|Year : 2018 | Volume
| Issue : 1 | Page : 26-30
Comparison of efficacy of mulligan's mobilization with movement with maitland mobilization along with conventional therapy in the patients with knee osteoarthritis: A randomized clinical trial
Aniqa Kiran1, Muhammad Junaid Ijaz1, Muhammad Mustafa Qamar2, Ayesha Basharat2, Akhtar Rasul2, Waqas Ahmed2
1 Department of Physiotherapy, Mayo Hospital, KEMU, Lahore, Pakistan
2 Department of Physiotherapy, Sargodha Medical College, UOS, Sargodha, Pakistan
|Date of Submission||23-Feb-2018|
|Date of Acceptance||21-Mar-2018|
|Date of Web Publication||05-Apr-2018|
Dr. Muhammad Mustafa Qamar
Department of Physiotherapy, Sargodha Medical College, UOS, Sargodha
Source of Support: None, Conflict of Interest: None
Objective: The objective of this study is to determine the outcome and efficacy of Mulligan's mobilization with movement (MWM) with Maitland mobilization along with conventional therapy in the patients with knee osteoarthritis (OA). Materials and Methods: A randomized controlled trial study was performed at the Department of Physiotherapy, Mayo Hospital, Lahore, Pakistan. Sixty-two patients were selected for the study. MWM was introduced in half of the patients and Maitland mobilizations in the second half for 2 weeks. The goniometry, visual analog scale (VAS), knee range of motion (ROM), and Western Ontario McMaster OA (WOMAC) Index for knee OA were the assessment tools used to assess all patients before and after 2 weeks of intervention. Paired sample t-test was used for analysis of results. Results: The mean pre- and postdifferences in MWM group were 4.06 ± 0.99, 10.19 ± 3.87, and 19.41 ± 7.58 for VAS, ROM flexion, and WOMAC Index, respectively, while the pre- and postmean difference values for Maitland mobilization group were 3.355 ± 1.05, 10.19 ± 5.5, and 12.28 ± 7.029 for VAS, ROM flexion, and WOMAC Index, respectively. The mean differences of both treatment interventions individually were significant and showed that both were clinically effective in treating the patients of knee OA. Conclusion: It was concluded that patients in both groups showed improvement in pain, ROM, and functions.
Keywords: Knee osteoarthritis, Maitland mobilization, Mulligan's mobilization with movement
|How to cite this article:|
Kiran A, Ijaz MJ, Qamar MM, Basharat A, Rasul A, Ahmed W. Comparison of efficacy of mulligan's mobilization with movement with maitland mobilization along with conventional therapy in the patients with knee osteoarthritis: A randomized clinical trial. Libyan Int Med Univ J 2018;3:26-30
|How to cite this URL:|
Kiran A, Ijaz MJ, Qamar MM, Basharat A, Rasul A, Ahmed W. Comparison of efficacy of mulligan's mobilization with movement with maitland mobilization along with conventional therapy in the patients with knee osteoarthritis: A randomized clinical trial. Libyan Int Med Univ J [serial online] 2018 [cited 2019 Jan 22];3:26-30. Available from: http://journal.limu.edu.ly/text.asp?2018/3/1/26/229382
| Introduction|| |
Osteoarthritis (OA) is “A diverse group of different conditions leading toward joint indications and signs which are coupled with the imperfect veracity of articular cartilage as well as other changes along the margins of bone underlying in affected joint.” The degeneration occurs due to disarrangement in the usual process of repair of a joint. When the process breaks the synchronicity, there is slow deterioration of the articular cartilage. As a result, the biomechanical influences on the joints are also changed due to loss of normal joint line of gravity. This ultimately leads toward symptomatic changes which are a focal loss of the cartilage covering the articular ends; loss of normal joint space requires for smooth grating, osteophyte formation in joint, and remolding of bone on peripheral areas and along the articular sides. In the elder patients of OA, weakening of the mobility patterns and resulting pain and swelling more commonly occurs in the joints of the lower limb preferably the knee , OA and its radiological associates track a typical course as the disease advancements occur and clinically useful staging system can be devised out of it. The Western Ontario McMaster OA (WOMAC) Index reflects the clinical severity of the disease. The WOMAC Index permits an effective, reproducible assessment of the degree of impairment by pain and loss of function.
The etiology of knee OA is vast. Many factors play multiple roles, and these factors include generalized constitutional factors such as the aging of a person, sex of the person, obesity and lifestyle, the genetics and heredity, the reproductive variables, and facts of status or economic backgrounds. OA is certainly most commonly found form of arthritis. Because of the prevalence of OA and due to the recurrent incapacity that goes along with disease in the knee, osteoarthritic patients face more trouble in activities such as climbing stairs, rising from a chair, in walking than any other disease by far. Some latest evaluations suggested that the overall expenses for the treatment of arthritis usually exceed 2% of the gross domestic product which is quite an amount.
The management of OA knee is a multidisciplinary approach mainly focusing on the lifestyle changes of population and education of postural alignments, the medicines which provide symptomatic relief, surgery either minor or major, and any alternative therapy or complementary therapies. Physiotherapy treatment for knee OA includes use of thermal agents, traditional Chinese acupuncture, tai chi programs, taping, transcutaneous electrical nerve stimulation, manual therapy, aquatic exercises, orthoses in the form of medial or lateral insoles, and weight loss programs.
Maitland and Mulligan mobilizations are used for the treatment of OA. A crucial constituent of Mulligan's mobilization with movement (MWM) states that the pain is that factor that always needs to be decreased or reduces while the therapist applies the glide and patient moves to a least possible level. While the application of Mulligan's MWM, advanced improvements can be obtained with the help of overpressure that should be again not causing any pain in the range available.
Maitland's techniques involve applying passive and accessory oscillatory movements to the various joints for treating ache and toughness which is of mechanical nature. This technique aims to reestablish motions generally the spin motion, the gliding motion, and the rolling motion of two joint surfaces, and we usually name the grades depending on what is this amplitude of oscillatory movement. This study aims at the comparison of the effectiveness of Maitland and Mulligan's mobilization in improving the knee range of motion (ROM) and functional evaluation.
| Materials and Methods|| |
A randomized clinical trial was carried out at the Department of Physical Therapy, Mayo Hospital, Lahore. The ethical committee approved the study according to the Helsinki accord. Informed consent was obtained from each patient. Sixty-two patients suffering from knee OA were randomly assigned into two groups. Selection criteria were demonstrated in [Table 1]. The first group (n = 31) received MWM along with conservative physiotherapy and the second group (n = 31) was treated with Maitland mobilization along with conservative physiotherapy. Each group received 6 sessions of either Mulligan's MWM or Maitland mobilization during 2 weeks (3 sessions/week).
Conventional physiotherapy, which was applied in both groups, included hot pack for 10 minand quardiceps isometrics. It enables strengthening of muscles to provide proper tracking to patella and ankle pumps to restore circulation that may be low due to prolonged immobility cycles due to pain. After conventional therapy, manual mobilization techniques depending on pain were applied. Grade I, II manual therapy mobilization techniques were applied for pain, however, Grade III applied to improve ROM.
Data collection procedure
Demographic details such as name, age, gender, socioeconomic status, education level, and marital status were also included in the study.
Data collection instrument
Outcome measures used for data collection were “WOMAC” Index, and goniometer was used to measure knee ROM. Visual analog scale (VAS) was used to measure the level of pain in patients. The goniometer was used to measure ROM of the knee, and WOMAC Index was used for pain and disability.
Data were entered and analyzed through SPSS (Statistical Package for the Social Sciences, SPSS for Windows, SPSS Inc., Chicago, IL, USA), version 21.0. All qualitative variables were presented in the form of frequency tables and percentages. All quantitative variables were presented in the form of mean ± standard deviation (SD) along with its range (maximum-minimum). Paired sample t-test and independent sampling test were used for result analysis. P < 0.05 was taken as significant.
| Results|| |
Of the 62 patients enrolled in this study, 48.4% were males and 51.6% were females. The mean age of patients was 47.47 ± 0.61 (range from 40 to 60 years).
Visual analog scale measurement before and after treatment
The mean paired difference in intensity of pain at VAS in MWM group after 2 weeks was 4.06 ± 0.99, whereas that of Maitland mobilization group was 3.35 ± 1.050. There was a highly significant difference between pre- and posttreatment value of both types of treatments [Table 2].
|Table 2: Visual analog scale, Western Ontario McMaster Osteoarthritis Index and range of motion in Mulligan's mobilization with movement and Maitland group at baseline and posttreatments|
Click here to view
Comparison of change in Western Ontario McMaster Osteoarthritis Index
At the end of the 2nd week, the mean paired difference on WOMAC Index in MWM group was 19.41 ± 7.58, whereas that of Maitland mobilization group was 12.28 ± 7.02. There was a highly significant difference between pre- and posttreatment value of both types of treatments [Table 2].
Comparison of change in range of motion
The mean paired difference in knee flexion after 2 weeks of treatment in MWM was 10.19 ± 3.87, while in Maitland mobilization group, mean paired difference was 10.19 ± 5.51. For knee extension, the mean paired difference of MWM group was 5.45 ± 1.29 and that of Maitland mobilization group was 2.13 ± 1.85 [Table 2].
| Discussion|| |
OA is common in people who are obese, overweight, involved in heavy weight lifting and moving around, laborers and people living in areas where they have to climb stairs daily, etc. Physiotherapy treatment has a big role in the treatment of pain that results in a functional loss. Physiotherapy treatment for knee OA includes use of thermal agents, traditional Chinese acupuncture, tai chi programs, taping, transcutaneous electrical nerve stimulation, manual therapy, aquatic exercises, orthoses in the form of medial or lateral insoles, and weight loss programs. Mobilization is commonly used treatment for knee pain management and to improve ROM. The aim of current study was to compare the effectiveness of Maitland and Mulligan's mobilization in improving the knee ROM and functional evaluation.
The results of this study showed that MWM was more effective in the treatment of knee OA in term of decreasing pain and increasing ROM. It was observed that patients who were treated with MWM technique along with conventional physiotherapy, their pain, functional disability, and knee ROM ranges improved greatly as compared to those who were treated with corrective Maitland mobilization technique along with conventional physiotherapy.
The results of this study were consistent with previous studies. A study has demonstrated that MWM is efficacious and feasible in knee OA. The result of this study is also consistent with studies involving mobilization at other joints. A study carried out on frozen shoulder suggests that Mulligan technique was more effective then Maitland mobilization. The MWM concept has the potential to produce immediate and long-lasting effects, even in patients that had not previously responded to other treatment for an extended period of time.
The limitation of this study
The sample size was not large enough to generalize the results. Moreover, the study was carried out for short duration with a follow-up for 2 weeks only. Future research is required to determine long-lasting effects of the treatment by taking follow-up assessments for a longer duration.
| Conclusion|| |
This study concluded that both Mulligan and Maitland techniques were effective for management of patients with knee OA.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, et al.
Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and therapeutic criteria committee of the American rheumatism association. Arthritis Rheum 1986;29:1039-49.
Banks K, Hengeveld E. Maitland's Clinical Companion: An Essential Guide for Students. Elsevier Health Sciences; 2009.
Corti MC, Rigon C. Epidemiology of osteoarthritis: Prevalence, risk factors and functional impact. Aging Clin Exp Res 2003;15:359-63.
Panush RS, Lane NE. Exercise and the musculoskeletal system. Baillieres Clin Rheumatol 1994;8:79-102.
Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. Validation study of WOMAC: A health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 1988;15:1833-40.
Ledingham J, Regan M, Jones A, Doherty M. Radiographic patterns and associations of osteoarthritis of the knee in patients referred to hospital. Ann Rheum Dis 1993;52:520-6.
Guccione AA, Felson DT, Anderson JJ, Anthony JM, Zhang Y, Wilson PW, et al.
The effects of specific medical conditions on the functional limitations of elders in the Framingham study. Am J Public Health 1994;84:351-8.
Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, et al.
American college of rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken) 2012;64:465-74.
Hing W, Bigelow R, Bremner T. Mulligan's mobilization with movement: A systematic review. J Man Manip Ther 2009;17:39E-66E.
Kirkley A, Webster-Bogaert S, Litchfield R, Amendola A, MacDonald S, McCalden R, et al.
The effect of bracing on varus gonarthrosis. J Bone Joint Surg Am 1999;81:539-48.
Raudenbush D, Sumner DR, Panchal PM, Muehleman C. Subchondral thickness does not vary with cartilage degeneration on the metatarsal. J Am Podiatr Med Assoc 2003;93:104-10.
Kazmi M, Devi J, Yamin K, Kumar S. Comparative study on the efficacy of Maitland technique (Grade IV) and mulligan technique, in the treatment of frozen shoulder. Pak J Rehabil 2013;2.
Lane LB, Bullough PG. Age-related changes in the thickness of the calcified zone and the number of tidemarks in adult human articular cartilage. J Bone Joint Surg Br 1980;62:372-5.
[Table 1], [Table 2]