International Journal of Health Sciences and Research

www.ijhsr.org ISSN: 2249-9571

Original Research Article

A Study to Determine the Effectiveness of Mobilization with Movement

Techniques in Knee Osteoarthritis Pain
Anjali Vyankatesh Kulkarni1, Manasi Madhav Kamat2
1
Assistant Professor, Dept. Of Physiotherapy, MAEER’S Physiotherapy College, Talegaon –Dabhade, Pune,
India.410507
2
Intern: MAEER’S Physiotherapy College, Talegaon –Dabhade, Pune, India, Masters in Rehabilitation
Sciences: University of Pittsburgh, USA
Corresponding Author: Anjali Vyankatesh Kulkarni

ABSTRACT

Background & Objectives: In India, Osteoarthritis (OA) knee is the most prevalent form of arthritis
and it is estimated that about 15 million people in the country are affected with it. The present study
was undertaken to determine the effectiveness of mulligan’s mobilization with movement techniques
on pain in knee osteoarthritis.
Methods: 30 patients (males and females) who attended BSTR hospital, Pune, India falling under the
inclusion criteria were selected with the informed consent. Subjects were randomly divided into two
groups: Control Group (15 subjects) and Experimental Group (15 subjects). On the first day, each
patient was subjected to 6-minute walk test and VAS (pain) and distance covered was noted. Control
group received conventional treatment (TENS and exercise program). Experimental group received
conventional treatment along with Mulligan’s mobilization with movement technique.
Result: At the end of 3 days treatment sessions, both the groups obtained successful outcomes, as
measured by significant reductions in VAS (p < 0.05) and improvement in 6-minute walk test distance
over a 3 days period. However post treatment distance covered in the experimental group (mean =37,
SD=16.882) was markedly better than the post treatment distance covered in control group (mean
=35, SD=23.146)
Conclusion: The study concluded that Mulligan’s Mobilization with Movement (MWM) technique is
effective in reducing pain in patients with knee osteoarthritis. Statistically significant reduction in
VAS (pain) and marked improvement in the distance covered by the subjects was observed in the
experimental group post treatment.

Key Words: Osteoarthritis knee, Mulligan Mobilization with Movement, TENS, six minute walk test.

INTRODUCTION patella. The tibio-femoral joint is the

The knee joint is formed by fusion weight-bearing joint of the knee. (2)
of lateral tibio-femoral, medial tibio-femoral Osteoarthritis (OA) is the most
and patello-femoral joints. The joint allows common arthritis in worldwide and
for flexion and extension (and a small approximately 10% of world’s population
degree of medial and lateral rotation). (1) who are 60 years or older have symptomatic
The knee joint consists of two articulations: OA. In India, it is the most prevalent form
Tibio-femoral - The medial and lateral of arthritis and it is estimated that about 15
condyles of the femur articulating with the million people in the country are afflicted
tibia. Patello-femoral – The anterior and with OA. (3) OA is a degenerative joint
distal part of the femur articulating with the disease. The chances of developing OA

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Anjali Vyankatesh Kulkarni et al. A Study to Determine the Effectiveness of Mobilization with Movement
Techniques in Knee Osteoarthritis Pain

goes up after age 45 years with the knee Mulligan’s concept allows us to
being the most commonly affected site in safely apply end range techniques that are
the lower limb. under the full control of the patient, remain
There are three compartments of the at end range for several seconds with no
knee. The compartments are: medial (inside) pain and provide a unique mechano-
tibio-femoral compartment, lateral (outside) receptive afferent impulse to the central
tibio-femoral compartment & patella- nervous system. (7) Mulligan’s mobilization
femoral compartment. Osteoarthritis can with movement (MWM) is a contemporary
affect one, two, or three compartments of form of joint mobilisation consisting of a
the knee. The most common place to get therapist-applied pain free accessory gliding
arthritis is in the medial compartment. force combined with active movement. (8)
Hence if one compartment is affected it is A plethora of studies have
termed as unicompartmental osteoarthritis. investigated several aspects related to
Degeneration on both the inside and outside muscle function such as strength, aerobic
of the knee is termed as bicompartmental capacity as well as pain, stiffness and ROM
osteoarthritis. When all the three in patients with OA. Despite these important
compartments are affected it is said to be advances, to our knowledge, few studies
tricompartmental osteoarthritis of knee have investigated the effects of different
joint. (4) types of mobilization technique on pain and
Pain is the earliest symptom. It functional capacity of patients with OA
occurs intermittently in the beginning, but knee. So this study aims to find the efficacy
becomes constant over months or years. A of mulligan’s mobilization with movement
coarse crepitus may be complaint by some techniques on pain in knee osteoarthritis.
patients. Swelling of joint is usually a late
feature, and is due to effusion caused by Aims and Objectives:
inflammation of the synovial tissues. Aim: To assess the efficacy of mulligan’s
Stiffness is initially due to pain and muscle mobilization with movement techniques on
spasm but later capsular contracture and pain in knee osteoarthritis.
incongruity of the joint surface contribute to Objectives:
it. Other symptoms are, a feeling of  To find out effect of mulligan’s MWM
instability of the joint, and locking resulting along with conventional treatment.
from loose bodies and frayed menisci. (5)  To compare effect of MWM and
Transcutaneous electrical nerve conventional treatment on pain in knee
stimulation (TENS) is a widely used osteoarthritis.
physical therapy modality for pain relief.
There are a few theories related to its MATERIALS AND METHODS
mechanism of effect as follows: inhibition MATERIALS:
of nociceptors, blockage of pain Stop watch, two small cones to mark the
transmission in afferent nerves, sympathetic turnaround points, pen, worksheets on a
blockage, gate control theory and increase clipboard, mulligan belt, stepper, TENS
in release of endogen opiates. Therapeutic machine.
exercise protocol includes stretching METHODOLOGY:
exercises and isometric exercises for entire  Study design – experimental pre-post.
lower limb. Knee OA is also associated with  Type of sampling- simple random
inhibition of the quadriceps, which leads to sampling.
poor knee extensor strength. Adding TENS  Place of study – Bhausaheb Sardesai
to a therapeutic exercise program for knee Talegaon rural hospital, Pune.
osteoarthritis can be more effective at  Sample size-30.
increasing quadriceps muscle activation by  Outcome measure – 6 minute walk test,
reducing pain during exercise. (6) (9)
(Visual analogue scale and distance).

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Anjali Vyankatesh Kulkarni et al. A Study to Determine the Effectiveness of Mobilization with Movement
Techniques in Knee Osteoarthritis Pain

INCLUSION CRITERIA: Exercise: The exercise programme

 Unilateral Tibio-femoral (medial and consisting of isometric exercises and
lateral compartment) OA knee. stretching exercises was taught to the
 American College of Rheumatology patients. Isometrics were given from the
(ACR) criteria to diagnose OA knee. (10) first day for all the three days and stretching
was added on the second and third day for
EXCLUSION CRITERIA: entire lower limb.
Inflammatory conditions like rheumatoid The isometric exercises consisted of
arthritis, contra-indications to 6 minute walk three exercises using a towel roll. The
test (unstable angina or myocardial participants were instructed to perform a
infarction during the previous month), total of 10 repetitions. Each repetition lasted
traumatic injury to knee joint (ligamentous 6 seconds with an interval of approximately
or meniscal injuries), active infection 3 seconds.
around knee (infection of the bursa), In the first exercise using the towel
patients who underwent knee surgery (total roll, the patients were placed in a supine
knee replacement and reconstruction position with knees flexed. The towel roll
surgery), psychological problems. was positioned between the patient’s knees,
PROCEDURE: and the patient was instructed to press the
30 patients (males and females) knees against the roll to perform a maximal
falling under the inclusion criteria were contraction. This exercise aimed to
selected with the informed consent. Subjects strengthen the hip adductor muscles.
were randomly divided into two groups In the second exercise, the patients
namely: Control group (15 patients) and were placed in a supine position with legs
Experimental group (15 patients). Patients straight. With the towel roll placed under
were treated with one session per day for 3 the ankle of the affected limb, the patients
consecutive days. On the first day each performed a maximal contractions. This
patient was subjected to 6-minute walk test exercise strengthened the hamstrings
and VAS (pain) and distance covered was muscle.
noted. In the third exercise, patients were in
Protocol: supine position with legs straight. With the
Control group (conventional group- towel roll placed under the knee, patients
TENS and exercise program): were asked to press the knee on the roll.
TENS: Conventional 2 pole TENS with This exercise aimed to strengthen
frequency of 100 Hz was given for 15-20 quadriceps muscle.
minutes for 3 days from day 1. (11) Patients The stretching exercises were
were treated in supine position with roll performed actively and included the
under their affected knee. following muscles and in order: the calf
(standing), quadriceps (standing knee bent)
and the hamstring muscles (long sitting with
both the knees extended, ankle dorsiflexion
with the help of towel) the patients were
instructed to perform these exercise
thrice/day for 2 days.
Experimental group: This group received
whole conventional treatment (as explained
above) along with Mulligan’s mobilization
with movement technique. Procedure for
Mulligan’s MWM: Mobilization technique
Figure 1: method of application of TENS
was selected based upon patient’s
complaint. There are two techniques which

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Vol.7; Issue: 4; April 2017
Anjali Vyankatesh Kulkarni et al. A Study to Determine the Effectiveness of Mobilization with Movement
Techniques in Knee Osteoarthritis Pain

were performed: the first is the medial or pain (medial glide with medial knee pain
lateral glide MWM depending on site of and lateral glide with lateral knee pain).

Figure 2: Application of medial glide starting position and movement for knee flexion

Figure 3: Application of lateral glide starting position and movement for knee flexion

The second mobilization technique was given as medial or lateral glide did not
was the “rotation” MWM: for patients with relieve patient’s pain in weight bearing
knee pain in weight bearing position position).
rotation MWM was given. (Rotation MWM

Figure 4: Application of rotation MWM for knee flexion in weight bearing position

Rule of three was followed for all is, on the third day, patients were re-
the mobilization techniques that is on day 1 assessed by 6-minute walk test thus noting
three repetitions were given, on day 2, six the change in the VAS and the distance.
repetitions and so on day 3, nine repetitions
were given. At the end of the treatment, that

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Anjali Vyankatesh Kulkarni et al. A Study to Determine the Effectiveness of Mobilization with Movement
Techniques in Knee Osteoarthritis Pain

Statistical Analysis: All the participants test and that of distance was done using
completed 3 day treatment sessions. The Unpaired t-test.
following table represents data with respect
to VAS and distance of the control and RESULT
experimental groups. Descriptive statistics Table 1. Showing VAS pre and post treatment
CONTROL EXPERIMENTAL
including p-value, standard deviation, mean PRE POST PRE POST
and t-value were calculated. 5 4.13 5.8 4.13
Comparison of VAS within the
Table 2. Showing distance walked in meters pre and post
groups was assessed using Wilcoxon signed treatment
rank test and that of distance within the CONTROL EXPERIMENTAL
PRE POST PRE POST
groups were done using paired t-test. 349 384 363 400
Comparison between VAS of two
groups was done using Mann-Whitney U
Table 3: Showing P value, t value, mean, standard deviation of control & experimental groups
GROUPS P-VALUE SIGNIFI-CANCE STANDARD DEVIATION MEAN t-VALUE
PRE POST PRE POST
EXPER 0.0002 Extremely significant 0.9411 1.246 5.800 4.133 -
VAS CONT. 0.0039 Very significant 1.069 0.7432 5.000 4.133 -
COMP. 0.0304 Significant Exp. Cont. Exp. Cont. -
0.9759 0.8338 1.667 0.8667
DISTANCE EXPER <0.0001 Extremely significant 59.245 66.036 363 400 8.488
CONT. <0.0001 Extremely significant 57.947 59.408 349 384 5.857
COMP. 0.7888 Not significant Exp. Cont. Exp. Cont. 0.2704
16.882 23.146 37 35

DISCUSSION as a form of manual therapy along with

OA knee is a cause of disability and TENS and exercise program was more
is responsible for deterioration of quality of effective for decreasing pain in over a three
life and functional capacity. (11) The current days period in patients with OA knee.
study was undertaken to assess the efficacy The mechanism(s) by which the
of Mulligan’s MWM techniques on pain in MWM exerts its ameliorative effects in
knee osteoarthritis. clinical practice remains somewhat of an
The study revealed that both enigma. It has been proposed that the MWM
treatment groups obtained successful treatment technique produces its effects by
outcomes, as measured by significant correcting positional faults of joints.(12)
reductions in VAS (p < 0.05) and Positional fault theory (Mulligan, 1995) (13)
improvement in 6-minute walk test distance says that joint alignment alteration occurs
over a 3 days period. However, the post due to injury or chronic/poor
treatment VAS in both the groups was arthokinematics which causes inconsistent
equal, that is, there was significant reduction bony congruencies that occur after strain or
in VAS. Unlike the post treatment distance injury. This results in movement restrictions
covered in the group which received & pain. MWM relocates joint in correct
Mulligan’s MWM along with conventional alignment therefore immediate pain relief
treatment for 3 days were markedly better occurs. This explains hypothetical
than the post treatment distance seen in mechanism for first successful Mulligan
conventional group. MWM. (12)
Patients in the experimental group The difference between groups is
appeared to be more satisfied with the likely attributable to the additional effects of
overall outcome of their rehabilitative clinical intervention consisting of
treatment than patients in the control group. Mulligan’s MWM techniques.
These results suggest that clinical
intervention consisting of Mulligan’s MWM

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Techniques in Knee Osteoarthritis Pain

PRE-EXISTING BELIEFS: SPECIFICITY OF APPLICATION.

INJURY & DAMAGE. APPLIED FORCE:
FEAR-AVOIDANCE. • DIRECTION
PAINLESS
EXPECTATION: • LEVEL
PLACEBO • LOCALIZATION
TREATMENTS
PRACTITIONER.

TRANSIENT BONY NON-OPIOD

DISPLACEMENT HYPOALGESIA

BIOMECHANIC PARADIGM NEURO-SCIENCE PARADIGM

 RE-ALLIGNMENT OF BONY  SYMPATHETIC NERVOUS SYSTEM
RELATIONSHIP ACTIVATION.
(POSITIONAL FAULT CORRECTION)  SENSORI-MOTOR STIMULATION.
 PAIN-GATE MECHANISM.

The rationale for the mobilization was statistically significant reduction in

approach to OA is that the reduced pain and VAS (pain) in the experimental group.
stiffness associated with mobilization However, there was marked improvement in
intervention allows patients to participate the distance covered post treatment in the
more successfully in the exercise program experimental group. Hence, with this
and activities of daily living. outcome taken into consideration,
Pollard H, Chiro GD et al (14) studied Mulligan’s MWM techniques can be
the effect of a manual therapy knee protocol implemented as an adjunct to the treatment
(MWM) on osteoarthritis knee pain. They in patients with OA knee pain.
investigated that, a short-term manual
therapy knee protocol significantly reduced Limitations:
pain suffered by participants with There is no long term follow-up for the
osteoarthritis knee pain and resulted in treatment groups in order to check them
improvements in self-reported knee function magnitude of improvement. The study was
immediately after the end of the 2 weeks conducted in a small group of population so
treatment period. Dimitrova E et al (15) cannot be generalised to whole population.
studied on efficacy of mobilizations with Hence a larger group is required.
movement in patients with knee
osteoarthritis; He concluded that, MWM is ACKNOWLEDGEMENT
feasible and efficacious in reducing pain and First and foremost, authors thank the almighty
improving function in individuals with knee God for bestowing on us his blessings for
osteoarthritis. completing our study successfully. We express
our sincere gratitude to our parents who always
wanted us to excel in our profession, for their
CONCLUSION AND CLINICAL untiring support, blessings and encouragement
IMPLICATIONS provided to us during all stages of our study.
The study concluded that Mulligan’s Authors are equally grateful to Dr. Ketaki V
Mobilisation with Movement (MWM) Kulkarni, Assistant Professor MIMER Medical
techniques is effective in reducing pain in College, Talegaon-D for her continuous support,
patients with knee osteoarthritis. The study able guidance throughout the course of this
also reveals that there was clinically study. Last but not the least we would like to
significant reduction in pain in both control thank all the subjects of our study, without
as well as experimental groups but there whom, this study would have not been possible.

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Techniques in Knee Osteoarthritis Pain

with Tibiofemoral Osteoarthritis.

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How to cite this article: Kulkarni AV, Kamat MM. A study to determine the effectiveness of
mobilization with movement techniques in knee osteoarthritis pain. Int J Health Sci Res. 2017;
7(4):258-264.

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