³EFFECTIVE OF MULLIGAN MOBILISATION - RK Universityrku.ac.in/spt/wp-content/uploads/2015/08/Group-17.pdf · ³EFFECTIVE OF MULLIGAN MOBILISATION ... With due respect, we would like

“EFFECTIVE OF MULLIGAN MOBILISATION

AND TAPING IN LATERAL EPICONDYLITIS”

Submitted by:

POOJA KALARIA

(12SPTPT11039)

DHARA KAPURIYA

(12SPTPT11040)

BPT 6th semester, JULY-2015

Guided by:

Dr NAMRATA CHANDRALA

Assistant professor, School of physiotherapy, RK University

II

CERTIFICATE

This is to certify that the project work entitled “Effect of Mulligan mobilization and

tapingin lateral epicondylitis”has been undertaken and written under my supervision and it

describes the original research work carried out by Ms. Pooja Kalaria and Ms. Dhara

Kapuriya registered at RK University in 6th semester Bachelors of Physiotherapy.

I

Signature of Guide

Name: Dr Namrata Chandrala

Degree: MPT ORTHO

Designation: Assistant professor

III

DECLARATION

We hereby certify that we are the authors of this project work. We certify to the best of

our knowledge, our project does not infringe upon anyone’s copyright nor violate any

proprietary rights and that any ideas, techniques, quotations, or any other material from the

work of other people included in our project published or otherwise, are fully acknowledged

in accordance with the standard referencing practices. We declare that this is a true copy of

our project, including any final revisions, as approved by my project review committee.

Signature.of candidate: Signature.of candidate:

Pooja kalaria Dhara Kapuriya

Enrolment no.: 12sptpt11039 Enrolment no.: 12sptpt11040

Date: 16th july 2015 Date: 16th july 2015

Place: Rajkot Place: Rajkot

IV

ACKNOWLEGEMENT

First and foremost we would like to thank our parents Lalitbhai Kalaria, Jagrutiben Kalaria and

Vinodbhai Kapuriya, Sarojben Kapuriya who are my living Gods and our brothers Arjun Kalaria

and Neel Kapuriya for their valuable support and encouragement, blessing and love which has

always been a source of inspiration and strength in accomplishing this academic task.

Our heartfelt gratitude to almighty God who has guided us this far and to whom goes all the honor

and glory for the successful completion of this study.

We wish to express our regards to our Director Dr Priyanshu Rathod School of Physiotherapy,

RK.University for his whole hearted guidance and meticulous suggestions in the completion of this

work and for all the facilities and support extended to me during this study. We are extremely thankful

for his constant encouragement and inspiration during the course of this study.

With due respect, we would like to express our sincere thanks to our guide Dr Namrata Chandrala

Senior lecturer of School of Physiotherapy, RK.University, for her judicious information, expert

suggestions, valuable guidance, continuous support, incessant reassurance during every stage of this

work and interest shown in this dissertation without which this work would not have been possible.

we would like to extend our heartfelt thanks to assistant lecturer, Dr Ankur Parekh, Dr Kajal

Anadkat and Dr Vaibhavi Ved for their valuable guidance, constant help and support throughout this

study and all the lecturers of my college who have taught me and gave their valuable suggestions

during the course of the study.

We shall fail our duties if we don’t acknowledge my Colleagues and Friends for their suggestions and

criticism while assisting us in this study.

Last but not the least we would like to thanks all the Individuals in our study without whom this task

would not have been possible.

Our sincere thanks to all the contributors whose names we might have missed but who truly deserve

our gratitude.

We would like to thank once again to all who have helped us all the while.

Signature: Signature:

Name: Pooja kalaria Name: Dhara Kapuriya

V

V

LIST OF ABBREVIATIONS

1. MWM: Mulligan’s Mobilization with Movement

2. US: Ultrasound

3. PRTEE: Patient Rated Tennis Elbow Evaluation

4. ECRB: Extensor Carpi Radialis Brevis.

V

VI

ABSTRACT

BACKGROUND:

Lateral epicondylitis is a painful musculoskeletal condition which is considered to be due to

over use, over stress or over exertion of wrist extensors(mainly ECRB) of the forearm with

production of pain around the common extensor origin. The study is to evaluate the efficacy

of taping and Mulligan mobilization in improving the functional ability and reduction of pain in

tennis elbow.

AIM:

1 To evaluate the effectiveness of taping, US and stretching exercise on pain and disability

of patient with lateral epicondylitis. 2 To evaluate the effectiveness of MWM, US and

stretching exercise on pain and disability of patient with lateral epicondylitis. 3 To compare

the effectiveness of taping and Mulligan mobilization technique on lateral epicondylitis.

METHODOLOGY:

1 Study design: Experimental study(pre test and post test). 2 Inclusion criteria: Age of 30-

60 years with symptomatic lateral epicondylitis on side, males and females, positive Cozens

test or Mills test confirming lateral epicondylitis. 3 Exclusion criteria: Patient having history

of trauma,surgery , acute infection, fractures around elbow complex, Patient who have

received steroids injection within last 30 days in elbow joint. 4 Sample size: 30 subjects. 5

sampling: Simple random sampling. 6 Study setting: Various physiotherapy clinics in

Rajkot.

RESULTS:

The result of this study indicate that the mean improvement in hand grip strength when

compared in pre and post treatment did not show significant improvement with in the groups

with p<0.05.

The result of this study indicate that the mean improvement in PRTEE when compared in pre

and post treatment shows significant improvement with in and between the groups with

p<0.05.

VII

CONCLUSION:

Mulligan mobilization was more effective than taping technique in reducing pain and

functional performance.

KEY WORDS:

Lateral epicondylitis, Mulligan mobilization (MWM), Hand Grip Strength, Patient Rated

Tennis Elbow Evaluation (PRTEE).

VIII

TABLE OF CONTENTS

Sr. No. TITLE Page No.

1. INTRODUCTION 1

2. AIMS & OBJECTIVES 6

3. REVIEW OF LITERATURE 10

4. METHODOLOGY 14

5. RESULTS 23

6. DISCUSSION 29

7. CONCLUSION 32

8. SUMMARY 34

9. BIBLIOGRAPHY 36

10. ANNEXURES 40

IX

LIST OF TABLES

Sr. No. TABLES Page No.

5.1 Comparison of PRTEE in group A and B(within group) 25

5.2 Comparison of Hand Grip Strength in group A and

B(within group)

26

5.3 Comparison of PRTEE between group A and B 27

5.4 Comparison of Hand Grip Strength between group A

and B

28

X

LIST OF GRAPHS

SR.

No.

GRAPHS PAGE

NO.

5.1 Comparison of PRTEE in group A and B 25

5.2 Comparison of Hand Grip Strength in group A and B 26

5.3 Comparison of PRTEE between group A and B 27

5.4

Comparison of Hand Grip Strength between group A and

B

28

XI

LIST OF FIGURES

SR. NO. FIGURES PAGE NO.

4.1 Lateral epicondylitis 2

4.2 Tapping applying method 16

4.3 Mulligan applying method 18

4.4 Grip strength measurement 17

4.5 Material used in study 20

XII

“EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS” Page 1

INTRODUCTION


INTRODUCTION

Tennis elbow or lateral epicondylitis is one of the most common lesions of the

forearm. It is a lesion affecting the origin of the tendons of the muscles that extend the wrist

joint mainly Extensor Carpi RadialisBrevis (ECRB) 1. The dominant arm is commonly

affected among both men and women with prevalence of 1-3 % 2 and in the age group of

30- 60 years3.

Fig 4.1

The commonest causative factor is present at elbow over-use or repetitive concentric

and eccentric contractions of the extensor muscles (mainly ECRB) which stabilizes the wrist.

These repetitive stresses (heavy lifting, repetitive hammering, scissoring, twisting, and in

tennis players with backhand stroke & inadequate forearm extensor power and endurance)

produces chronic overload due to biomechanical positional fault resulting in micro tearing &

fibrosis of the common wrist extensor origin. This presents as pain on gripping activities,

decreased grip strength and tenderness over the outer edge of the elbow 3, 4.

The Repeated tensile stress created at the origin of the ECRB may cause microscopic

tears at the musculotendinous junction and Angio-fibroblastic hyperplasia response may

follow. This leads to inflammation &mucinoid degeneration of the Extensor origin and

subsequent changes within the inelastic tendon such as thickening of the tendon’s sheath,


nodule formation & adhesions. Additional changes seen microscopically include a reduction

in vascularity ,fraying & splitting of collagen fibers and an increase in the amount of type III

collagen within a tendon which further weakens the tendon causing more microtears and

prolong the degeneration process5, 6.

Numerous manual therapy procedures have been developed to assist in the

management of Tennis elbow Indications and applications of these numerous manual

therapy procedures varies with each author, but the biomechanical effect of radio-humeral

gapping remains consistent with each technique8

A) Mulligan’s Mobilization with Movement (MWM): It is a class of manual therapy

technique (based on the principle of Kaltenborn i.e. passive accessory mobilization

technique applied parallel or perpendicular to the joint plane) that is widely used in the

management of musculoskeletal pain. It involves the manual application of a sustained glide

by a therapist to a joint, while a concurrent physiological movement of the joint is actively

performed by the patient7.MWM techniques are applied in case of positional fault of the

elbow joint Complex & they help to restore normal tracking of the radius on the capitulum. It

also prevents the contractile element pathology of the common extensor bundle so that

strengthening the forearm muscles can be done without painful symptoms8.

Several researchers have reported decrease in pain and increase in grip strength

during or shortly after MWM at the elbow13.

B)Taping: It is a cost effective treatment alternative for many common injuries &

overuse syndromes (hillfrank, 1991). Tape is applied across the joint in several layers and is

positioned to provide outside support and restrict forces that would apply stress on an

injured part.

Mulligan taping mainly aims to mainly, to reduce pain, improve function &

biomechanics12. It taping aim to control the fascia directly, establish proper structural

alignment, improve muscular recruitment & also increase proprioception stimulation

enhancing static & dynamic neuro-muscular retraining by balancing the tissue length/tension

relationship &motor control12, 14.


NEED OF THE STUDY


NEED OF THE STUDY

Mulligan mobilization is the commonest manual therapy procedures used in the

treatment of lateral epicondylitis. These techniques help in reduction of pain immediately

after the technique is applied for short period8, 9,10,11,15,16,17. Taping has been found effective

in decreasing the pain & restoring the joint play by maintaining & establishes proper

structural alignment by balancing the tissue length/tension relationship for prolonged

period12, 14.

There are many studies on the effects of Mulligan mobilization in the management of

lateral epicondylitis. However not many studies have evaluated the efficacy of using taping

technique as an adjunct to manual therapy approach. This study is an attempt to evaluate

the efficacy of taping as an adjunct to Mulligan mobilization in improving the functional

ability and reduction of pain in lateral epicondylitis. Therapeutic ultrasound and stretching

exercises are used to deal with the bio-chemical changes of the condition.

This study is to evaluate the efficiency of taping and Mulligan mobilisation in improving

the functional ability and reduction of pain in lateral epicondylitis.


AIM AND OBJECTIVES


AIM & OBJECTIVES

AIM :

1. To compare the effectiveness of taping and Mulligan technique on lateral epicondylitis

OBJECTIVES:

1. To evaluate the effectiveness of taping, US and stretching on pain and disability of patient

with lateral epicondylitis.

2. To evaluate the effectiveness of MWM, US and stretching on pain and disability of patient

with lateral epicondylitis.


HYPOTHESIS


HYPOTHESIS

ALTERNATIVE HYPOTHESIS:

Treatment using Mulligan mobilization and taping shows significant difference in pain and

disability in patients with lateral epicondylitis.

NULL HYPOTHESIS:

Treatment using Mulligan mobilization and taping does not show any significant difference in

pain and disability in patients with lateral epicondylitis.


REVIEW OF LITERATURE


REVIEW OF LITERATURE

1)Bryan Chung, J ability due Wiley.et.al (2010): Studied the validity of PRTEE. The

PRTEE had questionable discriminant ability due to its moderate test-retest reliability and

possibly due to low convergent validity with other measures of similar constructs. The

PRTEE appears to be sensitive to change, but the margin of difference between a clinically

relevant change and no change is very small.23

2)Tom J. Overend,Jennifer C, Wuori-Fearn, John .F. Kramer .et. at. (1999): Studied the

reliability of a questionnaire designs to assess forearm pain function in patient with lateral

epicondylitis. The PRTEE or PRFEQ has been found to effective in providing simple, quick

and reliable estimations of arm pain functions in patients with lateral epicondylitis.24

3) Bryan chung, J Preston wileyet. al. (2010): studied validity, responsiveness and

reliability of PRTEE .they conclude that it is having questionable discriminant ability due to

its moderate test-retest reliability and possibility due to low convergent validity with other

measures of similar constructs.14

4) Won-Hwee Lee, Oh et.at. (2011): Studied the effect of taping on wrist extensor force

reproduction and wrist joint position reproduction with or without lateral epicondylitis. The

lateral epicondylitis group had a significantly higher FR and JPR errors. Taping significantly

improved force reproduction and joint position reproduction error.16

5) AlirzaShamsoddini, Mohammad TaghiHollisaz, et.al. (2010) studied the initial

effect oftaping techniques in subjects with tennis elbow by testing grip strength, wrist

extensionmuscleforce and range of motion wrist extension immediately after the

application of tapingtechniques. Results showed impressive effect on wrist extension,

grip strength and pain. 17


6) Stasinopoulos, K Stasinopoulu, M I Johanson et. al (2012): Studied the exercise

program for the management of tennis elbow. Study described the use and effects of

strengthening and stretching exercise program in the treatment of tennis elbow. They

concluded that the well designed trial is needed to study the effectiveness of supervised

exercise program for tennis elbow consisting of eccentric and static stretching exercise. 19

7) Magnus Peterson, Stephen butler, et. al. (2011): studied randomized controlled clinical

trial on the effect of exercise versus expectation on pain, muscle strength, function and

quality of life in patients with long standing lateral epicondylosis. They found that exercise

group had greater and faster regression of pain, both during muscle contraction and muscle

elongation than the reference group. 20

8)MoneetKochar and AnkitDogra(2002): conducted a clinical study on Effectiveness of a

specific physiotherapy regimen on patients with Tennis Elbow on 66 patients who were

randomized into 3 groups, The first (MM) group was treated with a combination of

ultrasound therapy and Mulligan mobilization while the second group was treated with

ultrasound therapy alone for ten sessions (completed within three weeks). Both groups

followed a progressive exercise regime for a further nine weeks, third group as control

group. They were evaluated at weekly intervals from the time of selection until the third

week and finally at the 12th week with four outcome measures: visual analogue scale

(VAS), isometric grip strength, weight test and patient assessment test. The results

conclude that the MM group showed improvement on most parameters than other groups

and found that the addition of Mulligan mobilization to a regimen comprising ultrasound

therapy and progressive exercises brings about increased and faster recovery in patients

with tennis elbow15.

9)A Binder, G Hodge, A M Greenwood, B L Hazleman, and D P Page

Thomas(1985):Conducted a randomized study to determine the effectiveness of

therapeutic ultrasound in treatment of soft tissue lesions. They included 76 patients with

lateral epicondylitis, 38 were randomly allocated to receive ultrasound treatment and 38

placebo. The conditions of 24 patients (63%) treated with ultrasound and 11 (29%) given

placebo improved, the difference being significant at the 1%. Improvement in particular


clinical variables (pain score, weight lifting, grip strength) also showed an advantage for the

patients given ultrasound treatment and the result concluded that Ultrasound enhances

recovery in most patients with lateral epicondylitis18.

10)Pienimaki, Tuomo, Tarvainen .et.al. (2002), Studied the association between changes

in pain and grip strength and manual tests among patients with chronic tennis elbow. Pain

thresholds at the lateral epicondyle are strongly associated with pain on palpation and with a

positive Mill’s test. Resisted extension test results reflect decreased grip strength.25

11)OritShechtman, Lisa Gestewitz and Christine Kimble have done a study to examine

the reliability and validity of the digital DynEx dynamometer. Grip strength testing was

conducted on 100 healthy subjects (aged 20–40 years) using both the Jamar and DynEx

dynamometers in the second handle position.The results of this study indicate that

concurrent validity between the two instruments was excellent21.


METHODOLOGY


METHODOLOGY

Study Design: Experimental study (pre test and post test).

Study Setting: Various physiotherapy centres in Rajkot.

Sampling Technique: Convenient sampling technique

Study Population: Male and Female

Study Sample: 30 subjects

Study Duration: Training duration: Daily one session

Total Study duration - 2 weeks.


Fig 4.2: Mulligan Tapping


Fig 4.3:Hand grip strength


Fig 4.4: Mulligan Mobilisation


CRITERIA FOR SELECTION

INCLUSION CRITERIA

Age group of 30-60 years with symptomatic lateral epicondylitis on either side.

Both males and females.

Positive Cozens test or Mills test confirming lateral epicondylitis22, 24, 25.

EXCLUSION CRITERIA

Patient having history of trauma, surgery, acute infections.

Patient who have received steroid injections within last 30 days in elbow joint.

Severe neck or shoulder problems with radiating pain to upper limb.

Fractures around elbow complex.


MATERIALS USED IN THE STUDY Mulligan belt

Hand held dynamometer

Ultrasound machine frequency 1MHZ

Ultrasonic gel

couch

stool

Mulligan elastic adhesive tape

pen

paper

data collection sheet.

Patient rated tennis elbow evaluation.

Scissors

Fig 4.5


METHOD

Patients will be included in the study after the initial assessment and informed consent

will be taken. Subjects who fulfil the inclusion criteria will be assigned into two groups based

on convenient random sampling. Pre test evaluation will be done before starting treatment

which includes pain assessment using PRTEE and pain free grip strength by hand held

dynamometer.

Group A (n=15) will be given Mulligan’s Mobilization With movement on the involved

elbow joint, with patient lying in supine position having their elbow extended and forearm

pronated. The mulligan belt is kept around the therapist’s shoulder and a lateral glide will be

given to the proximal part of the patient’s elbow joint. During the lateral glide, the patient is

asked to perform the pain producing movement (such as gripping or resisted isometric

contraction wrist extensor). If the glide is applied correctly then the patient will not feel any

pain on Lateral Glide Produced Via The Mobilization Belt Concurrent With Strong Resisted

Isometric Wrist Extension. The dosages are 3 sets of 10 pain free mobilizations in each set

with one minute rest time between each set7, 8.

Group B (n=15) Mulligan taping: The subjects will be asked to rest the elbow in

supported position with the elbow is slightly flexion and pronated and wrist in extended

position to contract the ERCB. The tape will be placed on the proximal forearm, starting

medially and laterally parallel to the wrist line. This will be repeated 2 or 3 times. The tape is

tightened until the subject agrees that it snugs during a contraction of the wrist extensors,

but not impending blood flow. The tape should be comfortable when the wrist extensors are

relaxed.2

Both the groups received Pulsed Ultrasound therapy (UST) with a Frequency of 1

MHz & Intensity of 0.5w/cm2 for 5 min at the musculo-tendinous junction of ECRB on the

affected elbow 26, 27.

In addition, both the groups will be given stretching exercises. The stretching will be

given by flexion of the wrist with forearm pronated and elbow extended. This is held for few

seconds and then released. A total of 10 stretches will be given on session per day 20, 28.

Each group will be receiving the interventions one session per day up to 2 weeks.


At the end of 2nd week post test evaluation comprising of PRTEE& Pain free grip

strength will be conducted for both the groups. The result of pre &post test values of each

group is compared & differences in pre &post test values between groups will also be

compared.

30 subjects with pre diagnosed tennis

elbow will be taken.

Consent form will be taken.

2 groups: A and B

Pre & post assessment of PRTEE and

hand grip strength.

Group A :

Mulligan mobilization

Ultrasound

Stretching exercise

Group B:

Taping

Ultrasound

Stretching exercise


RESULTS


Result

A study was performed in which PRTEE and Hand grip strength was assessed in both

groups.

The pre and post values for PRTEE and Hand grip strength were collected for both the

groups.

Statistics was performed using unpaired t test and paired t test for Hand grip strength within

and between the groups respectively, whereas Wilcoxson test and Mann Whitney U test was

used for PRTEE within and between the groups respectively.


Table 5.1 Comparison of PRTEE in group A and B(within group)

variable mean

s.d.

W value P value

Result

PRTEE pre post Pre Post

pre post

Group A 52.1 46.53 14.92 14.39 120 <0.0001 0.0007 Significant

Group B 50.83 47.47 13.14 11.82 120 <0.0001 0.0007 Significant

Graph 5.1

The PRTEE comparison within group A and B with pre mean of group A being 52.10

and post mean being 46.53, whereas for group B pre= 50.83 and post=47.47.

The s.d. pre and post value for group A is 14.92 and 14.39 respectively. The s.d. pre

and post value for group B is 13.14 and 11.82 respectively.

The pre and post P value for both the groups being p<0.0001 and p=0.0007

respectively therefore the result is significant.


Table 5.2

Graph 5.2

The Hand grip stremgth comparison within group A and B with pre mean of group A

being 15.37and post mean being 15.99, whereas for group B pre= 14.56 and

post=14.95.

The s.d. pre and post value for group A is 4.931 and 5.099 respectively. The s.d. pre

and post value for group B is 6.054 and 6.054 respectively.

The p value=0.7375 for group A and 0.8624 for group B, therefore the result is not

significant.

Comparison of Hand grip strength in Group A and B(within group)

variable mean

s.d.

t value p value Result

Hand grip strength Pre post pre post

Group A 15.37 15.99 4.931 5.099 0.3385 0.7375 Not significant

Group B 14.56 14.95 6.054 6.054 0.1749 0.8624 Not significant


Table 5.3

Graph 5.3

The PRTEE between group A and B with pre mean difference of 5.567 and post

mean difference of 3.367.

The pre s.d. difference being 2.809 and post s.d. difference being 2.985.

The p value=0.0156, therefore the result is significant.

Comparison of PRTEE between Group A and B

variable mean

s.d.

U

value p value Result

PRTEE Pre-post pre-post Pre-post Pre-post

5.567 3.367 2.809 2.985 54 0.0156 Significant

Group A:

Group B:

Group A:

Group B:


Table 5.4

Graph 5.4

0

0.5

1

Hand grip strength Pre-post

Pre-post

Variable

mean

0.62

0.3867

comparison of hand grip strength between group A &

B

Group A:

Group B:

The Hand grip strength between group A and B with pre mean difference of 0.6200

and post mean difference of 0.3867.

The pre s.d. difference being 0.5158 and post s.d. difference being 0.2850.

The p value=0.1615, therefore the result is not significant.

Comparison of hand grip strength between group A and B

Variable mean

s.d.

t

value

p

value Result

Hand grip

strength Pre-post Pre-post Pre-post

Pre-post

0.62 0.3867 0.5158 0.285 1.478 0.1615

Not

significant


DISCUSSION


DISCUSSION

The present clinical trial was conducted to compare the effectiveness of Mulligan

moblisation and taping technique with common treatment of therapeutic ultrasound and

stretching exercise in subjects with lateral epicondyitis.

Result of the study were focused on improvement of grip strength was measured with

the help of hand dynamometer and reduction in function actually improvement scored based

on PRTEE for lateral epicondylitis. It was noticed that there was improvement in the above

parameters in both groups.

AlirzaShamsoddini, Mohammad TaghiHollisaz, et.al. (2010):Studied the initial

effect of taping techniques in subjects with tennis elbow by testing grip strength,wrist

extensionmuscleforce and range of motion wrist extension immediately after the

application of taping techniques.Results showed impressive effect on wrist extension,

grip strength and pain. 17

MoneetKochar and Ankit Dogra(2002): conducted a clinical study on Effectiveness

of a specific physiotherapy regimen on patients with Tennis Elbow on 66 patients who were

randomized into 3 groups, The first (MM) group was treated with a combination of

ultrasound therapy and Mulligan mobilization while the second group was treated with

ultrasound therapy alone for ten sessions (completed within three weeks). Both groups

followed a progressive exercise regime for a further nine weeks, third group as control

group. They were evaluated at weekly intervals from the time of selection until the third

week and finally at the 12th week with four outcome measures: visual analogue scale

(VAS), isometric grip strength, weight test and patient assessment test. The results

conclude that the MM group showed improvement on most parameters than other groups

and found that the addition of Mulligan mobilization to a regimen comprising ultrasound

therapy and progressive exercises brings about increased and faster recovery in patients

with tennis elbow15.


Mulligan mobilization is the commonest manual therapy procedures used in the

treatment of lateral epicondylitis. These techniques help in reduction of pain immediately

after the technique is applied for short period8, 9,10,11,15,16,17. Taping has been found effective

in decreasing the pain & restoring the joint play by maintaining & establishes proper

structural alignment by balancing the tissue length/tension relationship for prolonged

period12, 14.

LIMITATIONS OF THE STUDY

Subjects could not be followed up for longer period of time, to see long term

benefit.

Small sample size was used.

Majority of the subjects were females.

FURTHER RECOMMENDATION

longer duration are recommended with longer follow-up period to assess long

term benefits.

Conduct the study with larger sample size.

Further study should be carried out with acute or chronic injury subjects.


CONCLUSION


CONCLUSION

The present randomized clinical trial provided evidence to support the use of Mulligan

mobilization and taping techniques in relieving pain, improving grip strength and improve

functional performance in subject with tennis elbow.

In addition, results supported that Mulligan mobilization was more effective than taping

technique in reducing pain and functional performance.


SUMMARY


SUMMARY

The purpose of this study is to determine the effectiveness of Mulligan mobilization

and taping in lateral epicondylitis.

Individuals (N= 15) were randomly assigned into a group containing 13 females and 2

males in group A and group B containing 12 females and 3 males. Group A was treated with

Mulligan mobilization, US and stretching where as group B was treated with Mulligan taping,

US and stretching.

The measurement used are hand dynamometer and PRTEE. Each subject was

measured before and after 2 weeks of treatment.

The result of this study indicate that the mean improvement in hand grip strength

when compared in pre and post treatment did not show significant improvement within and

between the groups with p>0.05.

The result of this study indicate that the mean improvement in PRTEE when

compared in pre and post treatment shows significant improvement within and between the

groups with p<0.05.


BIBLIOGRAPHY


BIBLIOGRAPHY

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medicine. 2004;38;675-677

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pub, 2003.

4) Ched Starkey, Jeff Ryan. Evaluation of Orthopaedic and Athletic Injuries. 2nded, F A

Davis company, 2002.

5) Pamela K Levangie, Cynthia. C Norkin. Joint Structure & Function, A Comprehensive

analysis. 3rded, Jaypee pub. 2001.

6) Peggy.A.Houglum, Therapeutic Exercise for musculo skeletal injuries. 2ndedition..Human

Kinetics Publications,2004

7) Brian R Mulligan. Manual Therapy- ‘’NAGS’’, ‘’SNAGS’’, ‘’MWMS’’ etc. 4thed, Plane view

press, Welligton, 1995.

8) Jack miller ,Case study: mulligan management of “Tennis elbow”, published orthpaedic

Division Review May/June 2000

9) James H Cyriax, The Text book of Orthopedic Medicine, Diagnosis of soft tissue lesion,

volume one, 8th edition, A.I.T.B.S Pub. 2002.

10) Rene cailliet. Soft tissue pain & disability, 3rd edition, F.A.Davis Company, 1996.

11) James. H Cyriax, The text book orthopedic medicine, Treatment by manipulation,

massage and injection, 11th edition, Vol 2, A.I.T.B.S PUB.2002.

12) Mary Lynn Jocobs, Noelle Austin. Splinting the hand & upper extremity principles &

process, 2003, Lippincott Williams &wilkins pub.


13) Carolyn kisner, Lynn Allen Colby. Therapeutic exercises: foundations and technique.

4thed. Jaypee publications.2003.

14) Bill Vicenzino, Jane Brooks bank, Joanne Minto, Sonia offord, Aatitpaungmali, Initial

effects of elbow taping on pain free grip strength and pressure pain threshold,, Journal of

orthopedic & sports Physical therapy,2003;33: 400-407

15) Moneet, Kocher Dograankit . Effectiveness of specific physiotherapy regimen on patients

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ANNEXURE


ANNEXURE 10.1

CONSENT FORM


ETHICAL INFORMED CONSENT FORM

Study title: “ EFFECTIVENESS OF MULLIGAN MOBILIZATION AND TAPING IN LATERAL

EPICONDYLITIS.”

Subject’s Name:

Age : ____________Years Sex:___________

Address of the Subject___________________________________________________

___________________________________________________________

I have been explained in details about the various questions/tests that will be asked/performed is to

assess my functional capacity & health status etc. I have also been explained that all the tests are non-

invasive and without any side effect.

I understand that my participation in the study is voluntary and that I am free to withdraw at any time,

without giving any reason, without my medical care or legal right being affected.

I understand that the data obtained through the study may be used for research paper publication and I

also understand that my identity will not be revealed at any cost. I agree to give my consent for

taking my photograph and have no objection against it.

I agree to take part in the above study

Signature / Thumb impression of the subject ------------------

Date:

Name of Witness:___________________________________________

Signature of the Witness: ____________

Signature of Investigator --------------------

Date:


ANNEXURE 10.2

DATA COLLECTION FORM

Name:

Age: Gender:

Occupation: Contact no:

Address:

Chief complain:

Provisional diagnosis:

Pain history:

Site: Type:

Frequency: Duration:

Aggravating factors: Relieving factors:

Outcome measures:

PRTEE: Pre score Post score

Hand grip strength:

Pre score Post score


ANNEXURE 10.3

MEASUREMENT TOOL

Patient rated tennis elbow evaluation (PRTEE)

Clinical test: Cozen’s test

Mill’s test

Hand dynamometer


ANNEXURE 10.4

SCALES USED IN OUTCOME MEASURES

PATIENT-RATED TENNIS ELBOW EVALUATION

Name _______________________________ Date______________

Instruction: Please rate the activities in each category according to your difficulty.

Circle one for each activity.

1. PAIN in your affected arm

Rate the average amount of pain in your arm over the past week by circling the number

that best describes your pain on a scale from 0-10. A zero (0) means that you did not have any

pain and a ten (10) means that you had the worst pain imaginable.

RATE YOUR PAIN: Worst

No Pain Imaginable

When your are at rest 0 1 2 3 4 5 6 7 8 9 10

When doing a task with repeated arm 0 1 2 3 4 5 6 7 8 9 10

Movement

When carrying a plastic bag of groceries 0 1 2 3 4 5 6 7 8 9 10

When your pain was at its least 0 1 2 3 4 5 6 7 8 9 10

When your pain was at its worst 0 1 2 3 4 5 6 7 8 9 10

Pain score = ( ) = /50

EFFECT OF MULLIGAN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 46

2. FUNCTIONAL DISABILITY

A. SPECIFIC ACTIVITIES Rate the amount of difficulty you experienced performing each of the tasks listed

below, over the past week, by circling the number that best describes your difficulty on

a scale of 0-10. A zero (0) means you did not experience any difficulty and a ten (10)

means it was so difficultyou were unable to do it at all.

No Unable

Difficulty To Do

Turn a doorknob or key 0 1 2 3 4 5 6 7 8 9 10

Carry a grocery bag or briefcase by the handle 0 1 2 3 4 5 6 7 8 9 10

Lift a full coffee cup or glass of milk to your 0 1 2 3 4 5 6 7 8 9 10

Mouth

Open a jar 0 1 2 3 4 5 6 7 8 9 10

Pull up pants 0 1 2 3 4 5 6 7 8 9 10

Wring out a washcloth or wet towel 0 1 2 3 4 5 6 7 8 9 10

B. USUAL ACTIVITIES Rate the amount of difficulty you experienced performing your usual activities in

each of the areas listed below, over the past week, by circling the number that best

describes your difficulty on a scale of 0-10. By “usual activities”, we mean the

activities that you performed before you started having a problem with your arm. A

zero (0) means you did not experience any difficulty and a ten (10) means it was so

difficulty you were unable to do any of your usual activities.

1. Personal activities (dressing, washing) 0 1 2 3 4 5 6 7 8 9 10

2. Household work (cleaning, maintenance) 0 1 2 3 4 5 6 7 8 9 10

3. Work (your job or everyday work) 0 1 2 3 4 5 6 7 8 9 10

4. Recreational or sporting activities 0 1 2 3 4 5 6 7 8 9 10

Functional score= ( )/2= /50 Total score= = /100

EFFECTIVE OF MULLIGAN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 47

ANNEXURE 10.5

MASTER CHART

GROUP A

MULLIGAN MOBILISTAION, STRETCHING, ULTRASOUND

SR

NO

AGE GENDER PRTEE HAND GRIP

STRENGTH(kgs)

PRE

SCORE

POST

SCORE

PRE

SCORE

POST

SCORE

1 55 F 44 39.5 13.6 14

2 49 M 39.5 32.5 24 26.2

3 34 F 35 29.5 12 12.8

4 54 M 60 55 17.2 17.8

5 36 F 30 26 10.3 11.2

6 42 F 54.5 43 12.4 12.8

7 33 F 52.5 45.5 21.3 21.8

8 38 F 37.5 32 20.4 21

9 46 F 58 58 20.3 20.3

10 51 F 81 73 12 13

11 31 F 73 68.5 19.5 20

12 35 F 73.5 64 11.3 12

13 46 F 46 42.5 6.7 7

14 44 F 48 45.5 16.8 17

15 42 F 49 43.5 12.8 13


GROUP B

TAPPING,STRETCHING,ULTRASOUND

SR

NO

AGE GENDER PRTEE HAND GRIP

STRENGTH

PRE

SCORE

POST

SCORE

PRE

SCORE

POST

SCORE

1 55 F 52 49.5 6.5 7

2 44 F 42 42 11.4 11.4

3 50 F 45.5 43 22.1 23

4 38 F 28 26 22 22.5

5 47 M 35 33 26.7 27

6 52 M 79 68 8.2 9

7 60 F 40 32 7.6 8

8 52 F 46.5 46.5 13.3 13.3

9 37 F 50 50 14 14

10 50 F 54.5 50 11.2 11.8

11 33 F 51 47.5 16.8 17

12 40 F 65 60.5 11.3 12

13 40 M 67.5 63 21.9 22.2

14 33 F 46 42.5 12.6 13

15 46 F 60.5 58.5 12.8 13


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