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The treatment of musculoskeletal joint dysfunction may require a physiotherapist to use a number of

modalities. Developed manual therapy techniques include that of Brian Mulli-gan’s widely used mobilization with movement (MWM) for peripheral joint

pain1,2, also referred to as a Mulligan mobilization3-5 or a manipulative tech - nique6,7.

With respect to the research, the clinical efficacy of Mulligan’s MWM techniques has been established for im-proving joint function, with a number of

hypotheses for its cause and effect. Mul-ligan’s original theory for the effective-ness of an MWM is based on a mechani-cal model documented in his first teaching text8. This concept is related to minor positional faults that occur sec-ondary to injury and that lead to mal-tracking of the joint, resulting in symp-toms such as pain, stiffness, or weakness1. This theory in conjunction with the pre-scription of MWMs is still advocated in Mulligan’s latest edition and remains un-changed9. The cause of positional faults has been suggested as changes in the shape of articular surfaces, thickness of cartilage, orientation of fibers of liga-ments and capsules, or the direction and pull of muscles and tendons. MWMs cor-rect this by repositioning the joint, caus-ing it to track normally1,10. Subsequent research to date also suggests that the mechanisms behind the effectiveness of MWMs are based on mechanical dys-function and therefore positional fault correction1,3,11,12.

More recent studies have investi-gated further mechanisms and effects that may underpin MWM techniques, including hypoalgesic and sympathetic nervous system (SNS) excitation ef-fects5,13-15. Further research has estab-lished the effectiveness of MWMs for increasing joint range of motion (ROM),

ABSTRACT: Mulligan’s manual therapy technique at peripheral joints, namely mobiliza-tion with movement (MWM), has been well documented in research. The efficacy of MWM has been established in the treatment of joint dysfunction and various pathologies. The purpose of this systematic review was to critically evaluate the literature regarding MWM at peripheral joints and determine the overall efficacy related to MWM prescription. Elec-tronic databases (Cinahl, Medline and Amed via Ovid, Pubmed and Medline via Ebsco Health Databases, Cochrane via Wiley and PEDro) were searched up to August 2008 with no date restriction to identify all studies pertaining to MWM at peripheral joints. The key-words used were mobilisation with movement* OR mobilization with movement* OR MWM*; manual therapy AND (mobilisation* OR mobilization); mulligan mobilisation* OR mulligan mobilization*. Two researchers independently reviewed all papers and cross-examined reference lists for further potential studies. Methodological quality was assessed using the Downs and Black checklist, and tables were compiled to determine study charac-teristics. Twenty-one studies, which have investigated MWM at peripheral joints, were in-cluded for analysis. This review highlights that there is an overall moderate level of method-ological quality (mean = 15 (/28), SD ± 4.54, range = 4—23 /28). The efficacy of MWM at peripheral joints is well established for various joints and pathologies with 24 out of 25 stud-ies (96%) demonstrating positive effects. It would be advisable that future research have more robust methodology and investigate and/or implement all necessary established pa-rameters of MWM prescription.

KEYWORDS: Manipulative Technique, Manual Therapy, Mobilization with Movement (MWM), Mulligan Mobilization

1Associate Professor, Health and Rehabilitation Research Centre, AUT University, Auckland, New Zealand2Staff Physiotherapist, IRM Physiotherapy, Auckland, New Zealand3Staff Physiotherapist, Waikato Hospital, Waikato, New ZealandAddress all correspondence and requests for reprints to: Dr. Wayne Hing, wayne.hing@aut.ac.nz

Mulligan’s Mobilization with Movement: A Systematic Review

Wayne Hing, PhD1; Renee BigeloW, BHSc2; Toni BRemneR, BHSc3

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enhancing muscle function, or more specifically treating particular patholo-gies1,3,5,6,16-18.

The purpose of this review initially originated from a global search that was undertaken to explore the literature re-garding Mulligan’s manual therapy tech-niques. From this search, it became evi-dent that there has been no review or consensus regarding the prescription of MWMs in peripheral joints. Therefore, the purpose was to undertake a system-atic review to critically evaluate the lit-erature regarding the overall efficacy of MWM prescription and use at periph-eral joints in an attempt to formulate guidelines for clinical practice.

Methods

Search Strategy

Electronic databases (Cinahl, Medline and Amed via Ovid, Pubmed and Med-line via EBSCO Health Databases, Co-chrane via Wiley and PEDro) were searched to August 2008 with no date restriction to identify all studies pertain-ing to MWM at peripheral joints. The refined key terms were mobilisation with movement* OR mobilization with movement* OR MWM*; manual ther-apy AND (mobilisation* OR mobiliza-tion); mulligan mobilisation* OR mul-ligan mobilization*. These search phrases were adapted for particular da-tabases (Medline via Pubmed and EB-SCO, and EBSCO Health Databases), due to the excessive number of results (Figure 1). While performing the search, two independent researchers evaluated all titles and abstracts that were obtained from the various databases or from other sources to determine appropriate-ness. If this was unclear, the full-text ar-ticle was obtained to confirm whether MWM at peripheral joints was em-ployed. All articles to be included in this review were obtained in hard copy.

Exclusion criteria that were incor-porated during the search included studies prior to 1990, non-English writ-ten articles, studies not relevant to pe-ripheral joint manual therapy/MWM/physiotherapy, spinal manual therapy, chiropractic studies, non-original re-search, cadaver or animal studies, and/

or if there was no clear indication of the use of MWM. Due to the aim of this sys-tematic review, to obtain every study that had used MWM techniques, no re-strictions were placed on study design or methodological quality, as all literature needed to be reviewed to accurately ana-lyze the possible variations in its pre-scription. As papers were read, reference lists were cross-examined by both re-viewers for citations of other potentially relevant studies, and in total three stud-ies were subsequently retrieved from this process of cross-referencing7,19,20.

Review of Methodological Quality

The critical appraisal tool employed for this research was the Downs and Black checklist for the assessment of method-ological quality21. This tool has been stated to be valid and reliable for criti-cally evaluating experimental and non-experimental studies22,23, and it has pre-viously been used in many systematic reviews24-29. The Downs and Black tool consists of four categories: reporting (/11), external validity and power (/4), internal validity (bias) (/7), and internal validity (confounding or selection bias) (/6) totalling 28. The last item in this tool, regarding the power of a study, was modified due to its complexity and to ensure consistency with the scoring. The item was changed from a score out of five to a score out of one, and it was placed with the external validity cate-gory in the table. An example of a study in which this tool was previously modi-fied is Monteiro and Victora27.

Each article was assessed with this scoring system, independently by the two researchers, to decrease bias. The scores and content of each article were meticulously discussed throughout. If any disagreements arose, they were de-liberated between the two researchers and resolved. After critiquing each study, it was categorized as being of a strong, moderate, limited, or poor quality depending on its score (Table 1). This method of score categorization was adapted from previous systematic re-views that have used the Downs and Black checklist and have further classi-fied the resulting values24,26. No studies were excluded on the basis of limited

quality, due to the purpose of the review and its aim to assess all studies that have incorporated MWMs in peripheral joints.

Review of Study Characteristics

Using a generic critical appraisal check-list, data was extracted from the in-cluded 25 articles and information was recorded into tables under the following headings: design, purpose, participants, interventions, MWM prescription or other treatment, outcome measures and timing of assessment, statistical analysis, results, and strengths and limitations.

Results

During the search, articles were ex-cluded on the basis of the strict exclu-sion criteria previously mentioned. A total of 121 articles were identified from the stated databases (Figure 1). Once search results were matched for repeated articles between the databases, 22 were included for analysis. An additional 3 studies were found by means of further cross-referencing by both reviewers7,19,20, increasing the total to 25 studies for critical analysis—including 4 true ran-domized controlled trials (RCTs), 6 RCTs with participants as own control, 3 quasi-experimental, 3 non-experi-mental, 4 case studies, and 5 case re-ports. Both researchers performed the statistical calculations independently, to ensure correct results.

Methodological Scoring and Categorization (critical evaluation of the literature regarding MWM prescription at peripheral joints)

The included 25 articles were analyzed using the Downs and Black tool result-ing in a variation of data in relation to the particular study design (mean = 15/28; SD ± 4.54; range = 4—23/28). Table 2 reflects the reporting analyses of items 1 through 10. Table 3 reflects the reporting analyses of the external valid-ity items of 11 through 14. Table 4 out-lines the scoring for the internal validity items of 15 through 21. Table 5 also in-cludes internal validity items but focuses on confounding or selection biases of

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51

Initial global search followed by a refined

search (exclusion criteria implemented)

Articles retrieved by Amed (79), Cinahl via

Ovid (163), Cochrane via Ovid (65),

Cochrane via Wiley (89), and Pedro (28)

with normal search terms: 424

Articles retrieved by EBSCO Health

Databases (114), Medline via EBSCO (87),

and Medline via Pubmed (1078) with

adapted key terms due to excessive number

of results: 1279

Excluded: 360

NB: Includes databases

with repeated articles

Excluded: 1222

NB: Includes databases

with repeated articles

Cross-referencing of all articles for further

studies results: 3

Total articles identified for analysis in

relation to the final exclusion criteria: 121

Cross-matching of search results for repeated

articles results: 22

Final studies selected for the systematic

review of Mulligan’s Mobilization with

Movement: 25

items 22 through 27. In general, the studies were of a moderate level of meth-odological quality. Categorization of the methodological scores, as detailed in Table 1, was adapted from systematic

reviews that had previously used the Downs and Black critiquing tool for as-sessing quality of studies24,26.

As illustrated in Table 6, RCTs with participants as their own control

achieved the highest mean score (mean = 18.5) with the least variability (±1.71), meaning overall they were of moderate methodological quality. This is closely followed by true RCTs (mean = 17.5) and then non-experimental studies (mean = 17.33), both ranking at a mod-erate level of quality. Interestingly, the non-experimental group of studies had less variability (±3.68) compared to the true RCTs (±5.12). This suggests that there is greater variability (range = 11–23) in the methodological quality of true RCTs in this area of research, even though it includes the highest scoring study to date30. Quality of studies was

FiguRe 1. Flow chart outlining search results

TABLE 1. Categorization of total methodological scores

Quality Index: Percentage: Methodological Quality Score:

Strong 75% + 21 +Moderate 50–74% 14–20Limited 25–49% 7–13Poor < 25% < 7

Adapted from Hartling et al24 and Hignett26

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TABLE 2. reporting analysis via the Downs and black checklist for methodological quality

Author 1 2 3 4 5 6 7 8 9 10

Bisset et al30 1 1 1 0 2 1 1 1 1 0Kochar & Dogra4 1 1 1 1 1 1 1 0 0 0Slater et al42 1 1 1 1 0 1 1 0 0 0Teys et al5 1 1 1 1 1 1 1 1 1 1Collins et al3 1 1 1 1 0 1 1 0 1 1Paungmali et al14 1 1 1 1 1 1 1 1 1 0Paungmali et al15 1 1 0 1 1 0 1 1 1 0Teys et al40 1 1 1 1 0 1 1 1 1 1Vicenzino et al7 1 1 1 1 1 1 0 1 1 1Vicenzino et al18 1 1 1 1 0 1 1 1 1 1McLean et al31 1 1 1 1 0 1 1 0 0 1Reid et al32 1 1 1 1 2 1 1 0 1 1Yang et al33 1 1 1 1 2 1 1 0 1 0Abbot13 1 1 1 1 0 1 1 0 0 1Abbottet al41 1 1 1 1 0 1 1 0 1 0Paungmali et al6 1 1 1 1 2 1 1 1 1 1O’Brien & Vincenzino38 1 1 1 1 0 0 0 0 1 1Penso39 1 1 1 1 1 1 0 0 1 0Stephens20 0 0 1 0 0 0 0 0 1 0Vincenzino & Wright34 1 1 1 1 0 1 0 1 1 0Backstrom35 1 1 1 1 0 0 0 0 1 0DeSantis & Hasson16 1 1 1 1 0 1 0 0 1 0Folk36 1 0 1 1 0 1 0 0 1 0Hetherington19 0 1 0 1 0 0 0 0 0 0Hsieh et al37 1 0 1 1 0 1 0 0 1 0

1. Is the hypothesis/aim/objective of the study clearly described? 2. Are the main outcomes to be measured clearly described in the introduction or methods section? 3. Are the characteristics of the patients included in the study clearly described? 4. Are the interventions of interest clearly described? 5. Are the distributions of principle confounders in each group of subjects to be compared clearly described? 6. Are the main findings of the study clearly described? 7. Does the study provide estimates of the random variability in the data for the main outcomes? 8. Have all important adverse events that may be a consequence of the intervention been reported? 9. Have the characteristics of patients lost to follow-up been described? 10. Have the actual probability values been reported?1 = yes, 0 = no

more consistent in the group of RCTs with participants as their own control. The quasi-experimental studies31-33 had a mean score of 17.33 (±3.68), ranking them as moderate quality. Case studies and case reports had the lowest mean scores, 12.75 (±2.95) and 10.4 (±3.38) respectively, categorizing them as being of limited methodological quality. The range of case studies (range = 8–16) and reports (range = 4–14), however, was large, and two studies had a moderate level of quality16,34, which is in general equivalent to the quality of several true

RCTs, RCTs with participants as own control, quasi-experimental, and non-experimental studies.

When comparing the 4 categories from the Downs and Black tool, in re-gards to the mean, standard deviation, and range, it is evident that the different categories display either a low or moder-ate level of quality (Table 6). The catego-ries of external validity/power (/4) and internal validity (confounding and se-lection bias) (/6) generally scored low, which is indicated by their means, stan-dard deviations, and ranges, calculated

across all studies: 0.84 (±0.78) (range = 0–4/4) and 2.84 (±1.22) (range = 1–6/6), respectively. Reporting (/11) and inter-nal validity (bias) (/7) generally scored with a moderate level of quality, with scores of 7.16 (±2.22) (range = 2–11/11) and 4.64 (±1.87) (range = 0–7/7), re-spectively. Two studies in particular19,20 had the lowest total scores, resulting in an overall reduction of the mean values and increasing the variability of the data. The study that displayed the highest overall score (by Bisset et al30) of 23 out of 27 also illustrated consistency in all 4

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categories, which differs from the other studies, which only excelled in particu-lar categories.

Characteristics of Studies

Data extracted from the 25 studies for the generic critical appraisal checklist il-lustrate trends and variations in the overall characteristics of each study. De-signs of studies have been previously mentioned and are outlined in Table 6. The characteristics of the studies can be found in Table 7, and the results, along with summaries of strengths and limita-tions of the studies, are found in Table 8. Nearly half of the studies (12/25; 48%) investigated MWM effects on lateral

epicondylalgia. The next most common condition investigated was lateral ankle sprains (6/25; 24%). Following this, an equal number of studies have assessed the effects at the shoulder (4/25; 16%) and thumb (2/25; 8%), with pathologies including anterior shoulder pain and subacromial impingement for the shoul-der joint, and metacarpophalangeal (MCP) strains of the thumb. Only one study has investigated MWM at the wrist for de Quervain’s (4%).

All studies have examined the ef-fects of MWMs on genuine pathologies, where the participants presented with the condition, except for the study by Slater et al37, which induced lateral epi-condylalgia. It is important to highlight

also that this was the only study that did not conclude with any significant be-tween-group differences in response to the intervention of MWM versus pla-cebo. The genders of the participants varied between studies, although there was approximately equal male and fe-male representation across all the in-cluded studies. There was a large varia-tion in the average age of the participants, ranging from 17 to 79 years, which may reflect the six different pathologies in-vestigated, each with their own epide-miological data. MWM treatment dura-tions varied from one day to two months. Only 8 of the 25 studies included some form of follow-up, with all demonstrat-ing significant positive results from MWM use4,20,30,34-39.

Overall Efficacy of MWMs

All studies included in this review found significant positive results with MWM applications, when compared to placebo or control groups. The only study in which no significant results were found with pain pressure threshold (PPT) or strength was by Slater et al37, which is also the only study that investigated the efficacy of MWMs on an induced condi-tion. All other studies used patients with genuine pathologies, whereas this study induced lateral epicondylalgia pain via delayed onset of muscle soreness and hypertonic saline.

The most common significant re-sults found were increase in strength, reduction in pain levels, increase in PPT, improved upper limb tension tests, and overall function improve-ments when compared with placebo or control, mainly in lateral epicond-ylalgia4,6,7,13-15,20,30,31,34. No change in tem-perature pain threshold (TPT) has been found at the elbow15. Other interesting findings were that repeated applications of MWM, or MWM with naloxone, did not have an inhibitory effect on the pain-relieving effects, therefore suggesting that a non-opioid mechanism occurs for the analgesic response6,15. The only study investigating the required force for opti-mal effects demonstrated that best re-sults are gained when an MWM is ap-plied at either 66% or 100% of maximal force31. MWM treatment was also found

TABLE 3. external validity and power analysis via the Downs and black checklist for methodological quality

Author 11 12 13 14

Bisset et al30 1 1 1 1Kochar & Dogra4 0 0 1 0Slater et al42 0 0 0 1Teys et al5 0 0 0 1Collins et al3 0 0 0 0Paungmali et al14 0 0 0 1Paungmali et al15 0 0 0 0Teys et al40 0 0 0 0Vicenzino et al7 0 0 0 0Vicenzino et al18 0 0 0 0McLean et al31 0 0 0 1Reid et al32 0 0 0 0Yang et al33 1 0 0 0Abbot13 0 0 0 0Abbottet al41 0 0 0 1Paungmali et al6 0 0 0 1O’Brien & Vincenzino38 0 0 1 0Penso39 0 0 1 0Stephens20 0 0 1 0Vincenzino & Wright34 0 0 1 0Backstrom35 0 0 1 0DeSantis & Hasson16 0 0 1 0Folk36 0 0 1 0Hetherington19 0 0 1 0Hsieh et al37 0 0 1 0

11. Were the subjects asked to participate in the study representative of the entire population from which they were recruited?

12. Were those subjects who were prepared to participate representative of the entire population from which they were recruited?

13. Were the staff, places, and facilities where the patients were treated representative of the treat-ment the majority of patients received?

14. Did the study have sufficient power to detect a clinically important effect where the probability value for a difference being due to chance was less than 5%?

1 = yes, 0 = no

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to be superior in the long term when compared to corticosteroid injection30. Alterations in SNS function following an MWM were demonstrated, showing an increase in heart rate, blood pressure, skin conductance, blood flux, and skin temperature. These are similar to the ef-fects of spinal manipulation14. MWM applied at the elbow has shown to have beneficial effects on shoulder rotation ROM13.

At the shoulder, wrist, thumb, and ankle, similar results were found. These were decrease in pain; increase in ROM, PPT, strength, and joint glides; and im-proved function3,5,16,18,19,32,33,35-40. Again no change in TPT was found at the an-kle3. One study investigated MWM un-

der magnetic resonance imaging and found MWM to correct a position fault at the thumb, although this was not maintained post-MWM even though the positive effects were long lasting37.

Discussion

Methodological Quality

Overall, the results of this systematic re-view illustrate a moderate methodologi-cal quality among studies that have in-vestigated the use of Mulligan’s MWM technique at peripheral joints. RCTs that used participants as own controls had the highest methodological mean score (18.5/28) and the least variability (SD

±1.71). There was greater variability (range = 11–23) in the methodological quality of true RCTs in this area of re-search, however, this group includes the highest scoring study to date30. This study also displayed the highest overall score (23 out of 27), which illustrated consistency in all four categories as compared to all other studies, which had variable scoring in each category of the analysis. This illustrates that more con-sistently robust research is being pro-duced when participants are used as control groups; however, RCTs with true control groups are considered the high-est quality research design. As predicted, case studies and case reports had the lowest mean score; however, both had outliers, with large ranges from 8 to 16, and 4 to 14, respectively. This highlights the variability in the quality of this area of research.

The results from the methodologi-cal quality analysis via the Downs and Black critiquing tool displayed an over-all low to moderate level of quality across each category (Tables 1–6). The items within external validity and power were the least satisfied followed by internal validity (confounding and selection bias). Contributing to the low level of quality were two studies with the lowest score19,20, which as outliers resulted in an overall reduction of the mean values and increasing the variability of the data. The study that displayed the highest (Bisset et al30 with 23 out of 27) demonstrated the highest overall score with consis-tency in all four categories when com-pared to the other studies that only ex-celled in particular categories.

Strengths and Limitations of the Included Studies

This review has highlighted clear strengths and limitations within this area of research. These are clearly related to the analyses of categories and indi-vidual items of the Downs and Black critiquing tool, which are detailed in the following sections.

Reporting

Of the four categories within the Downs and Black critiquing tool, reporting per-

TABLE 4. internal validity—bias analysis via the Downs and black checklist for methodological quality

Author 15 16 17 18 19 20 21

Bisset et al30 0 1 1 1 0 0 1Kochar & Dogra4 0 0 1 1 1 0 1Slater et al42 0 0 1 1 1 0 0Teys et al5 1 1 1 1 1 1 1Collins et al3 1 1 1 1 1 0 1Paungmali et al14 0 1 1 1 1 1 1Paungmali et al15 1 1 1 1 1 1 1Teys et al40 1 1 1 1 1 1 1Vicenzino et al7 1 1 1 1 1 1 1Vicenzino et al18 1 1 1 1 1 1 0McLean et al31 1 0 1 1 1 0 1Reid et al32 0 1 1 1 1 0 1Yang et al33 0 1 1 1 1 0 1Abbot13 0 1 1 1 1 0 1Abbottet al41 0 1 1 1 1 1 1Paungmali et al6 1 1 1 1 1 1 1O’Brien & Vincenzino38 0 0 1 1 1 1 1Penso39 0 0 1 1 0 1 0Stephens20 0 0 1 1 0 0 0Vincenzino & Wright34 0 0 1 1 1 1 1Backstrom35 0 0 1 1 0 0 0DeSantis & Hasson16 0 0 1 1 0 1 1Folk36 0 0 1 1 0 1 0Hetherington19 0 0 0 0 0 0 0Hsieh et al37 0 0 1 1 0 0 0

15. Was an attempt made to blind study subjects to the intervention they have received?16. Was an attempt made to blind those measuring the main outcomes of the intervention?17. If any of the results of the study were based on “data dredging,” was this made clear?18. In trials and cohort studies, do the analyses adjust for different lengths of follow-up of patients,

or in case-control studies, is the time period between the intervention and outcome the same for cases and controls?

19. Were the statistical tests used to assess the main outcomes appropriate?20. Was compliance with the intervention/s reliable?21. Were the main outcome measures used accurate (valid and reliable)?1 = yes, 0 = no

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formed at the highest level: 90% of the studies included a clear aim and descrip-tion of inclusion and exclusion criteria, which are important for generalizability of results and also closely relates to the adequate explanation of characteristics (items 1, 3). Consistent and appropriate choice of outcome measures was em-ployed across the studies (item 2); for example, all studies investigating the ef-fects of MWM at the elbow used either pain-free grip strength or maximal grip strength as part of their assessment. In general, interventions were well out-lined (item 4); however, explicit details of MWM prescription were variable, which impacted the analysis of findings. Further weaknesses were evident, in-

cluding documenting confounding variables, adverse effects, and probabil-ity values (items 5, 8, 10).

Internal Validity

Internal validity is necessary to deter-mine treatment efficacy. Statistical anal-ysis was performed appropriately in the majority of studies, which illustrates strength of result analysis. Generally, there was high compliance with a low level of dropouts when reported (item 27), possibly reflecting the minimal ad-verse events documented. Randomiza-tion of participants to intervention groups is important in research to di-minish possible bias; however it only oc-

curred in 15 of the studies (60%) re-viewed here3-5,7,13-15,18,30-33,40-42 although it should be noted that 9 studies were ei-ther case reports or studies and there-fore only 16 studies had the potential for randomization (item 24). Although only 9 studies incorporated follow-up assess-ment to examine long-lasting effects of MWMs, time periods between the inter-vention and assessment were always consistent (item 18)4,6,20,30,34-38.

Sixteen of the 25 studies to date have not incorporated any form of con-trol or placebo group. Control groups are important for confirming treatment effectiveness and for reducing the effect of confounding variables. Although 6 studies used participants as their own controls, which decreases the level of in-ternal validity, it is understood that it is not always ethical to have true control groups receiving nil or placebo treat-ment. Blinding and concealment of in-tervention groups was a major limiting factor of internal validity within the studies (items 15, 16, 25). Less than 50% of the studies incorporated blinding, with only 7 studies demonstrating dou-ble blinding3,5-7,15,18,40. The majority of these studies incorporated other forms of physiotherapy treatment in combina-tion with MWMs16,20,35,36,38. This high-lights how confounding variables have been poorly considered within this re-search with only 5 studies taking it into account (item 26)5-7,14,30.

External Validity

External validity was generally poor, as only one study recruited participants that represent the population (items 11, 12)30. This is related to the fact that methods of recruitment, assessment, and treatment were poorly documented. The ratio of males and females was rela-tively equal in general, in conjunction with a large age range (range = 17–79 years), which increases overall external validity. A specific sample size is re-quired to detect a clinically significant change, which is indicated in the power calculation. Only 10 studies demon-strated power of 95% or more, which may reflect the significant number of studies with low participant numbers (item 14)5,6,14,30-33,40-42. Because 7 studies

TABLE 5. internal validity—confounding (selection bias) via the Downs and black checklist for methodological quality

Author 22 23 24 25 26 27

Bisset et al30 1 1 1 1 1 1Kochar & Dogra4 1 0 1 0 0 0Slater et al42 0 0 1 0 0 0Teys et al5 1 0 1 0 1 1Collins et al3 1 0 1 0 0 1Paungmali et al14 1 0 1 0 1 1Paungmali et al15 0 0 1 0 0 1Teys et al40 1 0 1 1 1 1Vicenzino et al7 0 0 1 0 1 1Vicenzino et al18 0 0 1 1 0 1McLean et al31 0 0 1 0 0 0Reid et al32 1 0 1 0 0 1Yang et al33 1 0 1 0 1 1Abbot13 0 0 1 0 0 0Abbottet al41 1 0 1 0 0 1Paungmali et al6 1 0 0 0 1 1O’Brien & Vincenzino38 0 0 0 0 0 1Penso39 1 0 0 0 1 1Stephens20 1 1 0 0 0 1Vincenzino & Wright34 1 1 0 0 0 1Backstrom35 1 1 0 0 0 1DeSantis & Hasson16 1 1 0 0 0 1Folk36 1 1 0 0 0 1Hetherington19 1 0 0 0 0 0Hsieh et al37 1 1 0 0 0 1

22. Were the patients in different intervention groups (trials and cohort studies) or were the cases and controls (case-control studies) recruited from the same population?

23. Were the study subjects in different intervention groups (trial and cohort studies) or were the cases and controls (case-control studies) recruited over the same time period?

24. Were the study subjects randomized to intervention groups?25. Was the randomized intervention assignment concealed from both patients and health care staff

until recruitment was complete and irrevocable?26. Was there adequate adjustment for confounding in the analysis from which the main findings

were drawn?27. Were losses of patients to follow-up taken into account?1 = yes, 0 = no

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l3 8

0 6

3 17

18

.5 (±

1.71

) 16

–21

as o

wn

cont

rol (

6)

Paun

gmal

i et a

l14

9 1

6 4

20

Paun

gmal

i et a

l15

7 0

7 2

16

Teys

et a

l40

9 0

7 5

21

Vic

enzi

no e

t al7

9 0

7 3

19

Vic

enzi

no e

t al18

9

0 6

3 18

Qua

si-ex

perim

enta

l (3)

M

cLea

n et

al31

7

1 5

1 14

17

(±2.

16)

14–1

9

Reid

et a

l32

10

0 5

3 18

Ya

ng e

t al33

9

1 5

4 19

Non

-exp

erim

enta

l (3)

A

bbot

13

7 0

5 1

13

17.3

3 (±

3.68

) 13

–20

A

bbot

tet a

l41

7 1

6 3

17

Paun

gmal

i et a

l6 11

1

7 3

22

C

ase

stud

y (4

) O

’Brie

n &

Vin

cenz

ino38

6

1 5

1 13

12

.75

(±2.

95)

8–16

Pe

nso39

7

1 3

3 14

St

ephe

ns20

2

1 2

3 8

Vin

cenz

ino

& W

right

34

7 1

5 3

16

C

ase

repo

rt (5

) Ba

ckst

rom

35

5 1

2 3

11

10.4

(±3.

38)

4–14

D

eSan

tis &

Has

son16

6

1 4

3 14

Fo

lk36

5

1 3

3 12

H

ethe

ringt

on19

2

1 0

1 4

Hsie

h et

al37

5

1 2

3 11

Mea

n (S

D)

7.

16

0.84

4.

64

2.84

15

.48

(±2.

22)

(±0.

78)

(±1.

87)

(±1.

22)

(±4.

54)

Ra

nge

2–

11

0–4

0–7

1–6

4–23

The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e47]

MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review

tAb

le 7

. C

hara

cter

istic

s of

the

incl

uded

stu

dies

P

resc

ript

ion

of

A

uth

or

Des

ign

P

urp

ose

Part

icip

ants

In

terv

enti

on

MW

M/o

ther

Rx

Tim

es o

f Ax

O/C

mea

sure

s

Biss

et e

t al30

Tr

ue R

CT

To in

vest

igat

e th

e

198

part

icip

ants

G

roup

1:

PT: 8

sess

ions

6

wee

ks a

nd

Glo

bal i

mpr

ovem

ent

effica

cy o

f PT

12

8 m

ales

, 8

sess

ions

of P

T fo

r 30

min

s ove

r 52

wee

ks

Grip

forc

e

in

terv

entio

n

70 fe

mal

es

Gro

up 2

: 6

wee

ks. I

nclu

ded

A

sses

sor’s

ratin

g of

co

mpa

red

with

M

ean

age:

48

cort

icos

tero

id

MW

M, t

hera

band

seve

rity

cort

icos

tero

id

in

ject

ion

exer

cise

s, an

d

Pain

(VA

S)

inje

ctio

n an

d w

ait

G

roup

3:

stre

tchi

ng.

El

bow

disa

bilit

y (p

ain-

an

d se

e fo

r lat

eral

wai

t and

see

Cor

ticos

terio

d

free

func

tion

epic

ondy

lalg

ia

inje

ctio

n:

qu

estio

nnai

re

1

inje

ctio

n, a

nd a

2nd

one

if ne

cess

ary

after

2 w

eeks

.

Wai

t and

see:

adv

ice,

educ

atio

n on

mod

ifica

tions

to A

DLs

,

enco

urag

e ac

tivity

,

usin

g an

alge

sic d

rugs

,

heat

, col

d, a

nd b

race

s.

Koch

ar &

Tr

ue R

CT

To co

mpa

re th

e

66 p

artic

ipan

ts

Gro

up 1

: com

bina

tion

US:

3 M

Hz,

W

eek

1, 2

, and

3

Pain

—VA

S sc

ale

Dog

ra4

eff

ects

of a

36

mal

es,

of U

S an

d M

WM

on

1.5

W/c

m2 , p

ulse

d Fo

llow

-up

at

Abi

lity

to li

ft 0–

3kg

com

bina

tion

of

30 fe

mal

es

10 se

ssio

ns (d

iffer

ent

1:5,

5 m

ins.

4 m

onth

s w

eigh

ts w

ith n

o pa

in,

MW

M a

nd U

S

Mea

n ag

e: 4

1 Rx

on

alte

rnat

e da

ys)

MW

M: e

lbow

24hr

s afte

r Rx.

ve

rsus

US

alon

e,

co

mpl

eted

in 3

wee

ks

exte

nded

, for

earm

Grip

stre

ngth

.

fo

llow

ed b

y an

and

an e

xerc

ise

pron

ated

, 10

reps

,

Wei

ght t

est

exer

cise

pro

gram

,

prog

ram

(9 w

eeks

). no

pai

n, g

lide

for l

ater

al

G

roup

2: U

S on

ly

sust

aine

d w

hile

ep

icon

dyla

lgia

on 1

0 se

ssio

ns

part

icip

ant l

ifted

co

mpl

eted

in

wei

ght t

hat

3 w

eeks

and

pr

evio

usly

pro

duce

d

an

exe

rcise

pa

in, f

or 3

sets

,

pr

ogra

m (9

wee

ks).

10 se

ssio

ns.

Gro

up 3

(con

trol

):

Prog

ress

ed M

WM

by

no

Rx

incr

easin

g w

eigh

ts b

y

0.

5kg.

Exer

cise

: str

etch

ing,

PRT,

conc

entr

ic/

ec

cent

ric e

xerc

ises.

[e48] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2

MulligAn’S MobilizAtion with MoveMent: A SySteMAtic ReviewtA

ble

7.

Cha

ract

eris

tics

of th

e in

clud

ed s

tudi

es (

cont

inue

d)

P

resc

ript

ion

of

A

uth

or

Des

ign

P

urp

ose

Part

icip

ants

In

terv

enti

on

MW

M/o

ther

Rx

Tim

es o

f Ax

O/C

mea

sure

s

Slat

er e

t al42

Tr

ue R

CT

To e

xam

ine

the

24

par

ticip

ants

D

ay 0

—in

duce

d Ex

erci

ses t

o in

duce

Be

fore

exe

rcise

, PP

T.

eff

ects

of a

late

ral

11 m

ales

, D

OM

S (e

ccen

tric

D

OM

S: re

peat

ed

inje

ctio

n,

McG

ill p

ain

glid

e M

WM

in

13 fe

mal

es

exer

cise

s on

non-

ec

cent

ric w

rist

and

MW

M

ques

tionn

aire

he

alth

y su

bjec

ts

Mea

n ag

e: 2

3 do

min

ant a

rm).

exte

nsio

n A

fter R

x

Mus

cle

forc

e

w

ith in

duce

d

D

ay 1

—in

ject

ed

cont

ract

ions

—5

sets

Fo

llow

-up

Max

imal

grip

forc

e

la

tera

l

hype

rton

ic sa

line

of 6

0 re

ps, w

ith

at d

ay 7

(d

ynam

omet

er).

epic

ondy

lalg

ia

(2

4hrs

pos

t-ex

erci

se)

1 m

in re

st in

terv

al

M

axim

al w

rist e

xten

sion

pain

to m

imic

tenn

is el

bow

be

twee

n se

ts. M

WM

:

forc

e (fo

rce

tran

sduc

er)

sym

ptom

s (pa

in

sust

aine

d la

tera

l glid

e,

dura

tion

10 m

ins)

, w

ith P

T’s h

and

th

en ap

plie

d M

WM

ag

ains

t par

ticip

ant’s

or

pla

cebo

Rx

ulna

. Par

ticip

ant s

upin

e,

sh

ould

er a

bduc

ted

20°,

elbo

w e

xten

ded

and

fore

arm

pro

nate

d.

Plac

ebo:

appl

icat

ion

of a

firm

cons

tant

man

ual c

onta

ct a

roun

d

th

e m

edia

l and

late

ral

as

pect

s of t

he el

bow

Teys

et a

l5 Tr

ue R

CT

Exam

ine

the

24

par

ticip

ants

G

roup

1: M

WM

Rx

MW

M: p

oste

rola

tera

l Be

fore

and

afte

r Rx,

A

ROM

(act

ive

pain

-fre

e

eff

ect o

f MW

M

11 m

ales

, G

roup

2: p

lace

bo

glid

e w

ith p

atie

nt

on 3

sess

ions

sh

ould

er el

evat

ion)

of

the

shou

lder

13

fem

ales

G

roup

3: c

ontr

ol

seat

ed. P

T pl

aced

han

ds

PP

T

in

rela

tion

to

Mea

n ag

e: 4

6

over

pos

terio

r sca

pula

RO

M a

nd P

PT

and

then

ar e

min

ence

of

ot

her h

and

over

ant

erio

r

aspe

ct o

f hea

d of

hum

erus

. Pos

terio

r glid

e

appl

ied

to h

umer

al h

ead.

Part

icip

ant a

ctiv

ely

ab

duct

ed a

rm.

Pl

aceb

o: a

/a, b

ut h

ands

of P

T w

ere

ante

riorly

on th

e cl

avic

le a

nd

st

ernu

m, a

nd a

n an

terio

r

glid

e w

ith m

inim

al fo

rce

w

as ap

plie

d

Con

trol

: no

man

ual

co

ntac

t of P

T.

Col

lins e

t al3

RCT

with

Ev

alua

te th

e 16

par

ticip

ants

G

roup

1: M

WM

. M

WM

: at t

aloc

rura

l Be

fore

and

W

eigh

t-be

arin

g D

F RO

M

part

icip

ants

eff

ect o

f MW

M

8 m

ales

, G

roup

2: p

lace

bo

join

t. Pa

rtic

ipan

t aft

er R

x PP

T

as o

wn

fo

r lat

eral

ank

le

8 fe

mal

es

Gro

up 3

: con

trol

W

B in

stan

ce

TP

T

cont

rol

spra

ins o

n RO

M

Mea

n ag

e: 2

8

posit

ion

with

(rep

eate

d

and

hypo

alge

sia

Belt

arou

nd P

T

mea

sure

s,

pe

lvis

and

dist

al

cr

osso

ver)

tibia

and

fibu

la.

The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e49]

MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review

Pa

tient

lean

ed b

ack

to cr

eate

PA

glid

e,

w

ith ta

lus a

nd

fo

refo

ot st

abili

zed

by P

T’s h

and

and

othe

r han

d ov

er

pr

oxim

al ti

bia

and

fibul

a to

mai

ntai

n le

g

al

ignm

ent.

Pl

aceb

o: a

/a w

ith b

elt

ov

er c

alca

neum

and

min

imal

forc

e, w

ith

st

abili

zing

han

d ov

er

m

etat

arsa

ls.

Con

trol

: pat

ient

in

st

ance

pos

ition

for 5

min

s with

no

man

ual

co

ntac

t of P

T.

Paun

gmal

i RC

T w

ith

To d

eter

min

e 24

par

ticip

ants

Ea

ch p

artic

ipan

t Rx

gro

up: l

ater

al

Befo

re, d

urin

g PF

GS

et a

l14

part

icip

ants

w

heth

er M

WM

17

mal

es,

com

plet

ed th

e 3

glid

e M

WM

with

an

d aft

er R

x PP

T

as o

wn

te

chni

que

at th

e 7

fem

ales

ra

ndom

ized

Rx

pain

-fre

e

TPT

co

ntro

l el

bow

pro

duce

s M

ean

age:

49

grou

ps (R

x, p

lace

bo,

dyna

mom

eter

Cute

neou

s blo

od fl

ux

(r

epea

ted

ph

ysio

logi

cal

co

ntro

l), at

sam

e gr

ippi

ng. P

artic

ipan

t

Skin

cond

ucta

nce

m

easu

res)

eff

ects

such

as

tim

e of

day

48

hrs

supi

ne, w

ith

Sk

in te

mpe

ratu

re

hypo

alge

sia a

nd

be

twee

n ea

ch

shou

lder

inte

rnal

ly

BP

SN

S fu

nctio

n in

sess

ion

rota

ted,

elbo

w

H

R

pa

tient

s with

ex

tend

ed, f

orea

rm

late

ral

pron

atio

n. 1

0 re

ps,

epic

ondy

lalg

ia

for 6

secs

, 15

sec r

est

pe

riod.

Pl

aceb

o: P

T ap

plie

d a

firm

man

ual c

onta

ct

w

ith b

oth

hand

s ove

r

the

elbo

w jo

int w

hile

part

icip

ant g

rippe

d th

e

dy

nam

omet

er p

ain-

free

.

Con

trol

: inv

olve

d th

e

pa

in g

rippi

ng a

ctio

n

on

ly (n

o m

anua

l for

ce

ap

plie

d).

Paun

gmal

i RC

T w

ith

Eval

uate

the

effec

t 18

par

ticip

ants

A

ll pa

rtic

ipan

ts

MW

M: p

artic

ipan

t in

Befo

re in

fect

ion

PFG

S et

al15

pa

rtic

ipan

ts

of n

alox

one

on

14 m

ale,

re

ceiv

ed

supi

ne p

ositi

on.

and

Rx, a

nd

PPT

as

ow

n

pain

relie

f fro

m

4 fe

mal

e in

trav

enou

sly

Rx ap

plie

d im

med

iate

ly

after

Rx

TPT

co

ntro

l an

MW

M ap

plie

d M

ean

age:

49

nalo

xone

, sal

ine

after

the

inje

ctio

n.

U

pper

lim

b ne

ural

test

(rep

eate

d

to la

tera

l

or n

o-su

bsta

nce

One

han

d st

abili

zed

pr

ovoc

atio

n (r

adia

l

mea

sure

s ep

icon

dyla

lgia

cont

rol o

n 3

the

dist

al h

umer

us o

n

nerv

e)

cr

osso

ver)

di

ffere

nt o

ccas

ions

, th

e la

tera

l asp

ect,

and

then

a M

WM

was

th

e ot

her h

and

appl

ied

appl

ied

to th

e el

bow

a

late

ral g

lide

to th

e

pr

oxim

al ra

dius

and

ulna

.

[e50] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2

MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review

tAb

le 7

. C

hara

cter

istic

s of

the

incl

uded

stu

dies

(co

ntin

ued)

P

resc

ript

ion

of

A

uth

or

Des

ign

P

urp

ose

Part

icip

ants

In

terv

enti

on

MW

M/o

ther

Rx

Tim

es o

f Ax

O/C

mea

sure

s

Teys

et a

l40

RCT

with

To

inve

stig

ate

24 p

artic

ipan

ts

3 se

ssio

ns o

f Rx

MW

M: p

artic

ipan

t Ba

selin

e an

d aft

er

Pain

-fre

e RO

M

part

icip

ants

th

e in

itial

11

mal

es,

with

24

hour

s in

seat

ed, t

hera

pist

on

each

appl

icat

ion

in th

e sc

apul

ar p

lane

as o

wn

eff

ects

of M

WM

13

fem

ales

be

twee

n ea

ch.

oppo

site

side,

one

hand

of

MW

M, s

ham

(g

onio

met

ric

co

ntro

l te

chni

que

on

Mea

n ag

e: 4

6.1

Rx w

as e

ither

pl

aced

on

the

scap

ula

or co

ntro

l m

easu

rem

ent)

(cro

ssov

er

shou

lder

RO

M

M

WM

, sha

m,

post

erio

rly w

hile

PPT

(dig

ital p

ress

ure

de

sign)

in

the

plan

e of

or co

ntro

l th

e th

enar

em

inen

ce

pa

in a

lgom

eter

)

th

e sc

apul

a an

d

of th

e ot

her h

and

was

PP

T in

par

ticip

ants

on

the

ante

rior a

spec

t

w

ith a

nter

ior

of th

e hu

mer

us.

shou

lder

pai

n

A

pos

tero

late

ral g

lide

to th

e aff

ecte

d sh

ould

er

at

the

hum

eral

hea

d.

Th

e pa

rtic

ipan

t the

n

el

evat

ed a

rm in

the

plan

e of

the

scap

ula

to

th

e pa

in o

nset

onl

y.

Sham

mob

iliza

tion:

repl

icat

ed th

e pr

evio

us

M

WM

exc

ept a

n an

terio

r

glid

e w

as p

erfo

rmed

with

han

ds p

ositi

oned

on th

e cl

avic

le/s

tern

um

an

d po

ster

ior h

umer

al

he

ad.

Min

imal

pre

ssur

e

w

as ap

plie

d w

hile

the

patie

nt a

ctiv

ely

elev

ated

the

arm

thro

ugh

half

of th

e av

aila

ble

pain

-

free

rang

e.

Con

trol

: par

ticip

ant s

at

fo

r the

sam

e le

ngth

of t

ime

but t

here

was

no

man

ual

co

ntac

t bet

wee

n th

e

th

erap

ist a

nd p

artic

ipan

t.

Vic

enzi

no

RCT

with

D

eter

min

e w

heth

er

24 p

artic

ipan

ts

Part

icip

ants

M

WM

: lat

eral

glid

e Be

fore

and

afte

r PF

GS

et a

l7 pa

rtic

ipan

ts

MW

M fo

r lat

eral

14

mal

e, re

ceiv

ed e

ither

of

the

elbo

w. O

ne

each

Rx

sess

ion

PPT

as

ow

n

epic

ondy

lalg

ia

10 fe

mal

e M

WM

Rx,

pla

cebo

ha

nd g

lidin

g th

e PF

GS

also

mea

sure

d

cont

rol

prod

uced

M

ean

age:

46

or co

ntro

l on

prox

imal

fore

arm

, du

ring

Rx

(r

epea

ted

hy

poal

gesia

affec

ted

and

and

othe

r sta

biliz

ing

m

easu

res)

an

d to

com

pare

un-a

ffect

ed a

rm.

the

dist

al h

umer

us,

effec

ts o

n th

e

Th

ey re

ceiv

ed

whi

le p

artic

ipan

t

aff

ecte

d an

d

al

l 3 in

terv

entio

n pe

rfor

med

pai

n-fr

ee

non-

affec

ted

arm

s

leve

ls on

diff

eren

t gr

ippi

ng.

days

Pl

aceb

o: fi

rm m

anua

l

cont

act o

ver e

lbow

join

t.

Con

trol

: no

man

ual

co

ntac

t fro

m P

T.

The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e51]

MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review

Vic

enzi

no

RCT

with

To

exp

lore

the

16 p

artic

ipan

ts

Gro

up 1

: WB

MW

M

WB

MW

M: i

n st

andi

ng

Befo

re a

nd a

fter

Post

erio

r tal

ar g

lide

et a

l18

part

icip

ants

de

ficits

in a

nkle

8

mal

es,

Gro

up 2

: NW

B M

WM

w

ith th

erap

ist m

anua

lly

Rx, o

n 3

sess

ions

W

B an

kle

DF

(a W

B

as o

wn

RO

M in

pat

ient

s 8

fem

ales

G

roup

3: c

ontr

ol

stab

ilizi

ng th

e fo

ot o

n

lung

e m

easu

red

with

a

co

ntro

l w

ith re

curr

ent

Mea

n ag

e: 2

0 A

ll pa

rtic

ipan

ts

the

plin

th, u

sing

belt

to

ta

pe m

easu

re)

(r

epea

ted

an

kle

spra

ins,

expe

rienc

ed 1

of

appl

y fo

rce

and

m

easu

res,

an

d in

vest

igat

e

the

3 co

nditi

ons

part

icip

ant m

ovin

g

cros

sove

r)

the

effec

t of a

in a

rand

omiz

ed

into

DF.

post

erio

r glid

e

se

quen

ce o

n 3

NW

B M

WM

: app

lied

MW

M ap

plie

d

se

para

te d

ays

with

the

part

icip

ant

in N

WB

and

WB

(at l

east

48

hour

s in

supi

ne ly

ing,

tibi

a

on

talo

crur

al D

F

apar

t).

rest

ing

on p

linth

and

ankl

e on

the

edge

.

Con

trol

gro

up: n

o

m

anua

l con

tact

or

m

ovem

ent.

The

part

icip

ant s

tood

for a

sim

ilar p

erio

d

of

tim

e sim

ilar t

o th

e

Rx

tim

e fo

r the

oth

er

tw

o gr

oups

.

McL

ean

Q

uasi-

To

ass

ess

6 pa

rtic

ipan

ts

MW

M fo

rce

leve

ls M

WM

: dire

cted

Be

fore

and

afte

r Rx

PFG

S et

al31

ex

peri-

di

ffere

nt m

anua

l 2

mal

es,

wer

e de

term

ined

to

war

ds th

e m

edia

l

Mus

cle

forc

e: m

easu

red

m

enta

l—

forc

es u

sed

in

4 fe

mal

es

for 3

3%, 5

0%, 6

6%

aspe

ct o

f the

uln

a.

w

ith a

flex

ible

pre

ssur

e

re

peat

ed

a M

WM

M

ean

age:

49

and

max

imum

. D

urat

ion

of e

ach

se

nsin

g m

at b

etw

een

m

easu

res

tech

niqu

e fo

r

All

part

icip

ants

Rx

tech

niqu

e w

as

ha

nd a

nd el

bow

(ran

dom

iz-

late

ral e

lbow

rece

ived

appl

icat

ions

no

mor

e th

an 1

0 se

cs.

at

ion,

no

ep

icon

dyla

lgia

of th

e M

WM

3

appl

icat

ions

with

cont

rol)

and

its e

ffect

s

tech

niqu

e co

ntra

ctio

n fo

r

on

hyp

oalg

esia

com

prisi

ng o

f the

ba

selin

e m

easu

re.

4 fo

rce

leve

ls in

a

2 ap

plic

atio

ns o

f the

ra

ndom

ord

er.

4 fo

rce

leve

ls, w

ith

2

min

rest

inte

rval

s.

Reid

et a

l32

Qua

si-

To in

vest

igat

e 23

par

ticip

ants

G

roup

1: s

essio

n 5

min

s war

m u

p Ba

selin

e, an

d aft

er

DF

ROM

usin

g a

WB

ex

peri-

th

e eff

ect o

f 8

mal

es,

1 =

sham

of

mod

erat

e in

tens

ity

each

appl

icat

ion

lung

e m

ovem

ent:

dist

ance

men

tal—

ta

locr

ural

join

t 15

fem

ales

m

obili

zatio

n,

of st

atio

nary

cyc

ling

of

gre

at to

e to

the

wal

l

cros

sove

r M

WM

on

DF

Mea

n ag

e: 2

5 se

ssio

n 2

=

ensu

ring

full

leg

(r

epea

ted

3 tim

es fo

r eac

h

desig

n

ROM

in

tr

ue M

WM

ex

tens

ion

prio

r

ankl

e)

(r

ando

miz

a-

part

icip

ants

Gro

up 2

: ses

sion

to A

x an

d Rx

tion,

no

w

ith d

ecre

ased

1 =

MW

M,

(for b

oth

sham

cont

rol)

rang

e fo

llow

ing

sess

ion

2 =

an

d M

WM

).

la

tera

l ank

le

sh

am

MW

M: p

artic

ipan

t

sp

rain

mob

iliza

tion

in h

igh

knee

ling,

7

day

perio

d in

aff

ecte

d an

kle

in

betw

een

sess

ions

W

B ne

utra

l pos

ition

,

belt

(pre

ssur

e

bi

ofee

dbac

k) at

infe

rior m

argi

n

of

the

med

ial m

alle

olus

.

[e52] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2

MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review

TABL

E 7.

Cha

ract

eris

tics

of th

e in

clud

ed s

tudi

es (c

ontin

ued)

(co

ntin

ued)

P

resc

ript

ion

of

A

uth

or

Des

ign

P

urp

ose

Part

icip

ants

In

terv

enti

on

MW

M/o

ther

Rx

Tim

es o

f Ax

O/C

mea

sure

s

Ta

lus a

nd c

alca

neus

fixed

with

ther

apist

’s

ha

nds w

hile

bel

t

glid

ed d

istal

tibi

a

an

terio

rly cr

eatin

g a

rela

tive

post

erio

r tal

ar

gl

ide

by th

e th

erap

ist.

Sh

am m

obili

zatio

n:

pa

rtic

ipan

t pro

ne ly

ing,

the

knee

was

pas

sivel

y

fle

xed

and

exte

nded

,

ensu

ring

the

talo

crur

al

jo

int r

emai

ned

stat

iona

ry.

Yang

et a

l33

Qua

si-

To in

vest

igat

e 30

par

ticip

ants

G

roup

1: A

BAC

M

WM

: Par

ticip

ant

Base

line,

and

at

Disa

bilit

y A

x: F

LEX

-Sf.

ex

peri-

th

e eff

ect o

f 6

mal

es,

(MRM

, ERM

, sit

ting

in a

rela

xed

3-w

eek

inte

rval

s Sh

ould

er co

mpl

ex

m

enta

l-

mob

iliza

tion

24 fe

mal

e. M

RM, M

WM

) po

sitio

n. B

elt p

lace

d fo

r 12

wee

ks

kine

mat

ics (

FAST

RAK

mul

tiple

- tr

eatm

ent a

nd to

M

ean

age:

55

Gro

up 2

: AC

AB

arou

nd th

e he

ad o

f

mot

ion

anal

ysis)

: sca

pula

trea

tmen

t de

term

ine

(M

RM, M

WM

, hu

mer

us to

glid

e

orie

ntat

ion,

hum

eral

tria

l w

heth

er a

MRM

, ERM

) th

e hu

mer

us h

ead

or

ient

atio

n, a

bduc

tion,

(ran

dom

iza-

di

ffere

nce

of

appr

opria

tely,

with

the

ha

nd-t

o-ne

ck, h

and-

to-

tio

n, n

o

trea

tmen

t

th

erap

ist’s

hand

ove

r

scap

ula

co

ntro

l) effi

cacy

exi

sts

the

appr

opria

te a

spec

t

amon

g th

ree

of

the

head

of

mob

iliza

tion

hu

mer

us. A

coun

ter

tech

niqu

es in

pr

essu

re w

as ap

plie

d

pa

tient

s with

w

ith th

e ot

her h

and

froz

en sh

ould

er

at th

e sc

apul

a. E

RM:

synd

rom

(FSS

)

Th

erap

ist’s

hand

s pla

ced

clos

e to

the

GH

J, an

d

th

e hu

mer

us w

as

br

ough

t int

o a

posit

ion

of m

ax ra

nge

in

di

ffere

nt d

irect

ions

.

MRM

: Par

ticip

ant

re

laxe

d in

supi

ne w

ith

th

e hu

mer

us in

rest

ing

posit

ion,

mob

iliza

tions

appl

ied.

Abb

ot13

N

on-e

xper

i- To

inve

stig

ate

23 p

atie

nts

Rand

om a

ssig

nmen

t M

WM

: par

ticip

ant i

n Be

fore

and

afte

r Rx

Pass

ive

ROM

m

enta

l—

the

effec

ts o

f a

18 m

ales

, of

left

or ri

ght a

rm

supi

ne, a

nd p

erfo

rmed

(gon

iom

eter

): in

pre-

/pos

t-

singl

e in

terv

entio

n 5

fem

ales

to

be

Ax

and

Rx

the

norm

ally

pro

voki

ng

pa

rtic

ular

inte

rnal

and

test

of

MW

M at

the

Mea

n ag

e: N

S (M

WM

) firs

t m

ovem

ent o

n th

e le

ft

exte

rnal

rota

tion

(r

ando

miz

a-

elbo

w o

n

an

d rig

ht si

de

tio

n)

shou

lder

RO

M

for p

atie

nts w

ith

late

ral

epic

ondy

lalg

ia

The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e53]

MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review

Abb

otte

t al41

N

on-e

xper

- D

eter

min

e w

hat

25 p

artic

ipan

ts

All

part

icip

ants

M

WM

: lat

eral

glid

e Be

fore

and

afte

r PF

GS

im

enta

l—

prop

ortio

n of

17

mal

es,

rece

ived

MW

M

of p

roxi

mal

med

ial

Rx, o

n ea

ch a

rm

Max

imal

grip

stre

ngth

pre-

/pos

t-

pts r

espo

nd to

8

fem

ales

to

una

ffect

ed a

nd

fore

arm

with

the

te

st

MW

M fo

r lat

eral

M

ean

age:

46

affec

ted

arm

di

stal

hum

erus

(ran

dom

iza-

ep

icon

dyla

lgia

,

(ran

dom

ized

ord

er),

stab

ilize

d, w

hile

tion)

w

heth

er P

GFS

in 1

Rx

sess

ion.

pa

rtic

ipan

t

an

d m

axim

um

If

part

icip

ant’s

pai

n pe

rfor

med

G

S in

crea

ses

co

uld

not b

e pr

evio

usly

pai

nful

aft

er 1

Rx

of

el

imin

ated

, Rx

mov

emen

t (fis

t,

MW

M, a

nd

w

as st

oppe

d gr

ippi

ng, w

rist

dete

rmin

ants

ex

tens

ion,

3rd

of re

spon

siven

ess

finge

r ext

ensio

n).

Ei

ther

of t

he fo

llow

ing

glid

es w

ere

perf

orm

ed

de

pend

ing

on p

artic

ipan

t’s

pa

in re

spon

se: d

irect

ly

la

tera

l or a

ppro

x 5°

post

erio

r, an

terio

r or

ca

udal

of l

ater

al.

Paun

gmal

i N

on e

xper

i- Ex

amin

e 24

par

ticip

ants

A

ll pa

rtic

ipan

ts

MW

M: p

atie

nt su

pine

Be

fore

and

afte

r PF

GS

et a

l6 m

enta

l—

whe

ther

19

mal

es,

rece

ived

late

ral

with

shou

lder

in

ever

y Rx

PP

T

repe

ated

in

itial

5

fem

ales

gl

ide

MW

M.

inte

rnal

rota

tion,

mea

sure

s hy

poal

gesia

M

ean

age:

50

Appl

ied

on 6

el

bow

ext

ende

d an

d

eff

ects

from

occa

sions

, app

rox

supi

nate

d. Th

erap

ist

MW

M ap

plie

d

48

hrs

apar

t st

abili

zed

the

hum

erus

to

late

ral

and

appl

ied

late

ral g

lide

epic

ondy

lalg

ia

at fo

rear

m. T

echn

ique

w

ere

mai

ntai

ned

pe

rfor

med

was

pai

n-fr

ee

after

repe

ated

w

ith p

artic

ipan

ts

appl

icat

ions

m

aint

aini

ng a

grip

for

ap

prox

6 se

cs a

nd re

peat

ed

10

tim

es w

ith 1

5-se

c

rest

inte

rval

s.

O’B

rien

&

Cas

e To

det

erm

ine

2 m

ale

part

icip

ants

Rx

1: 6

sess

ions

M

WM

Rx:

pos

terio

r Be

fore

, dur

ing

Pain

: VA

S V

ince

nzin

o38

stud

y th

e eff

ectiv

enes

s w

ith re

cent

ov

er 2

wee

ks

glid

e of

dist

al fi

bula

(p

ain,

inve

rsio

n RO

M)

ROM

: inv

ersio

n an

d D

F

of

MW

M ap

plie

d

(2–3

day

s) la

tera

l Rx

2: 3

sess

ions

w

hile

par

ticip

ant

and

after

eac

h Rx

(W

B)

at th

e an

kle

for

ankl

e sp

rain

s. ov

er 1

wee

k in

vert

ed th

e an

kle.

Func

tiona

l per

form

ance

ac

ute

late

ral a

nkle

A

ged

17 a

nd 1

8 N

o Rx

1: 3

Pa

ssiv

e ov

erpr

essu

re

(K

aikk

onen

scal

e)

pain

sess

ions

ove

r w

as ap

plie

d.

Fu

nctio

n: V

AS

1 w

eek.

Re

peat

ed 4

tim

es.

No

Rx2:

5

Stra

ppin

g ta

pe w

as

mea

sure

men

t ap

plie

d to

mai

ntai

n th

e

se

ssio

ns o

ver

post

erio

r glid

e aft

er e

very

1

wee

k Rx

sess

ion.

[e54] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2

MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review

tAb

le 7

. C

hara

cter

istic

s of

the

incl

uded

stu

dies

(con

tinue

d)

P

resc

ript

ion

of

A

uth

or

Des

ign

P

urp

ose

Part

icip

ants

In

terv

enti

on

MW

M/o

ther

Rx

Tim

es o

f Ax

O/C

mea

sure

s

Pens

o39

Cas

e st

udy

To a

sses

s the

effe

ct

25-y

ear-

old

2 se

ssio

ns w

ith

MW

M: I

nitia

lly

Base

line,

after

eac

h A

ctiv

e an

d pa

ssiv

e RO

M

of

MW

M u

sed

for

fem

ale

with

chro

nic

MW

M o

ver a

a

PA g

lide

on th

e M

WM

, 1 a

nd 4

mon

th

(DF,

PF, i

nver

sion,

th

e m

anag

emen

t m

edia

l left

ank

le

2-w

eek

perio

d di

stal

tibi

a an

d fib

ula

follo

w-u

ps

ever

sion)

of

a ru

nner

pa

in

Educ

atio

n re

gard

ing

was

per

form

ed in

Gas

troc

nem

ius a

nd so

leus

co

mpl

aini

ng o

f

stre

tchi

ng o

f W

B; h

owev

er, w

as

m

uscl

e le

ngth

ch

roni

c med

ial

ca

lf m

uscl

e an

d in

effec

tive.

An

AP

Pa

in-f

ree

ROM

(DF,

PF,

ankl

e pa

in

ru

nnin

g te

chni

que

glid

e to

the

dist

al

in

vers

ion,

eve

rsio

n)

tib

ia, w

ith st

abili

zatio

n

Fu

nctio

n (r

unni

ng,

to

the

post

erio

r foo

t,

hi

king

, effe

ctiv

e ca

lf

whi

le th

e pa

tient

stre

tch)

perf

orm

ed a

ctiv

e D

F

in

WB

on a

step

was

then

effe

ctiv

e.

Step

hens

20

Cas

e st

udy

NS

43-y

ear-

old

fem

ale

Rx

: 3 ti

mes

a w

eek

MW

M: l

ater

al

NS

Pain

: VA

S

with

left

sided

fo

r 1st

4 w

eeks

, m

obili

zatio

n of

the

A

ROM

: sho

ulde

r, el

bow

chro

nic l

ater

al

then

onc

e a

wee

k fo

rear

m at

the

elbo

w

an

d th

umb

ep

icon

dylit

is fo

r the

follo

win

g 4

du

ring

activ

e w

rist

St

reng

th: s

houl

der,

elbo

w,

wee

ks, t

hen

once

ex

tens

ion,

fore

arm

wris

t and

grip

ev

ery

2 w

eeks

for

supi

natio

n an

d

Spec

ial t

est:

resis

ted

wris

t

th

e la

st 6

wee

ks

grip

ping

. Dor

sal

ex

t with

elbo

w at

45°

Rx: M

WM

s, ic

e,

glid

e of

the

hand

Palp

atio

n

U

S, tr

ansv

erse

ap

plie

d at

the

wris

t

fr

ictio

ns, e

xerc

ises

durin

g ra

dial

be

gan

after

MW

M

devi

atio

n an

d th

e

Rx

, mas

sage

, m

etac

arpa

l of t

he

stre

tchi

ng, H

EP

thum

b w

as m

obili

zed

palm

erly

at th

e C

MC

durin

g th

umb

oppo

sitio

n.

Elbo

w w

as ta

ped

into

a la

tera

l glid

e.

Self-

mob

iliza

tions

wer

e

pe

rfor

med

aga

inst

a

do

orw

ay to

pro

vide

pain

relie

f.

Vin

cenz

ino

C

ase

stud

y To

inve

stig

ate

39-y

ear-

old

fem

ale

PT fo

r 6 se

ssio

ns

Initi

al p

hysio

Rx:

Be

fore

Rx,

dur

ing

VAS

& W

right

34

eff

ects

of a

w

ith ri

ght t

enni

s ov

er 5

wee

ks.

deep

and

pai

nful

2-

wee

k A

x ph

ase,

PPT

man

ipul

ativ

e

elbo

w

Incl

uded

2 w

eeks

m

assa

ge, i

ce, l

aser

, an

d at

6 w

eeks

G

rip st

reng

th

PT te

chni

que

Ax,

2 w

eeks

Rx

som

e fo

rm o

f sen

sory

fo

llow

ing

Rx

Func

tion

VAS

on p

ain

and

(4 se

ssio

ns),

and

stim

ulat

ion.

Pain

-fre

e fu

nctio

n

dy

sfun

ctio

n of

6 w

eeks

HEP

Ex

erci

ses—

stre

tchi

ng

qu

estio

nnai

re

The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e55]

MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review

a

patie

nt w

ith

and

grip

ping

exe

rcise

s.

tenn

is el

bow

Ex

perim

enta

l Rx:

MW

M—

late

ral g

lide

appl

ied

at th

e pr

oxim

al

pa

rt o

f the

fore

arm

whi

le st

abili

zing

the

late

ral a

spec

t of t

he

di

stal

hum

erus

(par

ticip

ant i

n su

pine

,

shou

lder

inte

rnal

rota

tion,

elbo

w e

xten

ded,

fore

arm

pro

nate

d).

Pa

rtic

ipan

t was

taug

ht

se

lf-m

obili

zatio

n an

d

ta

ping

(tap

ing

was

use

d to

repl

icat

e th

e la

tera

l for

ce

ap

plie

d at

the

elbo

w b

y

th

e M

WM

).

Back

stro

m35

C

ase

repo

rt

Intr

oduc

e M

WM

61

-yea

r-ol

d fe

mal

e Rx

: Man

ipul

atio

n M

WM

: rad

ial g

lide

of

At e

ach

sess

ion

Pain

(VA

S)

in

the

Rx o

f de

w

ith d

e Q

uerv

ain’s

of

cap

itate

on

prox

imal

row

of c

arpa

l Fo

llow

-up

at 4

mon

ths

Obs

erva

tion

Que

rvai

n’s

teno

syno

-viti

s of

first

sess

ion

only,

bo

nes.

3 se

ts o

f 10

reps

an

d 12

mon

ths

ROM

(gon

iom

eter

) Wris

t

te

nosy

novi

tis

the

right

wris

t M

WM

, ela

stic

of

eac

h of

the

post

-Rx

flexi

on, e

xten

sion,

radi

al

splin

t with

m

ovem

ents

(wris

t an

d ul

na d

evia

tion.

Th

umb

palm

er a

nd ra

dial

ho

rses

hoe

type

fle

xion

, ext

ensio

n,

ab

duct

ion.

in

sert

(int

rodu

ced

ul

na a

nd ra

dial

Stre

ngth

—iso

met

ric a

nd

on se

ssio

n 6)

, de

viat

ion,

and

thum

b

MM

T

ec

cent

ric a

nd

radi

al o

r pal

mer

Acc

esso

ry m

otio

n te

stin

g

co

ncen

tric

ab

duct

ion)

(pai

n-fr

ee).

Palp

atio

n

st

reng

then

ing,

D

one

at a

ll Rx

Fink

lest

ein

test

A

ROM

, ten

don

se

ssio

ns.

glid

ing,

tran

sver

se

WB

tech

niqu

e—

fric

tion,

ant

i- pa

rtic

ipan

t WB

thro

ugh

infla

mm

ator

ies a

nd

the

hand

and

the

sam

e

H

EP (A

ROM

, ra

dial

glid

e w

as

stre

ngth

enin

g,

perf

orm

ed a

s

te

ndon

glid

ing,

pa

rtic

ipan

t

fr

ictio

ns, s

elf-

MW

M)

prog

ress

ivel

y W

B

th

roug

h th

e rig

ht

up

per l

imb.

U

lna

glid

e of

trap

eziu

m

an

d tr

apez

oid

for

th

umb

radi

al a

bduc

tion.

Se

lf-M

WM

—W

B of

uppe

r lim

b. P

artic

ipan

t

appl

ied

ulna

glid

e on

fore

arm

(the

refo

re ra

dial

glid

e of

car

pal b

ones

),

sh

ifted

BW

(wris

t

flexi

on/e

xten

sion)

with

thum

b ab

duct

ed.

[e56] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2

MulligAn’S MobilizAtion with MoveMent: A SySteMAtic ReviewtA

ble

7.

Cha

ract

eris

tics

of th

e in

clud

ed s

tudi

es (c

ontin

ued)

P

resc

ript

ion

of

A

uth

or

Des

ign

P

urp

ose

Part

icip

ants

In

terv

enti

on

MW

M/o

ther

Rx

Tim

es o

f Ax

O/C

mea

sure

s

DeS

antis

C

ase

repo

rt

To d

escr

ibe

27-y

ear-

old

mal

e Ph

ysio

ther

apy

War

m-u

p: 5

min

M

easu

rem

ents

of

ARO

M (g

onio

met

er)—

&

Has

son16

the

effec

ts o

f w

ith le

ft sh

ould

er

3 tim

es a

wee

k w

arm

up

on c

ycle

pa

in a

nd A

ROM

ab

duct

ion

mai

nly

an M

WM

su

pra-

spin

atus

fo

r 30

min

s with

er

gom

eter

prio

r at

eve

ry P

T se

ssio

n M

MT

Rx re

gim

e fo

r te

ndin

opat

hy

a to

tal o

f 12

to e

ach

sess

ion.

Impi

ngem

ent t

ests

(Nee

r,

sh

ould

er

se

ssio

ns

Phas

e 1:

focu

sed

H

awki

ns K

enne

dy, e

mpt

y

im

ping

emen

t

on

dec

reas

ing

pain

can,

appr

ehen

sion)

(edu

catio

n on

rest

,

Func

tiona

l sta

tus:

cryo

ther

apy,

rest

orin

g

sh

ould

er p

ain

and

RO

M w

ith M

WM

).

disa

bilit

y in

dex

M

WM

: AP

glid

e

SF

-36

(glo

bal s

elf-

repo

rt

w

ith a

bduc

tion

ques

tionn

aire

)

mov

emen

t (gu

idin

g

Pa

in (V

AS)

mov

emen

t of t

he

sc

apul

ar a

nd h

umer

us

w

ith b

oth

hand

s).

Ph

ase

2: fo

cuse

d on

stre

ngth

enin

g ro

tato

r

cuff,

scap

ular

stab

ilizi

ng m

uscl

es,

im

prov

ing

func

tion,

educ

atio

n re

gard

ing

post

ure.

Ea

ch se

ssio

n en

ded

with

10

min

s of

cr

yoth

erap

y.

Folk

36

Cas

e re

port

To

des

crib

e th

e

39-y

ear-

old

fem

ale,

Rece

ived

OT

(7

2 co

rtiso

ne in

ject

ions

M

easu

rem

ent t

aken

Pa

in (M

CP

ext)

diffe

rent

ial

4.5

wee

ks a

fter

sess

ions

in 6

wee

ks),

for d

e Q

uerv

ain’s

. th

roug

hout

Rx

Swel

ling

diag

nosis

and

st

rain

to 1

st M

CP,

th

en re

ferr

ed fo

r O

T Rx

: spl

int

Follo

w-u

p at

2

ROM

(MC

P ex

t)

Rx

tech

niqu

es

with

dia

gnos

is tr

igge

r thu

mb

and

gutte

r use

, m

onth

s and

1

MM

T

fo

r str

aine

d 1st

of

de

Que

rvai

n’s

rele

ase

surg

ery,

activ

e RO

M e

xerc

ises.

year

pos

t-Rx

G

rip st

reng

th

M

CP

join

t. of

the

left

hand

th

en b

ack

to O

T,

Ope

ratio

n: tr

igge

r

Upp

er li

mb

tens

ion

test

s

w

hich

then

refe

rred

th

umb

rele

ase.

C

ervi

cal s

pine

Ax

to P

T PT

Rx:

MW

M at

De

Que

rvai

n’s te

sts

OT

eval

uatio

n/Rx

1st

MC

P w

ith

(fi

nkel

stei

ns, p

ince

r

pe

rfor

med

3 w

eeks

su

stai

ned

pain

-fre

e

stre

ngth

, pal

patio

n)

la

ter

inte

rnal

axi

al ro

tatio

n,

w

ith o

verp

ress

ure

at

the

end.

Het

herin

gton

19

Cas

e re

port

N

S N

S M

ajor

ity o

f pat

ient

s M

WM

: lat

eral

mal

leou

s Be

fore

, dur

ing,

and

Pa

in o

n in

vers

ion

Peop

le w

ith

Patie

nt’s

post

- w

ere

trea

ted

only

of

fibu

la g

lided

aft

er R

x RO

M

ankl

e in

jurie

s an

kle

spra

in w

ith

with

MW

Ms a

nd

post

erio

rly w

ith

O

ne le

g st

andi

ng te

st

wer

e ex

amin

ed

limite

d an

d ta

ping

ac

tive

inve

rsio

n

(bal

ance

—ey

es cl

osed

)

to

det

ect a

pa

infu

l RO

M

No

elec

tro-

phys

ical

(w

ith a

nd w

ithou

t

Swel

ling

posit

iona

l fau

lt

th

erap

ies w

ere

used

a

bel

t).

G

ait p

atte

rns

and

man

aged

Ta

ping

: tw

o st

rips

usin

g M

WM

of

25m

m ta

pe ap

prox

The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e57]

MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review

and

tapi

ng

15cm

in le

ngth

.

m

etho

ds

Post

erio

r glid

e ap

plie

d

an

d th

en ta

pe ap

plie

d

ov

er th

e la

tera

l mal

leol

us

an

d tr

avel

led

arou

nd th

e

lo

wer

leg

(tap

ing

chan

ged

after

24

hrs)

.

Hsie

h et

al37

C

ase

repo

rt

Inve

stig

ate

the

79

-yea

r-ol

d fe

mal

e M

WM

was

appl

ied

Self

MW

M:

MRI

: pre

-Rx,

M

RI

us

e of

MRI

for

with

righ

t thu

mb

to th

e pr

oxim

al

supi

natin

g th

e du

ring

1st R

x,

Pain

: VA

S

po

sitio

nal f

ault

pa

in

phal

anx

MRI

was

pr

oxim

al p

hala

nx

after

Rx

ARO

M: g

onio

met

er

and

MW

M e

ffect

s

take

n be

fore

, of

the

thum

b W

eek

1: p

ain,

(fl

exio

n of

IPJ a

nd M

PJ)

in th

e th

umb

du

ring

MW

M, t

hen

us

ing

othe

r han

d’s

ROM

, dist

ract

ion/

PR

OM

: thu

mb

radi

al

after

a co

urse

of

inde

x an

d th

umb,

co

mpr

essio

n, P

ROM

ab

duct

ion

MW

M R

x w

hile

per

form

ing

Wee

k 2

- a/a

G

rip st

reng

th: h

and

Part

icip

ant p

erfo

rmed

fle

xion

of t

he th

umb

Wee

k 3

- a/a

, grip

dy

nam

omet

er

self-

MW

Ms

unde

rgoi

ng M

WM

. st

reng

th

Com

pres

sion/

di

stra

ctio

n of

the

MPJ

.

Not

e: M

WM

= m

obili

zatio

n w

ith m

ovem

ent;

Rx =

trea

tmen

t; A

x =

asse

ssm

ent;

O/C

= o

utco

me;

RC

T =

rand

omiz

ed co

ntro

lled

tria

l; PT

= p

hysio

ther

apy;

AD

Ls =

act

iviti

es o

f dai

ly li

ving

; VA

S =

visu

al a

nalo

gue

scal

e; U

S =

ultr

asou

nd; M

Hz =

meg

a he

rtz;

W/c

m2 =

wat

ts p

er ce

ntim

eter

squa

red;

min

s = m

inut

es; P

RT =

pro

gres

sive

resis

tant

trai

ning

; rep

s = re

petit

ions

; kg

= ki

logr

am; h

rs =

hou

rs; D

OM

S =

dela

yed

onse

t m

uscl

e so

rene

ss; P

PT =

pre

ssur

e pa

in th

resh

old;

ARO

M =

act

ive

rang

e of

mot

ion;

a/a

= a

s abo

ve; W

B =

wei

ght-

bear

ing;

pt =

pat

ient

; PA

= p

oste

rior-

ante

rior;

DF

= do

rsifl

exio

n, R

OM

= ra

nge

of m

otio

n; S

NS

= sy

m-

path

etic

ner

vous

syst

em; T

PT =

tem

pera

ture

pai

n th

resh

old;

secs

= se

cond

s; PF

GS

= pa

in-f

ree

grip

stre

ngth

; BP

= bl

ood

pres

sure

; HR

= he

art r

ate;

NW

B =

non-

wei

ght-

bear

ing;

NS

= no

t sta

ted;

GS

= gr

ip st

reng

th;

appr

ox =

appr

oxim

atel

y; H

EP =

hom

e ex

erci

se p

rogr

am; C

MC

= c

arpo

met

acar

pal;

BW =

bod

y w

eigh

t; M

MT

= m

anua

l mus

cle

test

ing;

AP

= an

terio

r-po

ster

ior;

SF-3

6 =

Shor

t For

m 3

6; M

CP

= m

etac

arpo

phal

ange

al;

OT

= oc

cupa

tiona

l the

rapy

; ext

= e

xten

sion;

mm

= m

illim

eter

s; cm

= ce

ntim

eter

s; M

RI =

mag

netic

reso

nanc

e im

agin

g; IP

J = in

terp

hala

ngea

l joi

nt; M

PJ =

met

acar

pal p

hala

ngea

l joi

nt.

[e58] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2

tAb

le 8

. St

atis

tics,

resu

lts,

str

engt

hs, a

nd li

mita

tions

of t

he in

clud

ed s

tudi

es

Au

thor

St

atis

tica

l an

alys

is

Res

ult

s St

ren

gths

Li

mit

atio

ns

Biss

et e

t al30

Be

twee

n-gr

oup

C

ortic

oste

roid

inje

ctio

n sh

owed

sig

bette

r effe

cts a

t 6 w

eeks

but

• R

ando

miz

ed co

ntro

lled

tria

l • R

x pr

oced

ure

for P

T

diffe

renc

es a

naly

zed:

w

ith h

igh

recu

rren

ce ra

tes t

here

after

(47/

65 re

gres

sed)

and

• S

ingl

e bl

indi

ng

gr

oup

not c

lear

ly

Re

lativ

e ris

k

sig p

oore

r out

com

es in

long

-ter

m co

mpa

red

with

PT.

PT

was

supe

rior

• Lar

ge sa

mpl

e siz

e

defin

ed (r

efer

red

re

duct

ion.

to

wai

t and

see

at 6

wee

ks, b

ut th

ere

was

no

diffe

renc

e at

52

• Fol

low

-up

mea

sure

s

to a

noth

er st

udy

for

N

umbe

rs n

eede

d

wee

ks w

ith b

oth

repo

rtin

g a

succ

essf

ul o

utco

me.

PT w

as su

perio

r • C

onfo

undi

ng v

aria

bles

and

pres

crip

tion

expl

anat

ion)

to tr

eat.

to in

ject

ions

afte

r 6 w

eeks

. Thus

, cor

ticos

tero

id R

x sh

ould

be

avoi

ded

adve

rse

even

ts w

ere

take

n in

to

• Onl

y sin

gle

blin

ding

6-

poin

t im

prov

emen

t du

e to

its h

igh

recu

rren

ce, a

nd P

T sh

ould

be

impl

emen

ted

due

to it

s

cons

ider

atio

n

(Lik

ert s

cale

) su

perio

r ben

efit a

nd d

ecre

ase

in N

SAID

S pu

rcha

sing

• Mai

n fin

ding

s of s

tudy

clea

rly

de

scrib

ed

• Dro

p-ou

ts d

escr

ibed

• G

ood

exte

rnal

val

idity

and

pow

er

Koch

ar

One

-way

AN

OVA

. Su

bjec

tive:

Rx

grou

p 1

pain

dec

reas

ed b

y 5.

9cm

(p <

0.01

), an

d in

Rx

• Ver

y sim

ilar p

artic

ipan

t • B

lindi

ng w

as n

ot st

ated

&

Dog

ra4

Two-

way

AN

OVA

. gr

oup

2 by

1.6

7cm

(p <

0.01

). Rx

gro

up 1

was

supe

rior t

o th

e co

ntro

l

char

acte

ristic

s bet

wee

n gr

oups

• Th

e 2

Rx g

roup

s wer

e

Chi

squa

re te

stin

g.

and

grou

p 2

in th

e A

x sc

ore

at 1

2 w

eeks

.

and

base

line

mea

sure

men

ts

ra

ndom

ized

but

the

5%

leve

l of p

roba

bilit

y

Obj

ectiv

e: R

x gr

oup

1 w

as a

ble

to li

ft he

avie

r wei

ghts

than

gro

up 2

and

• R

ando

miz

atio

n, co

ntro

l gro

up

co

ntro

l gro

up w

as n

ot

ad

opte

d co

ntro

l gro

up (p

<0.0

1) fr

om th

e 2nd

wee

k on

war

ds.

• Val

id o

utco

me

mea

sure

s • C

ontr

ol g

roup

rece

ived

no

Grip

stre

ngth

in g

roup

1 im

prov

ed fr

om 2

2.74

kg–3

1.57

kg in

the

3 w

eeks

, • A

ppro

pria

te st

atist

ical

ana

lysis

Rx, i

.e., n

o pl

aceb

o gr

oup

and

was

sig

diffe

rent

from

the

cont

rol.

No

sig d

iffer

ence

s wer

e fo

und

in

• Cle

ar R

x pr

oces

s • L

earn

ing

effec

t of

grou

p 2.

• C

lear

incl

usio

n/ex

clus

ion

crite

ria

lift

ing

the

wei

ghts

O

vera

ll, co

ntro

l gro

up sh

owed

no

stat

istic

ally

sig

chan

ges i

n an

y pa

ram

eter

. • F

ollo

w-u

p m

easu

res

m

ay h

ave

occu

rred

Mos

t pat

ient

s in

the

inte

rven

tion

grou

ps sh

owed

com

plet

e re

cove

ry.

• D

rop-

outs

wer

e no

t

5

recu

rren

ces i

n th

e U

S gr

oup

indi

cate

d

Slat

er e

t al42

Sh

apiro

-Wilk

D

urin

g sa

line-

indu

ced

pain

and

in re

spon

se to

the

inte

rven

tion

of M

WM

• R

ando

miz

ed co

ntro

l tria

l • N

o bl

indi

ng

norm

ality

test

s. or

pla

cebo

, the

re w

ere

no si

g be

twee

n-gr

oup

diffe

renc

es in

VA

S, p

ain

• Pla

cebo

, and

inte

rven

tion

• Effe

ct o

f the

M

ann

Whi

tney

- di

strib

utio

ns, i

nduc

ed d

eep

tissu

e hy

pera

lges

ia, a

nd fo

rce

prod

uctio

n.

gr

oup

pr

ovok

ed D

OM

S

U te

st.

Ove

rall,

dat

a su

gges

ts th

at M

WM

doe

s not

act

ivat

e m

echa

nism

s • A

ppro

pria

te st

atist

ical

a

nd in

ject

ed

Two-

way

repe

ated

as

soci

ated

with

ana

lges

ia o

r for

ce au

gmen

tatio

n in

peo

ple

with

indu

ced

an

alys

is

hype

rton

ic sa

line

m

easu

res A

NO

VA.

late

ral e

pico

ndyl

algi

a • V

alid

out

com

e m

easu

res

• No

follo

w-u

p

Post

-hoc

test

s.

mea

sure

s

Stud

ent N

ewm

an

• Pos

sible

exc

essiv

e

Keul

s (SN

K) t

est

am

ount

of e

xerc

ise to

indu

ce D

OM

S, w

ith n

o

in

dica

tion

of w

hat t

he

am

ount

was

bas

ed o

n

• I

nduc

ed p

atho

logy

• No

recr

uitm

ent p

roce

ss

do

cum

ente

d

• N

o dr

op-o

ut o

r

com

plia

nce

docu

men

ted

Teys

et a

l5 Tw

o-w

ay A

NO

VA.

ROM

: mea

n in

crea

se o

f 16°

, 4°,

and

0° fo

r MW

M, p

lace

bo, a

nd co

ntro

l • R

ando

miz

ed, c

ontr

ol, a

nd

• No

follo

w-u

p

Post

-hoc

test

s gr

oup,

resp

ectiv

ely.

pl

aceb

o gr

oups

• L

imite

d ou

tcom

e

PP

T: m

ean

incr

ease

of 6

3kPa

, 26k

Pa, a

nd 2

0kPa

for M

WM

, pla

cebo

, and

• D

oubl

e bl

indi

ng

m

easu

res

cont

rol g

roup

, res

pect

ivel

y • C

lear

des

crip

tion

of d

iffer

ent

• Sub

ject

s may

not

in

terv

entio

n le

vels

re

pres

ent t

he p

opul

atio

n

The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e59]

• A

ppro

pria

te st

atist

ical

ana

lysis

from

whi

ch th

ey w

ere

• N

o dr

op-o

uts

re

crui

ted

• V

alid

out

com

e m

easu

res

• C

lear

incl

usio

n/ex

clus

ion

cr

iteria

Col

lins e

t al3

Paire

d sa

mpl

e

DF

ROM

: sig

incr

ease

in o

nly

the

MW

M R

x gr

oup.

• R

ando

miz

atio

n, p

lace

bo,

• No

follo

w-u

p

t-te

st.

PPT

and

TPT:

no

sig re

sults

, exc

ept a

n in

crea

se in

PPT

and

cont

rol

m

easu

rem

ents

O

ne-w

ay

in th

e pl

aceb

o gr

oup

post

-Rx

• App

ropr

iate

stat

istic

al

• Stu

dy d

id n

ot d

iscus

s

AN

OVA

an

alys

is

drop

-out

s

• Val

id o

utco

me

mea

sure

s • I

nade

quat

e po

wer

• D

oubl

e bl

indi

ng

• C

lear

incl

usio

n/ex

clus

ion

crite

ria a

nd d

iffer

ent g

roup

s

Paun

gmal

i 2

way

AN

OVA

. Th

e M

WM

tech

niqu

e ill

ustr

ated

hyp

oalg

esic

effe

cts w

ith si

mul

tane

ous

• Rx’s

rand

omiz

ed to

par

ticip

ants

• P

atie

nts,

how

ever

, act

ed

et a

l14

3 w

ay A

NO

VA.

sym

path

oexc

itatio

n (p

hysio

logi

cal e

ffect

s sim

ilar t

o th

ose

repo

rted

• C

ontr

ol a

nd p

lace

bo g

roup

s

as co

ntro

l/pla

cebo

Po

st-h

oc a

naly

ses.

with

spin

al M

WM

s).

• Ass

esso

r blin

ded

(c

ross

over

)

Paire

d t t

ests

with

PF

GS

incr

ease

d fr

om 1

27.1

N to

166

.2N

dur

ing

Rx a

nd th

en 1

74.1

N p

ost-

Rx

• Sam

ple

size

adeq

uate

to p

rodu

ce

• Onl

y sin

gle

blin

ding

bo

nfer

roni

(o

nly

durin

g an

d aft

er in

Rx

grou

p, n

ot p

lace

bo a

nd co

ntro

l).

a

high

pow

er

• Tes

ting

took

pla

ce in

a

ad

just

men

t PP

T on

ly in

crea

sed

in th

e Rx

gro

up.

• Mai

n fin

ding

s of s

tudy

clea

rly

co

ntro

lled

envi

ronm

ent

TPT

did

not c

hang

e in

the

Rx o

r pla

cebo

gro

up b

ut d

ecre

ased

in th

e co

ntro

l.

desc

ribed

(not

real

istic

)

M

WM

onl

y pr

oduc

ed m

ean

incr

ease

s of 4

.1%

HR,

3.5

% sy

stol

ic B

P, 3

.1%

• R

x pr

oced

ure

clea

rly d

escr

ibed

• N

o fo

llow

-up

mea

sure

s

di

asto

lic B

P.

• Alth

ough

cros

sove

r, al

low

ed

SN

S fu

nctio

n (s

kin

cond

ucta

nce,

cuta

neou

s blo

od fl

ux, a

nd te

mp)

wer

e al

l

for a

t lea

st 4

8-ho

ur in

terv

al

activ

ated

in th

e Rx

gro

up o

nly

(MW

M)

be

twee

n se

ssio

ns

Paun

gmal

i O

ne-w

ay A

NO

VA

No

sig d

iffer

ence

bet

wee

n gr

oups

with

diff

eren

t IV

inje

ctio

ns. A

ll gr

oups

• R

ando

miz

atio

n an

d co

ntro

l • Th

e st

udy

did

not d

iscus

s et

al15

impr

oved

on

scor

es p

ost-

MW

M w

ith av

erag

es b

eing

29%

, 18%

, 1.6

%,

• Dou

ble

blin

ding

how

long

nal

oxon

e m

ay

an

d 0.

2% fo

r PFG

S, P

PT, U

LTT,

and

TPT

, res

pect

ivel

y • N

o dr

op-o

uts

ta

ke to

hav

e eff

ects

, and

• C

ompl

ianc

e w

as m

easu

red

Rx/A

x w

ere

take

n

vi

a a

ques

tionn

aire

imm

edia

tely

afte

r

• Val

id o

utco

me

mea

sure

s

adm

inist

ratio

n

• C

arr-

over

effe

ct o

f Rx

• No

signi

fican

ce le

vels

wer

e in

dica

ted

whe

n

co

mpa

ring

pre-

and

post

-Rx

• Poo

r ext

erna

l val

idity

.

• N

o in

form

atio

n as

to

w

here

par

ticip

ants

wer

e re

crui

ted

from

• No

follo

w-u

p

Teys

et a

l40

AN

OVA

. Si

gnifi

cant

and

clin

ical

ly m

eani

ngfu

l im

prov

emen

ts in

bot

h RO

M

• Ran

dom

izat

ion

of R

x • N

il fo

llow

up

or lo

ng

Post

-hoc

test

s on

(1

5.3%

, F (2

,46)

= 1

6.31

P =

0.0

0) a

nd P

PT (2

0.2%

, F (2

, 46)

= 3

.44,

• D

oubl

e bl

indi

ng

te

rm A

x

each

dep

ende

nt

P =

0.04

) occ

urre

d im

med

iate

ly p

ost-

Rx. N

il sig

nific

ant d

iffer

ence

s • C

lear

Rx

proc

ess

• Par

ticip

ants

rece

ived

all

va

riabl

e. in

PPT

pre

-app

licat

ion.

The

chan

ge in

RO

M w

as n

ot re

late

d to

• C

lear

incl

usio

n/

th

ree

Rx’s–

?car

ry-o

ver

Pe

arso

n’s

impr

ovem

ent i

n PP

T (R

= 0

.29,

P =

0.1

7)

ex

clus

ion

crite

ria

eff

ect d

ue to

sam

e Rx

on

co

rrel

atio

n

• Val

id a

nd re

liabl

e

part

icip

ants

with

onl

y a

co

effici

ent

outc

ome

mea

sure

s

24-h

our w

ait

• C

ontr

ol g

roup

incl

usio

n • D

ecre

ased

ext

erna

l

• No

loss

to fo

llow

-up

va

lidity

due

to co

ntro

lled

labo

rato

ry e

nviro

nmen

t

[e60] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2

tAb

le 8

. St

atis

tics,

resu

lts,

str

engt

hs, a

nd li

mita

tions

of t

he in

clud

ed s

tudi

es (c

ontin

ued)

Au

thor

St

atis

tica

l an

alys

is

Res

ult

s St

ren

gths

Li

mit

atio

ns

Vic

enzi

no

One

-way

, Rx

gro

up h

ad a

sig

incr

ease

in P

FGS

and

PPT

post

-Rx,

com

pare

d • B

lindi

ng o

f par

ticip

ant a

nd

• Lim

ited

outc

ome

et a

l7 tw

o-w

ay,

to p

lace

bo a

nd co

ntro

l.

outc

ome

mea

sure

r

mea

sure

s

thre

e-w

ay

The

unaff

ecte

d ar

m h

ad a

dec

reas

e in

PFG

S po

st a

ll Rx

leve

ls • C

ontr

ol a

nd p

lace

bo

• No

follo

w-u

p m

easu

res

A

NO

VA

• T

ook

into

acc

ount

• I

nade

quat

e po

wer

conf

ound

ing

fact

ors

• Poo

r ext

erna

l val

idity

w

ith a

que

stio

nnai

re

(p

atie

nts n

ot

• No

drop

-out

s or a

dver

se e

ffect

s

repr

esen

tativ

e of

the

• A

ppro

pria

te st

atist

ical

popu

latio

n)

an

alys

is

• Cle

ar R

x pr

oces

ses

Vic

enzi

no

One

-way

W

B an

d N

WB

MW

M R

x te

chni

ques

bot

h pr

oduc

ed si

g ch

ange

s in

• Ran

dom

izat

ion

of R

x • N

o tr

ue co

ntro

l/pla

cebo

et

al18

A

NO

VA.

post

erio

r tal

ar g

lide

(effe

ct si

zes:

0.8,

0.9

).

cond

ition

s

grou

p—pa

tient

s

Post

hoc

test

s. Re

duce

d po

ster

ior t

alar

glid

e de

ficit

by 5

0% a

nd 5

5% fo

r the

affe

cted

• H

ad a

cont

rol c

ondi

tion

ex

perie

nced

all

3 Rx

Eff

ect s

ize

side

resp

ectiv

ely—

sig g

reat

er th

an co

ntro

l (p=

.003

). • D

oubl

e bl

indi

ng

co

nditi

ons (

cros

sove

r

calc

ulat

ions

. W

B D

F w

as im

prov

ed in

all

thre

e gr

oups

(WB,

NW

B, co

ntro

l gro

ups)

, • N

o dr

op-o

uts/

high

desig

n)

Pear

son

effec

t siz

e—0.

4, 0

.3, 0

.1.

co

mpl

ianc

e • P

oor s

ampl

e siz

e

corr

elat

ions

M

WM

s red

uced

affe

cted

side

defi

cit b

y ap

prox

26%

com

pare

d to

9%

• A

ppro

pria

te st

atist

ical

• N

o ou

tcom

e m

easu

re

redu

ctio

n in

cont

rol g

roup

.

test

ing

va

lidity

or r

elia

bilit

y

Th

ere

was

a si

g an

d su

bsta

ntia

l cor

rela

tion

betw

een

post

erio

r tal

ar g

lide

• C

lear

Rx

proc

edur

e • N

o fo

llow

-up

and

WB

DF

follo

win

g th

e W

B M

WM

but

no

corr

elat

ion

follo

win

g th

e

• Equ

al fe

mal

e/m

ale

m

easu

rem

ents

N

WB

MW

M.

re

pres

enta

tion

fo

r ana

lysis

of l

ong-

term

Ove

rall,

MW

Ms i

mpr

oved

dep

ende

nt v

aria

bles

imm

edia

tely

afte

r Rx

in

• Rep

eate

d m

easu

res

eff

ects

pa

tient

s with

chro

nic r

ecur

rent

late

ral a

nkle

spra

in

McL

ean

et a

l31

Sing

le-t

aile

d,

Mea

n ra

w fo

rce

data

rang

ed fr

om 3

6.8N

—11

3N. M

ean

stan

dard

ized

forc

e • S

ubje

ct w

as b

linde

d to

the

• Sm

all s

ampl

e siz

e

paire

d t-

test

. da

ta w

as 1

.2N

/cm

and

3.8

N/c

m.

PF

GS

scor

es th

roug

hout

• N

o co

ntro

l/pla

cebo

O

rtho

gona

l a

The

2 lo

wer

stan

dard

ized

forc

e le

vel s

core

s (1.

2 an

d 1.

9N/c

m) c

ause

d a

drop

• R

ando

miz

atio

n of

the

Rx

• Onl

y 1

outc

ome

mea

sure

prio

ri co

ntra

sts

in P

FGS,

whe

reas

the

high

er tw

o (2

and

3.8

N/c

m) c

ause

d an

incr

ease

in P

FGS.

forc

es g

iven

• S

hort

-ter

m st

udy

fo

r rep

eate

d

A p

riori

cont

rast

s sho

wed

no

sig ch

ange

in P

FGS

betw

een

the

2 lo

wer

forc

e • V

alid

out

com

e m

easu

res

• No

follo

w-u

p m

easu

res

m

easu

res a

naly

sis

leve

ls bu

t was

sig

grea

ter f

or th

e 3rd

(66%

) for

ce le

vel.

• Cle

ar in

clus

ion/

excl

usio

n • D

iffer

ent f

orce

s wer

e

O

vera

ll, le

vel o

f for

ce ap

plie

d du

ring

an M

WM

det

erm

ines

the

hypo

lage

sic

cr

iteria

appl

ied

with

onl

y 2

effec

ts.

• App

ropr

iate

stat

istic

al a

naly

sis

m

inut

e re

st (p

ossib

le

G

rip st

reng

th ch

ange

s obs

erve

d =

15–1

8%

accu

mul

ativ

e eff

ect o

f

pain

relie

f)

• N

o bl

indi

ng o

f the

rapi

sts

• No

indi

catio

n of

recr

uitm

ent p

roce

ss

Reid

et a

l32

Paire

d t-t

est.

Sign

ifica

ntly

gre

ater

impr

ovem

ent i

n ta

locr

ural

join

t DF

ROM

with

the

• Inc

reas

ed w

asho

ut p

erio

d •?

carr

y-ov

er e

ffect

des

pite

Shap

iro-W

ilk te

st.

true

WB

mob

iliza

tion

(t (2

2) =

2.5

23, P

= 0

.019

). M

ean

diffe

renc

e be

twee

n

(7 d

ays)

to re

duce

7 da

y w

asho

ut p

erio

d

Also

: ind

epen

dent

th

e tr

ue a

nd sh

am m

obili

zatio

n Rx

scor

es w

as e

qual

to 0

.45c

m (9

5%

ca

rry-

over

effe

ct

•?eff

ect o

f war

m u

p an

d

t-

test

(exc

lusio

n of

co

nfide

nce

inte

rval

= 0

.08—

0.82

cm).

Betw

een-

grou

p an

alys

es w

as e

qual

• U

se o

f pre

ssur

e bi

ofee

dbac

k

mea

sure

men

t of i

nten

sity

se

cond

Rx

findi

ngs)

0.

65cm

incr

ease

in R

OM

(95%

confi

denc

e in

terv

al =

0.1

5—1.

2cm

)

to e

nsur

e sa

me

forc

e fo

r

per p

artic

ipan

t

sa

me

part

icip

ant

•? cl

inic

al re

leva

nce

due

to

• R

ando

miz

atio

n to

Rx

sm

all c

hang

e de

tect

ed—

• B

lindi

ng o

f the

ass

esso

r

how

ever

, onl

y 2

Rx’s

• C

lear

Rx

proc

ess

pe

rfor

med

• C

lear

incl

usio

n/ex

clus

ion

• N

o tr

ue co

ntro

l gro

up

crite

ria

The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e61]

Yang

et a

l33

AN

OVA

Si

gnifi

cant

impr

ovem

ents

(p<.

01) i

n FL

EX-S

F, ar

m el

evat

ion,

• R

ando

miz

atio

n • P

artic

ipan

ts w

eren

’t

Inde

pend

ent t

-tes

ts

scap

ulo-

hum

eral

rhyt

hm, h

umer

al e

xter

nal r

otat

ion,

hum

eral

• I

nten

tion

to tr

eat a

naly

sis

bl

inde

d

in

tern

al ro

tatio

n fo

r bot

h ER

M a

nd M

WM

Rx.

No

signi

fican

t diff

eren

ce

• Thor

ough

stat

istic

al a

naly

sis

• Par

ticip

ants

rece

ived

all

betw

een

ERM

and

MW

M e

xcep

t for

scap

ulo-

hum

eral

rhyt

hm re

stor

atio

n • B

lindi

ng o

f the

ass

esso

r

thre

e Rx

’s - ?

carr

y-ov

er

• Cle

ar R

x pr

oces

s

effec

t

• Cle

ar in

clus

ion/

excl

usio

n

crite

ria

Abb

ot13

O

ne ta

iled

t-te

st

92%

resp

onde

d to

MW

M R

x (i.

e., R

x w

as p

ain-

free

). • R

x an

d A

x of

left

or ri

ght

• Onl

y pr

e-/p

ost-

test

PFG

S an

d m

ax g

rip st

reng

th w

ere

sig in

crea

sed

post

-Rx,

for t

he

ar

ms w

as ra

ndom

ly a

ssig

ned

de

sign,

i.e.,

no

grou

p

aff

ecte

d lim

b on

ly.

• Out

com

e m

easu

re w

as

co

mpa

rison

of

PFG

S w

as fo

und

to b

e m

ore

resp

onsiv

e to

chan

ge v

ersu

s max

grip

stre

ngth

relia

ble

fin

ding

s ove

r tim

e

• Cle

ar re

sults

• O

nly

1 ou

tcom

e m

easu

re

• Val

id st

atist

ical

test

ing

for a

• P

artic

ipan

ts w

ere

not

pre-

/pos

t-te

st d

esig

n

blin

ded

• No

follo

w-u

p m

easu

res

• Sam

ple

size

was

not

larg

e

an

d pr

edom

inan

tly m

ale

• Sam

ple

recr

uitm

ent

w

as n

ot e

xpla

ined

Abb

otte

t al41

O

ne-t

aile

d t-

test

92

% re

spon

ded

to M

WM

Rx

(i.e.,

Rx

was

pai

n-fr

ee).

• Suffi

cien

t pow

er to

det

ect

• Con

veni

ence

sam

ple

PFG

S an

d m

ax g

rip st

reng

th w

ere

sig in

crea

sed

post

-Rx,

for t

he a

ffect

ed

a

clin

ical

ly si

g ch

ange

• N

o fo

llow

-up

mea

sure

s

lim

b on

ly.

• Atte

mpt

to b

lind

outc

ome

• Onl

y on

e Rx

sess

ion

PFG

S w

as fo

und

to b

e m

ore

resp

onsiv

e to

chan

ge v

ersu

s max

grip

stre

ngth

mea

sure

r

(for a

chro

nic c

ondi

tion)

• R

ando

miz

atio

n of

lim

b • O

nly

one

inte

rven

tion

• R

x or

der

le

vel

• O

utco

me

mea

sure

s wer

e

• No

com

paris

on, c

ontr

ol,

appr

opria

te a

nd w

ell

or

pla

cebo

in

vest

igat

ed

• Goo

d de

scrip

tion

of R

x

prot

ocol

and

ada

ptat

ions

Paun

gmal

i O

wn

form

ula:

Th

e hy

poal

gesic

effe

ct o

f MW

M at

the

elbo

w d

id n

ot re

duce

with

repe

ated

• B

lindi

ng w

as a

dmin

ister

ed

• Num

ber o

f set

s was

not

et a

l6 m

axim

al p

ossib

le

appl

icat

ions

of t

he R

x te

chni

que

durin

g 6

succ

essiv

e se

ssio

ns.

• Val

id o

utco

me

mea

sure

s

stat

ed in

MW

M R

x

effec

t to

inve

stig

ate

A

ll Rx

sess

ions

resu

lted

in h

ypoa

lges

ic e

ffect

s, in

dica

ted

by a

n in

crea

se in

• C

lear

Rx

proc

ess

• No

cont

rol g

roup

or

th

e to

lera

nce

of th

e

PFG

S an

d PP

T.

• Cle

ar in

clus

ion/

excl

usio

n

rand

omiz

atio

n

hypo

alge

sic e

ffect

. PF

GS

sig in

crea

sed

over

the

sess

ions

but

PPT

rem

aine

d sim

ilar

cr

iteria

• P

artic

ipan

ts w

ere

not

O

ne w

ay A

NO

VA

• C

onfo

undi

ng v

aria

bles

and

rand

omly

sele

cted

ad

vers

e ev

ents

wer

e ta

ken

into

for t

he st

udy

(vol

unte

ers)

co

nsid

erat

ion

• N

o dr

op-o

uts/

high

com

plia

nce

• C

alcu

latio

n of

effe

ct si

ze

O’B

rien

&

Pear

son

corr

elat

ion

ROM

: (in

vers

ion)

impr

oved

dur

ing

MW

M a

nd to

a le

sser

ext

ent

• Cle

ar R

x pr

oces

s • I

nade

quat

e po

wer

(onl

y V

ince

nzin

o38

po

st R

x. D

F im

prov

ed p

ost M

WM

Rx.

• A

ppro

pria

te o

utco

me

mea

sure

s 2

subj

ects

)

Pa

in: i

mpr

oved

dur

ing

MW

M a

nd to

a le

sser

ext

ent p

ost R

x.

• Str

ong

and

sig co

rrel

atio

ns

• No

data

doc

umen

ted

for

Func

tion:

incr

ease

d w

ith R

x.

(pe

rfor

med

som

e st

atist

ical

c

ontr

ol p

erio

ds

Fu

nctio

nal p

erfo

rman

ce: s

tron

g po

sitiv

e co

rrel

atio

n be

twee

n M

WM

a

naly

sis a

s onl

y a

case

stud

y)

• Sub

ject

s do

not r

epre

sent

Rx

and

func

tion.

Str

ong

corr

elat

ions

bet

wee

n fu

nctio

nal p

erfo

rman

ce a

nd

• Pat

ient

s tre

ated

in a

n t

he g

ener

al p

opul

atio

n

fu

nctio

n, p

ain

and

func

tion,

func

tiona

l per

form

ance

and

pai

n, fu

nctio

nal

env

ironm

ent t

hat r

epre

sent

s (

both

spor

t pla

yers

/

pe

rfor

man

ce a

nd D

F, D

F an

d fu

nctio

n. M

oder

ate

corr

elat

ions

with

pai

n an

d

nor

mal

PT

Rx

ath

lete

s)

func

tion,

inve

rsio

n an

d D

F, fu

nctio

nal p

erfo

rman

ce a

nd in

vers

ion,

inve

rsio

n

• N

o bl

indi

ng o

r

an

d fu

nctio

n

ran

dom

izat

ion

• No

follo

w-u

p m

easu

res

[e62] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2

tAb

le 8

. St

atis

tics,

resu

lts,

str

engt

hs, a

nd li

mita

tions

of t

he in

clud

ed s

tudi

es (c

ontin

ued)

Au

thor

St

atis

tica

l an

alys

is

Res

ult

s St

ren

gths

Li

mit

atio

ns

Pens

o39

No

stat

istic

al a

naly

sis

Imm

edia

te re

lief o

f pai

n w

ith a

cces

sory

PA

mov

emen

t • C

lear

des

crip

tion

of c

ase

stud

y • N

o co

ntro

l,

repo

rted

an

d W

B D

F. In

crea

se in

ank

le D

F an

d ev

ersio

n RO

M. I

ncre

ase

in

w

ith th

orou

gh in

itial

Ax

ra

ndom

izat

ion,

or

gast

rocn

emiu

s and

sole

us m

uscl

e le

ngth

. Pat

ient

was

abl

e to

run

pain

-fre

e • F

ollo

w-u

p m

easu

res

bl

indi

ng

• Pat

ient

Rx

as in

a “r

eal-l

ife”

• No

stat

istic

al a

naly

sis

setti

ng

• Not

all

resu

lts w

ere

repo

rted

on

follo

w-u

p

• O

nly

one

part

icip

ant;

ther

efor

e po

or e

xter

nal

va

lidity

Step

hens

20

No

stat

istic

al a

naly

sis

Dec

reas

e in

pai

n im

med

iate

ly a

fter M

WM

, whi

ch la

sted

1–2

day

s. • L

itera

ture

revi

ew o

n • N

o ra

ndom

izat

ion,

repo

rted

W

hen

pain

was

agg

rava

ted,

self-

mob

iliza

tions

elim

inat

ed th

e pa

in.

co

nditi

on (l

ater

al e

pico

ndyl

itis)

cont

rol,

or b

lindi

ng

A

fter 4

wee

ks, e

lbow

was

still

TO

P, T

rP st

ill te

nder

on

mas

sage

, inc

reas

e in

and

Rx ch

oice

s • R

x is

not r

epro

duci

ble

stre

ngth

and

end

uran

ce.

• Cle

ar c

ase

hist

ory

• Stu

dy d

id n

ot st

ate

thei

r

D

/C a

fter 2

3 Rx

’s. A

t D/C

, pat

ient

repo

rted

succ

essf

ul se

lf -x

for r

elie

ving

• R

epre

sent

s rea

l-life

aim

pa

in 1

00%

of t

he ti

me,

had

prog

ress

ed e

xerc

ises t

o pa

in-f

ree.

Repe

ated

situa

tion

in re

gard

s to

• Onl

y 1

subj

ect,

so re

sults

m

ovem

ents

and

hea

vy li

fting

at w

ork

still

exa

cerb

ated

sym

ptom

s.

Rx

rece

ived

are

not g

ener

aliz

able

and

M

obili

zatio

ns st

ill e

ffect

ive

in d

ecre

asin

g pa

in

inad

equa

te p

ower

• Did

not

incl

ude

data

for

ou

tcom

e m

easu

res

• Did

not

disc

uss

co

mpl

ianc

e w

ith H

EP

• N

o st

atist

ical

ana

lysis

• Did

not

disc

uss r

elia

bilit

y

or

val

idity

of o

utco

me

mea

sure

s

• N

o fo

llow

-up

mea

sure

s

Vin

cenz

ino

Pe

arso

n co

rrel

atio

n Li

ttle

prog

ress

mad

e w

ith in

itial

PT

Rx p

rior t

o th

e st

udy.

• Cle

ar c

ase

hist

ory,

• S

ingl

e ca

se st

udy

limits

&

Wrig

ht34

co

effici

ents

. PF

GS

incr

ease

d du

ring

Rx p

hase

s B a

nd C

.

outc

ome

mea

sure

s,

gene

raliz

abili

ty o

f

Line

ar re

gres

sion

A

ll 6

item

s on

the

pain

-fre

e fu

nctio

n qu

estio

nnai

re, w

hich

cau

sed

Rx

pro

cedu

res a

nd re

sults

findi

ngs

m

odel

pa

in b

efor

e, ha

d im

prov

ed fo

llow

ing

Rx.

• Val

idity

and

relia

bilit

y • M

any

diffe

rent

Rx’s

Impr

ovem

ent i

n gr

ip st

reng

th w

as co

rrel

ated

with

impr

ovem

ents

in fu

nctio

n

of

out

com

e m

easu

res s

tate

d

appl

ied;

ther

efor

e di

fficu

lt

an

d de

crea

se in

pai

n.

• Adv

erse

eve

nts s

tate

d

to d

eter

min

e w

hich

sole

ly

At

6 w

eeks

: no

pain

, ful

l fun

ctio

n, a

stro

ng co

rrel

atio

n w

as il

lust

rate

d th

at a

s

pr

oduc

ed e

ffect

s

fu

nctio

n in

crea

sed,

pai

n de

crea

sed

(r=

-0.9

2, p

<0.

0001

)

• No

rand

omiz

atio

n,

co

ntro

l gro

up

• N

o lo

ng-t

erm

follo

w-u

p

m

easu

res

Back

stro

m35

N

o st

atist

ical

ana

lysis

Ra

pid

redu

ctio

n in

pai

n le

vel:

25%

afte

r firs

t ses

sion,

and

50%

afte

r 3rd

sess

ion.

• C

lear

out

com

e m

easu

res

• No

rand

omiz

atio

n or

re

port

ed

Afte

r 12

sess

ions

(2 m

onth

Rx

perio

d), a

ll im

pairm

ents

reso

lved

exc

ept 0

.5cm

• C

lear

Rx

prot

ocol

cont

rol

of sw

ellin

g at

the

right

wris

t • F

ollo

w-u

p m

easu

res a

t • I

nade

quat

e po

wer

as o

nly

Ther

e w

ere

no p

ainf

ul li

mita

tions

for A

DLs

.

4 m

onth

s and

12

mon

ths

1

part

icip

ant

At 1

2-m

onth

follo

w-u

p, th

ere

was

still

no

evid

ence

of w

rist/t

hum

b pa

in o

r • R

epre

sent

s rea

listic

PT

Rx

• No

stat

istic

al a

naly

sis

func

tiona

l defi

cits

for a

pat

ient

with

com

plic

ated

• N

o bl

indi

ng o

f out

com

e

de

Que

rvai

n’s te

nosy

novi

tis

m

easu

rer o

r par

ticip

ant

The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e63]

• Una

ble

to g

ener

aliz

e

re

sults

to p

opul

atio

n as

only

1 p

artic

ipan

t

• U

ncle

ar o

f stu

dy d

esig

n

(w

heth

er is

was

a c

ase

repo

rt o

r stu

dy, a

s ter

ms

w

ere

used

inte

r-

ch

ange

ably

)

• N

otes

wer

e no

t com

plet

e

fo

r all

outc

ome

mea

sure

s

DeS

antis

N

o st

atist

ical

D

urin

g ea

ch M

WM

sess

ion,

NRP

S sc

ore

was

redu

ced

by 2

–3 p

oint

s. • C

lear

cas

e hi

stor

y, ou

tcom

e • C

ase

repo

rt (n

on-

& H

asso

n16

anal

ysis

repo

rted

Rx

sess

ions

4–6

of M

WM

impr

oved

pai

n-fr

ee R

OM

by

30–4

5°; b

y th

e

m

easu

res,

Rx p

roce

dure

s

expe

rimen

tal)

last

sess

ion

= 17

5° (o

vera

ll in

crea

se =

80°

) (cl

inic

ally

sig)

.

and

resu

lts

• No

rand

omiz

atio

n,

M

WM

stop

ped

on 7

th se

ssio

n as

par

ticip

ant n

o lo

nger

repo

rted

pai

n du

ring

• C

ontin

uous

Ax

repo

rted

cont

rol g

roup

, blin

ding

,

ac

tive

abdu

ctio

n, h

ad a

chie

ved

near

-ful

l ARO

M, a

nd h

ad v

ery

little

pai

n on

• R

elev

ant i

mpr

ovem

ents

of

or

gro

up co

mpa

rison

s

ov

erhe

ad a

ctiv

ities

.

sym

ptom

s pre

- and

pos

t-

• Sin

gle

case

repo

rt d

oes

Ove

rall,

at D

/C th

e pa

tient

had

no

posit

ive

impi

ngem

ent t

ests

, im

prov

ed

• Rep

rese

nts r

ealis

tic P

T Rx

not p

rovi

de co

mpa

rison

fu

nctio

n, im

prov

emen

t (>1

0%) o

n di

sabi

lity

scal

es

fo

r sho

ulde

r im

ping

emen

t

of R

x eff

ects

• R

epor

ted

valid

ity a

nd re

liabi

lity

• M

any

diffe

rent

Rx’s

of

out

com

e m

easu

res

ap

plie

d; th

eref

ore

diffi

cult

to d

eter

min

e

w

hich

sole

ly p

rodu

ced

effec

ts

• N

o st

atist

ical

test

ing

repo

rted

Folk

36

No

stat

istic

al

OT

Rx h

ad n

ot im

prov

ed p

atie

nt’s

sym

ptom

s ove

rall

over

pas

t 10

mon

ths.

• Cle

ar c

ase

hist

ory,

outc

ome

• Cas

e re

port

(non

-

anal

ysis

repo

rted

Pa

tient

had

per

siste

nt lo

ss o

f mot

ion,

tend

erne

ss, t

rigge

r sym

ptom

s, an

d lo

ss

m

easu

res,

Rx p

roce

dure

s,

ex

perim

enta

l)

of

dai

ly fu

nctio

n.

an

d re

sults

• N

o ra

ndom

izat

ion,

Pa

tient

’s pr

eope

rativ

e sy

mpt

oms h

ad n

ot im

prov

ed a

fter t

he o

pera

tion.

• C

ontin

uous

ass

essm

ent

co

ntro

l gro

up, b

lindi

ng,

Onc

e re

ferr

ed to

PT

and

perf

orm

ed M

WM

Rx,

1 se

ssio

n of

MW

M R

x

re

port

ed

or

gro

up co

mpa

rison

s

ab

olish

ed p

ain

with

MC

P ex

tens

ion

and

the

patie

nt c

ance

lled

2nd P

T

• Fol

low

-up

com

mun

icat

ion

• Sin

gle

case

repo

rt d

oes

appo

intm

ent,

as a

ll ac

tiviti

es w

ere

now

sym

ptom

-fre

e. At

follo

w-u

p (2

mon

ths

2

mon

ths,

then

1 y

ear l

ater

not p

rovi

de co

mpa

rison

an

d 1

year

), th

e pa

tient

confi

rmed

she

had

rem

aine

d sy

mpt

om-f

ree

post

-the

• S

ig im

prov

emen

ts o

f sym

ptom

s

of R

x eff

ects

M

WM

Rx

pr

e- a

nd p

ost-

MW

M R

x w

ith

• Man

y di

ffere

nt R

x’s

su

stai

nabi

lity

up to

a y

ear

ap

plie

d; th

eref

ore

diffi

cult

to d

eter

min

e w

hich

sole

ly

pr

oduc

ed e

ffect

s

• N

o re

port

ed st

atist

ical

test

ing

• No

repo

rted

relia

bilit

y

or

val

idity

of o

utco

me

mea

sure

s sta

ted

Het

herin

gton

19

No

stat

istic

al

Re-e

valu

atio

n of

pai

n-fr

ee m

ovem

ent a

fter t

he M

WM

s res

ulte

d in

a m

arke

d • C

lear

Rx

proc

edur

e w

ith

• Onl

y a

retr

ospe

ctiv

e ca

se

anal

ysis

incr

ease

in p

ain-

free

RO

M.

eff

ectiv

e re

sults

serie

s rev

iew

re

port

ed

One

-legg

ed st

andi

ng te

st (e

yes c

lose

d) p

ost-

MW

Ms a

nd ta

ping

reve

aled

• S

ome

appr

opria

te o

utco

me

• No

rand

omiz

atio

n,

incr

ease

d ba

lanc

e eq

ual t

o th

at o

f the

uni

njur

ed si

de.

m

easu

res u

sed

bl

indi

ng, o

r con

trol

Gai

t pat

tern

s also

subs

tant

ially

impr

oved

• Stu

dy is

not

repr

oduc

ible

due

to la

ck o

f inf

orm

atio

n

and

poor

met

hodo

logi

cal

qu

ality

[e64] The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2

tAb

le 8

. St

atis

tics,

resu

lts,

str

engt

hs, a

nd li

mita

tions

of t

he in

clud

ed s

tudi

es (c

ontin

ued)

Au

thor

St

atis

tica

l an

alys

is

Res

ult

s St

ren

gths

Li

mit

atio

ns

• No

stat

istic

al a

naly

sis

• N

o fo

llow

-up

mea

sure

s

• N

o da

ta p

rodu

ced

for

ou

tcom

e m

easu

res

• No

relia

bilit

y or

va

lidity

disc

usse

d

• N

o ch

arac

teris

tics o

r

base

line

mea

sure

s

opar

ticip

ants

stat

ed

Hsie

h et

al37

N

o st

atist

ical

D

urin

g M

WM

, pos

ition

al fa

ult w

as co

rrec

ted

(und

er M

RI).

• Blin

ding

of p

erso

n in

terp

retin

g • N

o st

atist

ical

ana

lysis

an

alys

is re

port

ed

End

of w

eek

1—st

ill h

ad p

ain,

lim

ited

ROM

, pai

n on

dist

ract

ion,

MRI

• P

oor p

ower

, as o

nly

pain

with

PRO

M.

• Fol

low

-up

at 3

wee

ks

on

e pa

rtic

ipan

t

En

d of

wee

k 2—

pain

, lim

ited

ROM

, pai

n w

ith d

istra

ctio

n.

• App

ropr

iate

out

com

e • N

o bl

indi

ng, c

ontr

ol,

End

of w

eek

3—no

pai

n, n

orm

al R

OM

, nor

mal

grip

stre

ngth

, pai

n-fr

ee

m

easu

res

or

rand

omiz

atio

n

di

stra

ctio

n. M

RI d

emon

stra

ted

patie

nt h

ad h

ad a

pos

ition

al fa

ult.

• Cle

ar R

x pr

oces

s • U

nabl

e to

gen

eral

ize

• C

lear

des

crip

tion

of c

ase

hist

ory

re

sults

to p

opul

atio

n

as

onl

y on

e pa

rtic

ipan

t

• P

artic

ipan

t per

form

ed

se

lf Rx

, and

ther

e w

as n

o

m

entio

n of

com

plia

nce

Not

e: si

g =

signi

fican

t; PT

= p

hysio

ther

apy;

NSA

IDS

= no

n-st

eroi

dal a

nti-i

nflam

mat

orie

s; Rx

= tr

eatm

ent;

AN

OVA

= a

naly

sis o

f var

ianc

e; cm

= ce

ntim

eter

s; p

= pr

obab

ility

; Ax

= as

sess

men

t; kg

= k

ilogr

am; U

S =

ultr

asou

nd; i

.e. =

ther

efor

e; M

WM

= m

obili

zatio

n w

ith m

ovem

ent;

DO

MS

= de

laye

d on

set m

uscl

e so

rene

ss; P

PT =

pre

ssur

e pa

in th

resh

old;

VA

S =

visu

al a

nalo

gue

scal

e; R

OM

= ra

nge

of m

otio

n; k

Pa =

kilo

pasc

al; D

F =

dors

iflex

ion;

TPT

= th

erm

al p

ain

thre

shol

d; P

FGS

= pa

in-f

ree

grip

stre

ngth

; N =

new

tons

; HR

= he

art r

ate;

BP

= bl

ood

pres

sure

; SN

S =

sym

path

etic

ner

vous

syst

em; I

V =

intr

aven

ous;

ULT

T =

uppe

r lim

b te

nsio

n te

st;

WB

= w

eigh

t-be

arin

g; N

WB

= no

n-w

eigh

t-be

arin

g; ap

prox

= ap

prox

imat

ely;

max

= m

axim

um; N

/cm

2 =

new

tons

per

cent

imet

er sq

uare

d; T

OP

= te

nder

on

palp

atio

n; T

rP =

trig

ger p

oint

; D/C

= d

ischa

rge;

HEP

= h

ome

exer

cise

pro

gram

; AD

Ls =

act

iviti

es o

f dai

ly li

ving

; NRP

S =

num

eric

pai

n ra

ting

scal

e; A

ROM

= a

ctiv

e ra

nge

of m

otio

n; O

T =

occu

patio

nal t

hera

py; M

CP

= m

etac

arpo

phal

ange

al; P

ROM

= p

assiv

e ra

nge

of m

otio

n; M

RI

= m

agne

tic re

sona

nce

imag

ing.

The Journal of Manual & ManipulaTive Therapy n voluMe 17 n nuMber 2 [e65]

MulligAn’S MobilizAtion with MoveMent: A SySteMAtic Review

(28%) were case studies or reports with only one participant, this decreases the overall level of power and therefore va-lidity of the results in general16,20,23,35-37.

Characteristics and Efficacy

As discussed previously, there are many established effects of MWMs at various joints, whether it is positional fault cor-rection or hypoalgesic effects. A recent review discusses the different concepts of the effects of an MWM in relation to positional faults and pain relief12. It is evident that many joints are yet to be examined including, for example, the hip and knee. The majority of studies (12/25; 48%) reviewed here examined elbow joint-related pathology (lateral epicondylagia), followed by ankle sprains (6/25; 24%), shoulder joint dys-function (4/25; 16%), MCP strains (2/25; 8%), and de Quervain’s at the wrist (1/25; 4%). Research has not been limited to age with subjects ranging from 17 to 79 years of age, which exem-plifies the technique’s effects on various populations. In general, the efficacy of MWM as a manual therapy technique, as analyzed, is well established with pos-itive results in 24 out of 25 studies. The most common effects studied to date in-clude increases in strength, reduction in pain levels, increase in PPT, improved neural tests, and improved function. The clinical benefit of this technique is there-fore confirmed and well supported by research.

Strengths and Limitations of this Systematic Review

The specific aims of this systematic re-view have been clearly outlined, which originated from a global search sur-rounding Mulligan manual therapy techniques. The need for the investiga-tion into the commonly prescribed MWM technique was indicated, as it had not yet been reviewed and it was evident that it is generally an ill-defined area. The methods of critiquing and ana-lyzing have been consistently and thor-oughly performed by two researchers throughout in an attempt to reduce bias. Extensive use of search terms, databases, and cross-referencing ensured that all

possible studies relative to MWM pre-scription at peripheral joints were in-cluded for analysis. A valid and reliable critical appraisal checklist to assess the methodological quality of randomized and non-randomized studies was em-ployed, and previous categorization of the tool was located.

This systematic review consists of some unavoidable limitations. This in-cludes the access of only-English written articles and a search performed up until August 2008. This leads to the possibility of the exclusion of other studies that may be pertinent to this review and, therefore, the guidelines for clinical practice. Lastly, this review lacks a com-plete statistical analysis that may, to an extent, weaken the interpretation of re-sults. However, the primary focus of this systematic review was a descriptive analysis in order to fulfill the outlined purposes.

Future Research

Subsequent to the extensive research and analysis undertaken for this system-atic review, it is evident that there are inconsistencies, gaps, and methodologi-cal limitations within the literature sur-rounding MWM treatment at periph-eral joints.

The methodological quality of fu-ture research needs to be more robust in order to build an improved evidence base in this commonly used area of manual therapy, as currently it is of a moderate level. Internal validity of stud-ies can be strengthened via the use of randomized controlled trials, optimally including double blinding and placebo groups. The external validity can be en-hanced by the inclusion of a greater number of participants, who are repre-sentative of populations that may benefit from MWM treatment. This will con-tribute to creating sufficient power and, therefore, the detection of clinically sig-nificant results. A limiting factor that can be easily resolved is the reporting within studies. This needs to be im-proved by documenting adverse events, dropouts, confounding variables, and specific explanation of methods of re-cruitment, assessment, and the MWM treatment procedure. Inclusion of fol-

low-up assessment will further examine the long-lasting effects of MWMs. Out-come measures used in studies should aim to be valid and reliable to further increase consistency of results and therefore internal validity.

Conclusion

Mulligan’s peripheral MWM techniques are commonly used within musculo-skeletal physiotherapy. This systematic review of the MWM prescription at pe-ripheral joints highlighted that this area of research has an overall moderate methodological quality, with evident strengths, limitations, and inconsisten-cies. The specific parameters identified for MWM prescription in the literature are variable and in general inconsis-tently implemented and explained. The efficacy of MWMs is well established for various joints and pathologies; however, due to the methodological quality of the studies, it is apparent that further re-search is warranted into the specific pa-rameters of MWMs.

To conclude, this manual therapy technique is widely used and advocated for many aspects of peripheral joint dys-function. This systematic review has presented an evaluation of MWMs spe-cific to peripheral joints, in an attempt to guide the clinician appropriately and to provide a basis for future research into this area.

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