
8 52 F 46.5 46.5 13.3 13.3
9 37 F 50 50 14 14
10 50 F 54.5 50 11.2 11.8
11 33 F 51 47.5 16.8 17
12 40 F 65 60.5 11.3 12
13 40 M 67.5 63 21.9 22.2
14 33 F 46 42.5 12.6 13
15 46 F 60.5 58.5 12.8 13
EFFECTIVE OF MULLIGAN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 47