Mulligan's mobilization-with-movement, positional faults and pain relief: Current concepts from a critical review of literature

EMMATKA trial: the effects of mobilization with movement following total knee arthroplasty in women: a single-blind randomized controlled trial

BACKGROUND

Mobilization with Movement (MWM) is an examination and management approach for correcting the intra-articular translational and rotational movements to facilitate the active physiological movement. The study aimed to determine the effects of MWM on Total Knee Arthroplasty (TKA) using a randomized controlled trial (RCT) design.

METHODS

The trial is registered (ISRCTN ref: 13,028,992). A blinded examiner assessed patients at pre-surgical (before TKA), post-surgical (at 3-weeks post-TKA), 6-weeks and 6-months post-TKA. Participants were randomly assigned to receive MWM (six sessions, between 3 and 6 weeks post-TKA) plus standard rehabilitation (intervention group) or standard rehabilitation alone (control group) of outpatient rehabilitation including range of motion and strengthening exercises, cycling, gait and stair training. Outcome measures were range of motion (goniometer), pain (visual analogue scales), physical function (Timed Up and Go (TUG)), a 15-m walk test, and health status (Western Ontario and McMaster (WOMAC) Osteoarthritis Index). Change in outcome measures from post-surgical to 6 weeks and 6 months post-TKA were compared between groups. The primary outcome was change in knee flexion range of motion at 6 weeks.

RESULTS

84 women scheduled for TKA were randomly allocated to intervention (n = 42) or control (n = 42); mean ± (SD) age 65.1 ± 7.4 and 66.8 ± 8.9 years, respectively. The intervention group demonstrated significantly greater increase in knee flexion at both 6 weeks (median (IQR) + 10.000 (20.000) compared with + 2.500 (6.250) in the control group) and 6 months (+ 12.500 (15.000) and + 5.000 (10.000) respectively) (both p < 0.05). There were no differences between groups in secondary outcomes.

CONCLUSION

Introducing MWM for TKA rehabilitation has greater benefits for women post-TKA in increasing knee joint flexion range of motion than the standard rehabilitation programs in the short and medium-term. This evidence-based approach offers a promising adjunctive intervention for optimizing recovery and rehabilitation process following TKA in women. Clinicians should consider including MWM approach in post-TKA rehabilitation programs.

LEVEL OF EVIDENCE

I.

Effects of instrument-assisted manipulation and mobilization with movement in chronic non-specific low back pain: A randomized controlled trial

BACKGROUND

Low back pain is the third most reported complaint after headache and chronic fatigue, and more than 80% of the population will experience low back pain at some point in their lives.

OBJECTIVE

We conducted this study to investigate the effects of instrument-assisted manipulation (IAM) and mobilization with movement (MWM) on joint range of motion (ROM), pain, proprioception, endurance, back awareness, and disability in individuals with chronic nonspecific low back pain (CNSLBP).

METHODS

51 participants with CNSLBP were randomized to one of three groups: (1) MWM; (2) IAM; or (3) core exercise. Joint ROM, pain, proprioception, endurance, back awareness, and disability were assessed at baseline, week 2 and 6.

RESULTS

Joint ROM and activity pain scores increased in all groups (p < 0.05). Both activity and resting pain improved in the MWM group (p < 0.001; p = 0.004). Most measures related to proprioception improved in the MWM group (p = 0.005; p = 0.016; p = 0.016). Endurance increased in all groups, but the flexor endurance increase was higher in the MWM group (p < 0.05). Back awareness and disability increased in all groups (p < 0.05), but disability increased most in MWM group (p = 0.022).

CONCLUSIONS

MWM could effectively improve pain, proprioception, endurance, and disability.

The Clinical Significance of Mulligan's Mobilization with Movement in Shoulder Pathologies: A Systematic Review and Meta-Analysis

Background: Mulligan's mobilization with movement (MWM) is a manual therapy technique designed to address musculoskeletal pain and joint mobility. Despite immediate reported improvements by patients, the clinical significance of MWM compared with other interventions remains uncertain. Objective: To assess the clinical effectiveness of MWM for shoulder pathologies compared with other treatment methods. Methods: The databases PubMed, Web of Science, Cochrane Library, Scopus, and the Physiotherapy Evidence Database (PEDro) were searched up to June 2024. Inclusion criteria were limited to randomized controlled trials published in English and Turkish languages, focusing on the MWM technique for shoulder pathologies. Two independent reviewers evaluated methodological quality based on the PEDro scale. Outcome data were analyzed for pain, function, and range of motion (ROM) using SPSS Statistics 29.0. Results: Twenty-seven studies (1157 participants) were included. MWM demonstrated statistical superiority in function (MD = -11.24, 95% CI: [-18.33, -4.16], p = 001) and shoulder flexion and abduction ROM compared with other mobilization techniques. There was a significant MD in pain intensity, which was -1.55 cm (95% CI: [-2.60, -0.51], p = 0.00), with high heterogeneity (I2 = 93%), favoring MWM in comparison with control group. MWM was significantly better for shoulder abduction ROM in comparison with physical therapy interventions (MD = -14.44, 95% CI: [1.98, 26.90], p = 0.02) with high heterogeneity (I2 = 90%) and control group (SMD = 56.67, 95% CI: [7.71, 111.63], p = 0.02) with high heterogeneity (I2 = 96%). However, clinical significance was not consistently achieved. Conclusions: Although some statistical significance was found when comparing MWM with other her treatment methods, it was observed that most of the statistically significant data did not reach clinical significance. Upon closer examination, outcome measures that showed clinical significance, either the interventions in the comparison group were inadequate, not evidence-based, or the improvements within the group were not logical.

Efficacy of telerehabilitation for total knee arthroplasty: a meta-analysis based on randomized controlled trials combined with a bibliometric study

BACKGROUND

Physical therapy (PT) is widely employed in osteoarthritis (OA). This study aimed to explore the research development of PT for OA and to identify the emerging treatment, and verify its efficacy.

MATERIALS AND METHODS

The Web of Science Core Collection was used to conduct the bibliometric analysis. Furthermore, a meta-analysis based on randomized controlled trials (RCTs) was performed to evaluate the identified treatment's efficacy.

RESULTS

A total of 3,142 articles were retrieved from the Web of Science Core Collection, and the annual publication volume shows an exponential growth trend (R2 = 0.9515). Keyword analysis demonstrated that telerehabilitation (TELE) in total knee arthroplasty (TKA) has become a hotspot since 2020. To assess the effectiveness of TELE, we conducted a meta-analysis of 25 RCTs including 4402 patients. In the total analysis, the TELE group exhibited superior outcomes compared to the traditional face-to-face (FTF) rehabilitation group in terms of pain (standardized mean differences [SMD]: - 0.15, 95% CI - 0.27 to - 0.04, P = 0.01), passive flexion (MD: 2.60, 95% CI 0.77 to 4.44, P = 0.005), quadriceps muscle strength (SMD: 0.32, 95% CI 0.04 to 0.61, P = 0.03), and cost (SMD: - 0.50, 95% CI - 0.88 to - 0.12, P = 0.009). The subgroup analysis also demonstrated that the fixed equipment-assisted telerehabilitation (FEAT) group and the mobile device-assisted telerehabilitation (MDAT) group were superior to the FTF group. Moreover, patients in the FEAT group exhibited better prognoses than those in the MDAT group. No significant differences in the other measured outcome were observed.

CONCLUSION

Telerehabilitation proved to be more effective than traditional FTF rehabilitation in patients who underwent TKA. Further research is warranted to compare the different TELE interventions to establish the best protocols and timing for interventions.

Efficacy of Mulligan thoracic sustained natural apophyseal glides on sub-acromial pain in patients with sub-acromial impingement syndrome: a single-blinded randomized controlled trial

PURPOSE

To investigate the effects of Mulligan thoracic sustained natural apophyseal glides (SNAGS) techniques and traditional exercises on pain, shoulder function, size of sub-acromial space, and shoulder joint range in patients with sub-acromial impingement syndrome.

METHODS

Seventy-four patients with sub-acromial impingement syndrome (25 to 40 years) joined this research and were allocated randomly into two equal groups; experimental group A (Mulligan SNAGS and exercise) and control group B (exercise only). All patients were assessed by visual analogue scale (VAS) for pain intensity, Shoulder Pain and Disability Index (SPADI) for shoulder function, plain x-ray for the size of sub-acromial space, and goniometer for shoulder range of motion (ROM). The measurements were performed at two intervals (baseline and after four weeks of intervention).

RESULTS

After 4 weeks of intervention, there were statistically significant differences between groups, in favor of Mulligan SNAGS, on sub acromial space size, pain intensity, shoulder function, and shoulder joint range of motion (p < 0.05). In within-group analysis, there were also statistically significant differences between pre- and post-treatment in all measured variables (p < 0.05).

CONCLUSION

Mulligan thoracic spine (SNAGS) mobilization into extension and traditional exercises improve sub acromial space size, pain intensity, shoulder function, and shoulder joint range of motion in patients with sub acromial impingement syndrome. It is recommended to mobilize the thoracic spine by mulligan SNAGS in the treatment of sub-acromial impingement syndrome.

Assessing the Impact of Maitland Mobilization Combined With a Conventional Physiotherapy Regimen Using the Visual Analog Scale and Disability of the Arm, Shoulder and Hand Scale in Diabetic Frozen Shoulder With Moderate Tissue Irritability Level

Background Patients suffering from diabetic frozen shoulder face particular challenges, including limited shoulder motion and excruciating pain. Although traditional physiotherapy methods are commonly used, it is important to investigate the effectiveness of combining Maitland mobilization with traditional treatments, especially considering patients' tissue irritability levels as often patients cannot tolerate mobilization and exercises due to tissue irritability. This study aimed to investigate the impact of Maitland mobilization combined with a conventional physiotherapy regimen on pain and functional ability using the Visual Analog Scale (VAS) and Disability of the Arm, Shoulder and Hand (DASH) scales in diabetic patients suffering from a frozen shoulder with moderate tissue irritability levels. Methodology A total of 30 diabetic patients suffering from frozen shoulders with moderate irritability levels were assigned to two groups. Group A was administered conventional physiotherapy which consisted of hot moist packs, therapeutic ultrasounds, and exercises. Group B received conventional therapy with Maitland mobilization. The treatment lasted for six weeks with four sessions per week. Pre- and post-treatment pain and disability were assessed using the VAS and DASH scales. Results Post-treatment Groups A and B showed significant improvements. In Group A, the mean VAS score reduced from 4.97 ± 0.26 to 4.00 ± 0.19 (p < 0.001), while Group B showed a greater reduction from 5.00 ± 0.21 to 2.71 ± 0.13 (p < 0.001). Both groups showed an improvement in DASH scores, with the DASH score decreasing from 27.17 ± 2.37 to 21.89 ± 1.89 in Group A (p < 0.001). Group B showed more significant improvement from 27.23 ± 1.73 to 15.12 ± 0.78 (p < 0.001). Intergroup analysis between both groups showed significantly better outcomes in Group B in both VAS and DASH scores (p < 0.001). Conclusions Maitland mobilization with conventional physiotherapy significantly decreases pain and improves functional recovery in diabetic patients suffering from frozen shoulders with moderate tissue irritability levels.

Comparison of muscle energy technique and mobilization with movement to reduce pain and improve functional status in subjects with anterior innominate ilio-sacral dysfunction

OBJECTIVE

This study aimed to compare Muscle energy technique (METs) and Mobilization with movement (MWM) for pain reduction and improving functional status in subjects with anterior innominate iliosacral dysfunction.

METHODOLOGY

Thirty-six patients with anterior innominate iliosacral dysfunction were randomly assigned to both groups. Numeric Pain Rating Scale (NPRS) and Modified Oswestry Disability Index (MODI) were used to measure pain and functional disability. Four weeks of treatment sessions were given to each participant.

RESULTS

The findings of this study have revealed that statistically, differences were present within and between two groups (p-value <0.05) in the Numeric Pain Rating Score and Modified Oswestry Disability Index. After 4 weeks of treatment, pain intensity decreased and functional ability increased to a greater extent in the MET group, with a mean value of 3.05 ± 0.96 for pain and 23.82 ± 4.39 for modified Oswestry index as compared to the MWM group with a mean value of 4.58 ± 1.06 for pain and 30.29 ± 5.89 for modified Oswestry index in mobilization with movement group.

CONCLUSION

This study concluded that both Muscle Energy Technique and Mobilization with Movement techniques are effective in reducing pain and improving functional ability in patients with Anterior Innominate Iliosacral dysfunction. But when both groups were compared with each other Muscle Energy Techniques were more effective than Mobilization with Movement.

Crushing Consequences: A Case Report on the Rehabilitation of a Middle Phalangeal Fracture in an Industrial Incident

Hand injuries, particularly fractures involving the phalanges and metacarpals, are common occurrences in various settings, including industrial environments. Prompt and effective management of these injuries is crucial to minimize long-term disability and facilitate return to work. This case report focuses on the rehabilitation of a middle phalangeal fracture in an industrial worker following Kirschner wire (K-wire) fixation. The patient, a 24-year-old male, sustained the injury while operating an electric stamping machine. Emergency surgery was performed to stabilize the fracture, and subsequent physiotherapy was initiated due to persistent difficulties in hand function. The rehabilitation protocol aimed to address pain, improve range of motion, and enhance grip strength through passive range of motion exercises, movement with mobilization techniques, blocking exercises, and grip strengthening exercises. Mulligan's mobilization with movement (MWM) concept was incorporated to facilitate rapid pain relief and movement restoration. Follow-up assessments after four weeks of rehabilitation revealed significant improvements in pain levels, range of motion, strength, and overall quality of life. The case underscores the importance of timely intervention and comprehensive rehabilitation strategies in managing traumatic hand injuries in industrial settings, aiming to optimize treatment outcomes and promote successful return to work.

The effect of mulligan mobilization technique application in addition to conventional physiotherapy on pain and joint range of motion in people with neck pain

BACKGROUND

To evaluate the effect of the Mulligan mobilization technique on pain intensity and range of motion in individuals with neck pain.

METHODS

Forty individuals with mechanical neck pain were enrolled in the study. The patients were randomly divided into 2 groups and a total of 10 sessions of treatment were administered to all 2 groups for 2 weeks, 5 days a week. Mulligan mobilization technique, electrophysical agents, active range of motion, and stretching exercises were carried out in the Mulligan group. In contrast, only electrophysical agents and exercises were applied to the conventional physiotherapy group. Range of motion (ROM) of the neck, Visual Analog Scale (VAS), Neck Pain and Disability Scale (NPDS), and Short-Form 36 Health Survey (SF-36) were used for evaluation.

RESULTS

Statistical analyses were done to compare the amounts at the baseline and immediately after treatment. Statistically significant improvements were found in the post-treatment ROM, VAS, NPDS values in both groups (p < 0.05). When the differences were compared, the results of the Mulligan group were significantly better than the conventional physiotherapy group (p < 0.05). There was no significant difference between the groups in terms of SF-36 parameters (p > 0.05).

CONCLUSIONS

This study showed that the Mulligan mobilization technique plus conventional physiotherapy is more effective than conventional physiotherapy in increasing joint range of motion, reducing pain, and reducing neck disability.

TRIAL REGISTRATON

ClinicalTrials.gov (NCT05074576).

Effect of Mobilization With Movement on the Glenohumeral Joint Positional Fault in Subacromial Impingement

Introduction Subacromial impingement (SAI) is a prevalent shoulder condition characterized by mechanical compression within the subacromial region. It presents with symptoms like shoulder pain and restricted motion, impacting a significant portion of the population. Neer's classification delineates three progressive stages of SAI, ranging from bursa edema to chronic rotator cuff tears. The etiology involves intrinsic and extrinsic factors, leading to altered kinematics and impingement. The study aims to determine the effect of mobilization with movement (MWM) on the glenohumeral joint positional fault in patients with SAI. Materials and methods The study comprised 80 participants diagnosed with SAI, selected based on the inclusion and exclusion criteria, and randomly divided into two groups, each consisting of 40 subjects. Group A received conventional therapy, while Group B received MWM in addition to conventional therapy. Treatment sessions, lasting 45 minutes, were administered five times weekly for four weeks. Pre- and post-treatment assessments included the visual analog scale (VAS), range of motion (ROM), acromion humeral distance (AHD), and acromion tuberosity index (ATI). Results The results demonstrated that there was an extremely significant improvement in VAS, shoulder ROM, and ADH in both groups, with a p-value of 0.0001, except for the ATI, which showed significant improvement in Group B with a p-value of 0.0001 compared to Group A. Conclusions Based on statistical analysis, the study found that MWM significantly improved joint positioning fault and has been beneficial in reducing pain and improving ROM.

Adverse Events Reported in Trials Assessing Manual Therapy to the Extremities: A Systematic Review

Objective: This review aimed to describe the quality and comprehensiveness of adverse event (AE) reporting in clinical trials incorporating manual therapy (MT) as an intervention for extremity conditions using the Consolidated Standards of Reporting Trials (CONSORT)-Harms extension as the benchmark. The secondary aim was to determine whether the quality of AE reporting improved after the availability of the CONSORT reporting checklist. Design: Systematic review. Methods: A literature search was conducted using multiple databases to identify trials where MT was used to treat extremity conditions. Studies that reported AEs were identified and evaluated using the CONSORT-Harms extension. The frequency of trials reporting study AEs before and after the publication of the updated 2010 CONSORT statement was calculated, along with the categorization of how study AEs were reported. Results: Of the 55,539 studies initially identified, 220 trials met all inclusion criteria. Eighty trials (36.4%) reported AE occurrence. None of the studies that reported AEs adhered to all 10 criteria proposed by the 2010 CONSORT-Harms extension. The most commonly reported criterion was number four, which clarified how AE-related information was collected (30% of trials). The least reported criterion was number six, which describes the participant withdrawals for each arm due to AEs and the experience with the allocated treatment (1.3% of trials). The nomenclature used to describe AEs varied substantially. Fifty-nine of 76 trials (33.3%) were published after the updated CONSORT Harms-checklist was available, compared to 21 of 44 trials (46.7%) published before it was available. Conclusion: Reporting of AEs in trials investigating MT for extremity conditions is poor. Every included trial lacked adherence to all 10 criteria proposed by the CONSORT-Harms Extension. The quality and comprehensiveness of AE reporting did not improve after the most recent CONSORT update recommending AE reporting. Clinicians must obtain informed consent before performing any intervention, including MT, which requires disclosing potential risks, which could be better known with improved tracking, analyzing, and reporting of AEs. The authors recommend improved adherence to best practices for adequately tracking and reporting AEs in future MT trials.

The effects of Core Stability Exercises and Mulligan's mobilization with movement techniques on sacroiliac joint dysfunction

Purpose

Sacroiliac joint dysfunction (SIJD), while being the primary contributor to low back pain, is still disregarded and treated as low back pain. Mulligan's Mobilization with Movement (MWM) Techniques and Core Stability Exercises (CSE) are often used to treat low back pain. There is not much evidence that it is effective in SIJD. To evaluate the effectiveness of CSE coupled with MWM (CSE + MWM) in the treatment of SIJD.

Methods

39 patients with SIJD were recruited and randomly divided into distinct groups as follows: control group (n = 13), CSE group (n = 13) and CSE + MWM group (n = 13). The Numerical Pain Rating Scale (NPRS), the Roland Morris Disability Questionnaire (RMDQ), the Range of Motion (ROM), the Pressure Pain Threshold (PPT) and the pelvic tilt angle asymmetry ratio in the sagittal plane (PTAR) were used to gauge the intervention's success both before (M0) and after (M1) it. All experimental data were statistically analyzed.

Results

The SIJ-related pain metric significantly decreased in both the CSE + MWM group and the CSE group between M0 and M1, as determined by the NPRS and RMDQ. Between M0 and M1, The CSE group's left axial rotation ROM and lumbar flexion ROM were significantly decreased. The CSE + MWM group's extension ROM and left lateral flexion ROM both significantly increased between M0 and M1. In the difference variable (M1-M0), the CSE + MWM group substantially outperformed control group in the left lateral flexion ROM and outperformed the CSE group in the left axial rotation ROM.

Conclusion

In individuals with SIJD, CSE + MWM is beneficial in lowering pain, disability, and function. Treatment with CSE and MWM approaches for SIJ appears to boost this efficacy.

Management of Low Back Pain With Concurrent Hamstring Tightness: A Case Report Highlighting the Efficacy of Proprioceptive Neuromuscular Facilitation, Mulligan's Two-Leg Rotation Technique, and Exercise Regimen

Low back pain (LBP) is a prevalent musculoskeletal issue characterized by discomfort in the lumbosacral region. LBP localized between the 12th thoracic vertebra and inferior gluteal folds is common and often lacks a clear etiology. Various factors contribute to LBP, including increased lumbar lordosis, diminished abdominal muscle strength, reduced back extensor muscle endurance, and flexibility limitations in the back extensors, iliopsoas, and hamstrings. Treatment modalities for LBP encompass surgical intervention, pharmacotherapy, lumbar injections, psychotherapy, chiropractic care, and physiotherapy, with manual therapy being a prominent approach. Physiotherapists employ a spectrum of manual techniques, including mobilization, manipulation, and massage, to address LBP. Hamstring flexibility plays a pivotal role in spinal mechanics, and tight or shortened hamstrings can exacerbate LBP. Mulligan's techniques, notably the two-leg rotation (TLR) technique, are valuable interventions for addressing hamstring tightness in cases of LBP. Proprioceptive neuromuscular facilitation (PNF) was also used to manage pain and improve strength. This case report outlines the management of a 32-year-old male presenting with LBP and hamstring tightness coupled with core muscle weakness. Through comprehensive assessment and physiotherapeutic interventions, significant improvements were observed in pain intensity, lumbar range of motion, disability, straight leg raise (SLR), and core muscle strength following a three-week physiotherapy intervention.

Effects of exercise combined with cervicothoracic spine self-mobilization on chronic non-specific neck pain

To investigate the short-term effects and differences between exercise alone and exercise combined with self-mobilization training on chronic non-specific neck pain (CNSNP). Thirty subjects who met the criteria were recruited and randomly assigned to the exercise training group, the exercise combined with cervical self-mobilization training group (ECCM), and the exercise combined with cervicothoracic self-mobilization training group (ECCTM). The exercise training group received 6 weeks of deep neck flexor under biofeedback and scapular stability training, and the other two groups received 6 weeks of cervical self-mobilization and cervicothoracic self-mobilization, respectively, in addition to exercise training. Neck pain, cervical range of motion (ROM), neck disability, strength and endurance of deep neck flexor and quality of life were assessed before and after 6 weeks of training. The study results showed that all the three training programs for 6 weeks increased the strength and endurance of deep neck flexor, increased cervical ROM, reduced pain, and improved neck function (P < 0.05). The exercise combined with self-mobilization two groups compared with only the exercise training group had better improvement in ROM of extension, lateral flexion, rotation and quality of life (P < 0.05). Compared with exercise alone and exercise combined with cervical self-mobilization training, the exercise combined with cervicothoracic self-mobilization training was the best in improving ROM of right lateral flexion (exercise training group vs ECCTM: P < 0.01, d = 1.61, ECCM vs ECCTM: P < 0.05, d = 1.14) and pain (exercise training group vs ECCTM: P < 0.05, d = 1.34, ECCM vs ECCTM: P < 0.05, d = 1.23). Deep flexor muscle and shoulder stability training can improve the endurance and strength of the deep flexor muscles of the neck and coordinate the movement patterns of the shoulder and neck. Self-mobilization techniques can promote improvements in cervical lateral flexion and rotation range of motion, alleviate neck disability and further improve quality of life. A combination of exercise and cervicothoracic self-mobilization training appears beneficial for the management of neck pain.

Efficacy of PowerBall Versus Mulligan Mobilization With Movement on Pain and Function in Patients With Lateral Epicondylitis: A Randomized Clinical Trial

Background Lateral epicondylitis (LE), sometimes referred to as tennis elbow or lateral elbow tendinopathy (LET), is one of the most common repetitive stress disorders in the elbow joint. Often, this involves the attachment of the extensor carpi radialis brevis muscle. This study's primary focus is on treating people with LE, a condition that causes repetitive movements of the upper extremities. There is currently no research on how PowerBall gadget workouts affect the function and pain of individuals with lateral epicondylitis. Exercises using the "PowerBall device," which applies both intrinsic and extrinsic pressure to the wrist, elbow, and shoulder muscles, are thought to be beneficial forms of resistance training. It has been shown that there are improvements in strength, function, range of motion (ROM), discomfort, and quality of life (QOL). On the other side, it has been demonstrated that LE patients have reduced discomfort while using Mulligan Mobilization with Movement (MMWM). Methods The 50 patients with LE were split into two groups for the single-blinded, randomized clinical study after baseline assessment and randomization: Group A was the intervention group, and Group B was the conventional group. The "PowerBall device" exercise was provided to participants in Group A, and MMWM was given to those in Group B. Both groups can benefit from basic workouts and ultrasonography by following the prescribed routine. Quantification of pain, function, grip strength, and range of motion was done at the start and finish of therapy using the Visual Analogue Scale (VAS), Patient Rated Tennis Elbow Evaluation (PRTEE), portable dynamometer, and goniometer. Results After therapy, both groups showed considerable improvement (p<0.05). Both descriptive and inferential statistics were employed in the data analysis. Numerous statistical tests were employed, such as the student's paired and unpaired t-test and the chi-square test. From a statistical and clinical perspective, Group A's outcomes were more significant. On the visual analog scale, there was a decrease in pain intensity for wrist and elbow mobility at rest (p<0.0003), activity (p<0.003), PRTEE (p<0.001), grip strength (p<0.03), and range of motion (p<0.01). Both groups' assessments after rehabilitation indicated increases in pain and function; however, Group A (0.03) benefited more and saw early success with the PowerBall device. Conclusion Findings show that a three-week program incorporating resistance training exercises mediated by a "PowerBall device" enhances upper limb performance beyond traditional exercise treatment and increases grip strength, wrist extension strength, internal and external rotator concentric and eccentric strength. The findings and observations indicate that both groups have significantly improved.

Rhizarthrosis Part II: A New Approach of Manual Therapy and Therapeutic Exercise

Rhizarthrosis (RA), also known as trapezium-metacarpal osteoarthritis, is a degenerative condition affecting the thumb's first joint, leading to functional impairment and pain. Conservative treatment options are preferred for mild to moderate cases (Eaton-Littler grades I and II) and typically encompass a range of therapeutic modalities, including manual therapy. However, for the existing manual therapy techniques, there is a lack of comparative studies for efficacy, and therapeutic exercises are often generic and non-specific to RA. This study proposes a novel treatment protocol that combines manual therapy with specific therapeutic exercises grounded in the biomechanical analysis of the trapeziometacarpal joint. The focus is on enhancing joint stability, reducing pain, and improving function. The manual therapy component includes three phases. A passive phase, during which joint distractions are applied to alleviate discomfort and improve joint mobility. An active phase that addresses joint mobility on the adduction-abduction plane, the first plane of movement to suffer limitation: the therapist facilitates the isometric adduction of the thumb, followed by an assisted abduction. A second active phase is where Mulligan's Mobilization With Movement concept is applied. This technique involves passive pain-free joint mobilization with simultaneous active finger movements, to provide additional therapeutic benefits. The therapeutic exercises component focuses on strengthening the first dorsal interosseous muscle as an abductor to reduce thumb adductor muscle activation and joint stress. Patients are encouraged to perform finger spreading exercises using a rubber band between the first and fifth fingers, emphasizing first dorsal interosseous activation and stability of the thumb. This type of muscle strengthening does not involve movement of the trapeziometacarpal joint. It is recommended to start performing 5-10 repetitions or 5 seconds of isometric contraction, repeat throughout the day, and progressively increase the load by adding a turn to the rubber band or changing it, increasing the number of repetitions bringing it to 15 and/or increase the isometric contraction time to 10/15 seconds. The proposed therapeutic rationale, informed by biomechanical insights, lays a promising foundation for further investigation. Nevertheless, empirical validation through rigorous clinical trials remains essential to substantiate its clinical utility and advance the management of RA.

Effects of device-performed and manual hip traction and vibration therapy in older adults with symptomatic hip osteoarthritis: A randomized single-blind controlled trial

BACKGROUND

Traction-and-vibration-therapy (TVT) relieves pain in participants with hip osteoarthritis. Hip TVT is usually performed manually by the physiotherapist.

OBJECTIVE

A medical device was developed to perform hip-TVT in order to investigate effects on hip disability, pain intensity, recovery of balance and functional mobility in older adults with hip osteoarthritis and also to reduce physiotherapists' workload and help standardize treatment of hip TVT.

METHODS

In a block-randomized 3-month controlled trial involving 28 older adult participants with symptomatic primary hip osteoarthritis (SPHOA), one group (n= 10) received device-performed TVT, one (n= 10) manual TVT, and one (n= 8) sham/placebo therapy. Hip disability (Harris Hip Score), pain intensity (visual-analog-scale), recovery of balance and gait (Functional Gait Assessment) and functional mobility (Timed-Up-and-Go-test) were assessed at baseline, after 3 weeks without intervention, and after 3-month intervention.

RESULTS

The Device TVT and Manual TVT groups exhibited superior outcomes compared to the Placebo group in terms of hip disability (p= 0.005 and p< 0.001, respectively), pain intensity (p= 0.002 and p< 0.001, respectively), and functional mobility (TUG) (p= 0.012 and p= 0.011, respectively). Furthermore, the recovery of balance and gait (FGA) showed a significant improvement in the Device TVT group when compared to the Placebo group (p= 0.043). The effect sizes ranged from 0.17 to 0.51, indicating moderate to large effects.

CONCLUSION

Device-performed-TVT is comparable to manual hip-TVT for reducing pain and improving mobility in older adults with SPHOA, and may be beneficial in terms of reducing physiotherapists' workload and better therapy standardization.

Immediate effect of craniocervical flexion exercise and Mulligan mobilisation in patients with mechanical neck pain - A randomised clinical trial

Background

Mechanical neck pain (MNP) is one of the most prevalent musculoskeletal pathologies in the present time. Physiotherapy management strategies comprising manual therapy and exercise therapy are routinely administered in patients with MNP.

Objective

To compare the immediate effect of craniocervical flexion (CCF) exercise and Mulligan mobilisation on pain, active cervical range of motion (CROM) and CCF test performance in patients with MNP.

Methods

This prospective, randomised, single-blinded study involved 26 patients with MNP (16 females; mean age; 31 . 12 ± 8 . 40 years) randomised to a single session of active CCF exercise (3 sets of 10 repetitions) or Mulligan mobilisation (3 sets of 6-10 repetitions). Pain intensity was measured on a numerical pain rating scale (NPRS), active CROM was measured using CROM device, and CCF test performance with surface electromyography (EMG) from bilateral sternocleidomastoid (SCM) and anterior scalene (AS) muscles recorded pre- and immediately post-intervention by an assessor blinded to the treatment groups. Mann-Whitney U test was used to analyse between groups and Wilcoxon signed rank test was used to analyse within-group significance for pain and CROM, Cochran-Mantel-Haenszel correlation test was used to analyse the CCF test performance on EMG from the bilateral SCM and AS muscles.

Results

Comparison between pre- and post-intervention readings revealed statistically significant within-group (p < 0 . 05 ) and no between-group significant difference for pain, ROM, and CCF test performance, indicating both interventions were equally effective.

Conclusion

Patients with MNP who received active CCF exercise or Mulligan mobilisation exhibited similar reduction in pain intensity and increased CROM and CCF test performance post-intervention. Surprisingly, AS surface EMG amplitudes were increased post-intervention in both groups warranting further exploration of its role in neck pain.

Promoting Flexibility and Functionality in a Surgically Managed Tibial Fracture: A Case Report on Physiotherapeutic Interventions for Postoperative Stiffness

This case study explains the complete care of a 45-year-old male patient who had a high-impact road injury that resulted in a displaced proximal tibial fracture. Substantial soft tissue damage was discovered during the initial assessment, requiring careful thought before undergoing surgery. A customized physiotherapy program was instituted after an incremental strategy involving open reduction and internal fixation. The patient made a satisfactory functional recovery, regaining nearly normal mobility and going back to daily activities within 12 weeks despite difficulties encountered during the rehabilitation phase, including temporary postoperative complications. The present study underscores the significance of a multidisciplinary approach involving Mulligan mobilization in the effective management of intricate proximal tibial fractures. It also underscores the importance of meticulous surgical intervention and organized rehabilitation protocols in enhancing patient outcomes and regaining functional abilities to improve patients' quality of life.

The effectiveness of mobilization with movement on patients with mild and moderate carpal tunnel syndrome: A single-blinded, randomized controlled study

STUDY DESIGN

Single-blinded, randomized controlled study.

INTRODUCTION

Carpal Tunnel Syndrome (CTS) causes pain and loss of function in the affected hand. The mobilization with movement (MWM) technique is a manual therapy method applied to correct joint movement limitation and to relieve pain and functional disorders.

PURPOSE OF THE STUDY

This study aimed to examine the effectiveness of MWM technique on pain, grip strength, range of motion, edema, hand reaction, nerve conduction, and functional status in patients with CTS.

METHODS

A total of 45 patients enrolled in the study. The MWM group (n = 18) completed a 4-week combined conservative physiotherapy and MWM program, whereas the control group (n = 18) received only the 4 weeks of conservative physiotherapy. Pain severity according to the numerical rating scale was used as primary outcome.

RESULTS

We found an improvement within the subjects in resting pain (MWMG:5.1 ± 3.6 vs 1.1 ± 2.4, Effect Size (ES)=1.3; CG:4.5 ± 3.3 vs 1.0 ± 2.2, ES=1.1), in activity pain (MWMG:6.5 ± 3.7 vs 1.1 ± 2.4, ES=1.5; CG:4.8 ± 3.4 vs 2.2 ± 2.3, ES=1) and in night pain (MWMG:5.9 ± 3.2 vs 1.8 ± 2.5, ES=1.2; CG:5.3 ± 4.2 vs ± 2.3 ± 3.5, ES=0.9). For between the groups, a statistical difference was found for the activity pain, Disabilities of the Arm Shoulder and Hand Questionnaire score (MWMG:52.2 ± 23.8 vs 27 ± 24.7, ES=1.3; CG:47.0 ± 24.8 vs 41.5 ± 22.1, ES=0.2), Michigan Hand Outcomes Questionnaire (MHQ-1), (MWMG:44.4 ± 23.7 vs 74.7 ± 24.5, ES=1.3; CG:44.8 ± 17.4 vs 57.4 ± 21.7, ES=0.9) and MHQ-5 (MWMG:68.8 ± 13.1 vs 82.5 ± 11.5, ES=0.9; CG:63.4 ± 26.7 vs 59.3 ± 25.8, ES=0.1) parameters in favour of MWM group.

DISCUSSION

This study showed that MWM compared to conservative physiotherapy might be more effective in reducing perceived symptoms in mild and moderate CTS patients.

CONCLUSIONS

MWM produced a small benefit to recovery of activity pain and upper extremity functionality level outcomes of patients with mild to moderate CTS when added to a traditional CTS physical therapy program.

The hip joint mobilization with movement technique improves muscle activity, postural stability, functional and dynamic balance in hemiplegia secondary to chronic stroke: a blinded randomized controlled trial

BACKGROUND

People with stroke generally experience abnormal muscle activity and develop balance disorder. Based on the important role of the proximal joints of the lower extremity in balance maintenance, hip joint mobilization with movement technique can be applied to enhance normal joint arthrokinematics. Therefore, the present study aimed to investigate the effectiveness of hip joint mobilization with movement technique on stroke patients' muscle activity and balance.

METHODS

Twenty patients aged between 35 and 65 years old with chronic stroke were randomly assigned either to an experimental group (n = 10) or to a control group (n = 10). Both groups participated in a 30-minute conventional physiotherapy session 3 times per week for 4 weeks. The experimental group received an additional 30-minute's session of hip joint mobilization with movement technique on the affected limb. The muscle activity, berg balance scale, time up and go, and postural stability were measured at baseline, 1-day and 2-week follow-up by a blinded assessor.

RESULTS

The experimental group showed a significant improvement in berg balance scale, time up and go, and postural stability (p ≤ 0.05). The rectus femoris, tibialis anterior, biceps femoris, and medial gastrocnemius muscles' activations of the affected limb during static balance test markedly changed along with the biceps femoris, erector spine, rectus femoris, and tibialis anterior muscles during dynamic balance test after hip joint mobilization with movement technique. The mean onset time of rectus abdominus, erector Spine, rectus femoris, and tibialis anterior muscles activity significantly decreased in the affected limb after hip joint mobilization with movement technique compared to the control group (p ≤ 0.05).

CONCLUSIONS

The results of the present study suggest that a combination of hip joint mobilization with movement technique and conventional physiotherapy could improve muscle activity and balance among chronic stroke patients.

TRIAL REGISTRATION NUMBER

The study was registered in the Iranian Registry of Clinical Trials (No; IRCT20200613047759N1). Registration date: 2/08/2020.

[Physiotherapeutic therapy modalities for lateral epicondyopathy]

Physiotherapy interventions can have a positive effect on the symptoms and relief of symptoms of lateral epicondylopathy (LE). However, there is currently no standard physiotherapy protocol for treating LE. Today, a multimodal treatment approach that focuses on progressive exercise therapy is recommended. While in the past, most treatment protocols were based on eccentric training, recent research shows that other forms of training can also improve pain and function in tendinopathies.

K, A. P. K, J. P, B. A. Effect of Mulligan’s mobilization combined with motor control exercises on pain functional ability and muscle activity in sacroiliac joint dysfunction

Introduction and Aim: Sacroiliac joint dysfunction accounts 15% to 30% 0f low back ache conditions, If the SIJ is hypomobile, it cannot be effectively absorbed forces causing other body parts may be overstressed causing musculoskeletal dysfunction. This study’s aim is to identify the effect of mulligan’s joint mobilization techniques, motor control exercises and, aerobic exercises on pain functional ability and muscle activity in patients with SI joint dysfunction.   Methodology: Randomized controlled study was done by selecting patients with SI joint dysfunction. 185 participants with low back pain were evaluated and out of them 116 had positive SI joint dysfunction and 95 were selected based on selection criteria.  Computer- assisted randomization was done to divide the participants into three groups. Based on that group I has got 30, group II has 33, and group III has 32. Group I participants underwent Mulligan’s mobilisation for SI joint and followed by motor control exercises, Group II participants underwent motor control exercises and Group III participants underwent Aerobic exercises. All the treatment was given for 45 minutes 5 days per week for 6 weeks of duration. This study uses functional disability, Transverses abdominis muscle endurance, and pain measured using the Oswestry disability index, pressure biofeedback and numerical pain scale respectively.   Results:  On comparing group I and group II, the group I shows a significant improvement in all the outcomes. The ANOVA results show that the p-value is < .00001. The result is significant at p <0.05.   Conclusion: This study concludes that mulligans mobilization with motor control exercises would significantly improve pain, functional disability, and transverses abdominis muscle endurance.

The cognitive-behavioral aspects of the Mulligan concept of manual therapy: A systematic review

Low back pain (LBP) is a common clinical problem imposing a prominent socio-economic burden. The purpose of this systematic review was to investigate the biopsychosocial effects of the Mulligan Concept (MC) of manual therapy (MT) when applied to patient's with LBP. Three researchers independently evaluated the literature quality, and completed a review on five online databases (Medline, Cochrane Library, Science Direct, ProQuest and Google Scholar) for articles published from January 1st 2010 to November 20th 2021, using a combination of free words, Wildcards and Medical Subject Headings (MESH) terms: " Mulligan mobilization " AND " back pain " OR " SNAGs." In total, 62 studies were selected for full-text reading, from which finally 6 studies were included in the present review. The results revealed that the studies where the MC of MT was applied to treat LBP mainly lacked concern regarding the effect that the intervention has on the cognitive and behavioural parameters. The ones that introduced measure outcomes for at least some parts of the cognitive behavioural components, showed that the MC has a positive effect, even though without a long-term follow-up assessment. This review summarized that the evidence of the MC on cognitive behavioural (CB) aspects of patients with LBP is controversial and scarce.

Effects of Mulligan Mobilization with Movement in Subacute Lateral Ankle Sprains: A Pragmatic Randomized Trial

Objective: In a pragmatic and randomized clinical trial, patients with lateral ankle sprains were assessed, under blinded conditions, for their responsiveness and improvements during Mulligan mobilization-with-movement (MWM) therapy. Methods: Overall, 51 participants with subacute lateral ankle sprains (Grade I-II) were recruited. Following an MWM screening procedure, responders were randomized to either an intervention group (MWM) or a sham group. The MWM group received inferior tibiofibular, talocrural, or cubometatarsal MWM. The treatment or sham was administered upon three sessions, each 4 days apart. Changes from baseline were measured and compared between the sessions for dorsiflexion range of motion, pain, stiffness perception, and the Y-balance test. Results: In total, 43 participants were considered responders to MWM. Using a two-way repeated-measure ANOVA, a statistical and clinically meaningful improvement in dorsiflexion range of motion was revealed in the MWM group (p = 0.004, 1rst = +1.762 cm; 3rd = +2.714 cm), whereas no improvement following the first session occurred in the sham group (p = 0.454, 1rsttrial = +1.091 cm; 3rdtrial = +1.409 cm). Pain and stiffness significantly improved, yet below the clinically meaningful level. The MWM group demonstrated a significant improvement after three sessions for the Y-balance test (p = 0.001, +8.857 cm). Conclusion: More than 80% of participants with subacute lateral ankle sprains responded well to the MWM approach. Three sessions of pragmatically determined MWM provided a significant and clinically meaningful benefit in dorsiflexion range of motion and Y-balance test performance compared to a sham treatment.

The immediate effect of sustained natural apophyseal glide on postural stability and pain in individuals presenting with flexion-dominant chronic low back pain: A randomized single-blinded placebo-controlled trial

BACKGROUND

Low back pain (LBP) is a common musculoskeletal problem, which commonly affects balance. Sustained natural apophyseal glide (SNAG) is a successful treatment approach for LPB. However, its influence on balance problems has not been studied before.

OBJECTIVE

To investigate the immediate effect of SNAG on postural stability and pain in individuals with flexion-dominant chronic low back pain (FCLBP).

METHODS

Randomized placebo-controlled trial in which 64 participants with FCLBP were randomly allocated into two groups (SNAG and sham). SNAG group (n= 32) received central lumbar SNAG on the symptomatic lumbar level(s). Sham group (n= 32) received sham SNAG. The outcome measures were postural stability indices; overall stability index (OSI), anteroposterior stability index (APSI), and mediolateral stability index (MLSI) in addition to pain intensity. Outcomes were assessed using the Biodex Balance System and visual analog scale respectively. Measures were taken before and immediately after interventions.

RESULTS

There were statistical significance and high effect size (ES) in favor of the SNAG group regarding OSI, APSI, and pain (p< 0.01, cohen's d ES =1.3, 1.4, 1.1 respectively). MLSI showed moderate ES (cohen's d= 0.7) but did not reach a statistically significant level (p= 0.05).

CONCLUSION

Lumbar SNAG produces an immediate improvement in postural stability and pain in individuals with FCLBP.

The forgotten radial nerve: A conceptual framework for treatment of lateral elbow pain

BACKGROUND

Lateral elbow pain is a prevalent musculoskeletal overuse disorder that has serious consequences for musculoskeletal health, occupational performance, and overall healthcare burden. Available treatment options (traditional therapy and steroid injections) have been studied rigorously, yet supporting evidence is weak. The majority of treatment options available are targeted at the local pathology of the common extensor tendon as the apparent source of pain, and do not adequately address the cause, the source of overuse, and mechanism of injury.

PURPOSE

The purpose of this paper is to describe a novel approach, a regional interdependence model, to reduce symptoms of upper extremity musculoskeletal overuse in populations at risk by addressing a broader systematic approach versus a localized symptom driven approach for the assessment and treatment of lateral elbow pain.

METHODS

The proposed framework - Think in nerve length and layers (TINLL)- accounts for nerve tension and muscle balance in the entire extremity. In this paper we describe the application of the TINLL model for assessment and treatment of SRSN irritation in individuals with lateral elbow pain and propose a method for treatment and for further studies. The proposed treatment approach combines mobilization with movement, elastic taping, and isometric exercises to address impairment at each level: joint alignment, neural tension, and the superficial sensory nervous system.

RESULTS

Our findings of reduced pain with a relatively small number of therapy sessions in a small retrospective cohort of patients using the TINLL framework for assessment and treatment supports further formal study of this approach in a larger cohort with longer follow-up to determine effectiveness compared to current treatments.

CONCLUSION

Future studies will test and compare the efficacy of the TINLL framework and model of treatment on the short- and long-term outcomes in individuals with chronic lateral elbow pain compared to traditional therapy.

Effectiveness of manual therapy in patients with distal radius fracture: a systematic review and meta-analysis

OBJECTIVE

To determine the effectiveness of manual therapy (MT) for functional outcomes in patients with distal radius fracture (DRF).

METHODS

An electronic search was performed in the Medline, Central, Embase, PEDro, Lilacs, CINAHL, SPORTDiscus, and Web of Science databases. The eligibility criteria for selecting studies included randomized clinical trials that included MT techniques with or without other therapeutic interventions in functional outcomes, such as wrist or upper limb function, pain, grip strength, and wrist range of motion in patients older than 18 years with DRF.

RESULTS

Eight clinical trials met the eligibility criteria; for the quantitative synthesis, six studies were included. For supervised physiotherapy plus joint mobilization versus home exercise program at 6 weeks follow-up, the mean difference (MD) for wrist flexion was 7.1 degrees (p = 0.20), and extension was 11.99 degrees (p = 0.16). For exercise program plus mobilization with movement versus exercise program at 12 weeks follow-up, the PRWE was -10.2 points (p = 0.02), the DASH was -9.86 points (p = 0.0001), and grip strength was 3.9 percent (p = 0.25). For conventional treatment plus manual lymph drainage versus conventional treatment, for edema the MD at 3-7 days was -14.58 ml (p = 0.03), at 17-21 days -17.96 ml (p = 0.009), at 33-42 days -15.34 ml (p = 0.003), and at 63-68 days -13.97 ml (p = 0.002).

CONCLUSION

There was very low to high evidence according to the GRADE rating. Adding mobilization with movement and manual lymphatic drainage showed statistically significant differences in wrist, upper limb function, and hand edema in patients with DRF.

Effect of Sustained Natural Apophyseal Glides on Stiffness of Lumbar Stabilizer Muscles in Patients With Nonspecific Low Back Pain: Randomized Controlled Trial

OBJECTIVE

The aim of this study was to investigate the immediate effect of Mulligan sustained natural apophyseal glides (SNAGs) on muscular stiffness by using ultrasound shear wave elastography, pain, and function in patients with nonspecific low back pain.

METHODS

In a prospective, randomized, controlled, double-blinded study, 30 participants with nonspecific low back pain were randomly divided into 2 groups: a real SNAG group (aged 21.0 ± 1.7, 5 men, 10 women) and sham SNAG group (aged 20.4 ± 0.5, 4 men, 11 women). Muscular stiffness of the multifidus and erector spinal muscles with ultrasound shear wave elastography, visual analog scale, the sit and reach, flamingo balance, the functional reach, side bridge, and Biering-Sorensen tests were made before and immediately after intervention. The Oswestry Disability Index score was recorded only baseline.

RESULTS

After intervention, the change in visual analog scale, sit and reach, Biering-Sorensen, and side bridge tests scores were significantly different between real SNAG and sham SNAG groups (P < .05), but there was no significant difference in functional reach and flamingo balance test scores between the groups (P > .05). There was no significant difference for all measurements between pre- and post-intervention in sham SNAG group (P > .05). There was a significant reduction in muscular stiffness in the real SNAG group. But there was no change in muscular stiffness between pre- and postintervention in the sham group (P > .05).

CONCLUSIONS

This study demonstrated that the Mulligan SNAG technique had a positive effect on pain severity, flexibility, trunk muscle endurance, and muscle stiffness in patients with nonspecific LBP.

A comparison of mobilization and mobilization with movement on pain and range of motion in people with lateral ankle sprain: A randomized clinical trial

BACKGROUND

Maitland and Mulligan mobilization techniques are two manual therapy methods to increase the range of motion following immobility treatment. The present study was conducted to compare two therapeutic methods, namely mobilization and mobilization with movement (MWM), on the pain and range of motion in people with lateral ankle sprain.

METHODS

A total of 40 individuals with grade two lateral ankle sprain were randomly divided into two groups, including the Maitland's mobilization intervention group, and the Mulligan's mobilization intervention group. Both groups underwent treatment every other day for two consecutive weeks. The pain intensity was measured using the Visual Analogue Scale (VAS), and the ankle dorsiflexion movement range using the Weight Bearing Lunge Test (WBLT) before and one day after the intervention.

RESULTS

There were no significant differences between the two groups in terms of pain (P = 0.297) and range of motion (P = 0.294) before the intervention. Meanwhile, after the intervention, a significant change was observed in both groups in terms of these variables, which indicates the effectiveness of both interventions (P < 0.001) and the greater effect of the mobilization with movement in reducing pain (P = 0.037) and increasing the range of motion (P = 0.021).

CONCLUSIONS

Both techniques significantly improved the range of motion and reduced pain in people with lateral ankle sprain, but Mulligan's technique was significantly more effective among the two, perhaps due to joining active and passive mobilizing tensile forces as well as interaction of afferents and efferents in the reflex arc.

Effect of weight-bearing wrist movement with carpal-stabilizing taping on pain and range of motion in subjects with dorsal wrist pain: A randomized controlled trial

STUDY DESIGN

Randomized control trial.

INTRODUCTION

During weight-bearing wrist movement, potential stabilizing forces caused by carpal stabilizing taping (CST) may restrict movement of the carpal bones, allowing greater wrist joint extension.

PURPOSE OF THE STUDY

The purpose of study was to investigate the effect of CST during weight-bearing wrist movement on pain intensity and range of motion (ROM) of wrist extension in subjects with dorsal wrist pain.

METHODS

Thirty participants with dorsal wrist pain when weight bearing through the hand were randomly allocated into 2 groups: (1) a CST group using rigid tape and (2) placebo taping (PT) group using elastic tape. Subjects performed weight-bearing wrist movements with CST or PT in 6 sessions for 1 week. Active and passive ROM (AROM and PROM), and the visual analog scale (VAS) were assessed at baseline and after the intervention.

RESULTS

The AROM and PROM of wrist extension increased significantly in both groups compared with preintervention values (P < .01). Comparing the PT and CST groups, the differences between preintervention and postintervention AROM (mean difference [MD] = +8.6°) and PROM (MD = +6.8°) were significantly greater in the CST group than in the PT group (P < .01). The CST group also showed greater improvement in VAS compared with the PT group (MD = -18 mm) (P < .01).

CONCLUSION

We recommend CST during weight-bearing wrist movement as an effective intervention for both increasing wrist extension ROM and decreasing pain in patients with dorsal wrist pain during weight bearing through the hand.

An unusual presentation of acute myocardial infarction in physiotherapy direct access: findings from a case report

BACKGROUND

Shoulder pain (SP) may originate from both musculoskeletal and visceral conditions. Physiotherapists (PT) may encounter patients with life-threatening pathologies that mimic musculoskeletal pain such as Acute Myocardial Infarction (AMI). A trained PT should be able to distinguish between signs and symptoms of musculoskeletal or visceral origin aimed at performing proper medical referral.

CASE PRESENTATION

A 46-y-old male with acute SP lasting from a week was diagnosed with right painful musculoskeletal shoulder syndrome, in two successive examinations by the emergency department physicians. However, after having experienced a shift of the pain on the left side, the patient presented to a PT. The PT recognized the signs and symptoms of visceral pain and referred him to the general practitioner, which identified a cardiac disease. The final diagnosis was acute myocardial infarction.

CONCLUSION

This case report highlights the importance of a thorough patient screening examination, especially for patients treated in an outpatient setting, which allow distinguishing between signs and symptoms of musculoskeletal from visceral diseases.

Immediate Effects of Ankle Joint Mobilization With Movement on Postural Control, Range of Motion, and Muscle Strength in Healthy Individuals: A Randomized, Sham-Controlled Trial

CONTEXT

Ankle proprioception is one of the crucial components contributing to postural control. Although the effects of Mulligan's mobilization with movement (MWM) on postural control, ankle dorsiflexion range of motion (DFROM), and muscle strength in people with ankle disorders have previously been investigated, it is still unclear whether ankle MWM had ability to change postural control, DFROM, and muscle strength.

OBJECTIVES

To reveal pure effects of MWM on postural control, ankle DFROM, and muscle strength in healthy individuals.

DESIGN

A prospective, randomized, double-blinded, sham-controlled study.

SETTING

Musculoskeletal laboratory, Dokuz Eylul University, Turkey.

PARTICIPANTS

Forty students in good health recruited from a local university.

INTERVENTIONS

Mulligan's MWM or sham application over ankle joint.

MAIN OUTCOME MEASURES

The primary outcome was postural control and measured using limits of stability (LOS) test. The secondary outcomes were tibialis anterior muscle strength and ankle DFROM, which were measured using handheld dynamometer and weight-bearing lunge test, respectively. All outcomes were assessed before and immediately after intervention.

RESULTS

Left and right ankle DFROM and LOS overall score showed a statistically significant improvement compared with first measurement in both groups (P < .05). However, LOS time was significantly improved only in the MWM group (P < .05). Statistical analyses of between-group mean differences showed that Mulligan's MWM provided significant improvement in the LOS in forward-right direction compared with sham application (P = .03).

CONCLUSIONS

The results of this study suggest that the application of Mulligan's MWM on ankle joint might be beneficial to improve postural control in forward right direction in individuals with healthy ankles. On the other hand, both MWM and sham application were able to increase overall postural control and DFROM, and MWM had no superiority over sham application for increasing these 2 variables.

The effect of Mulligan's mobilization with movement following total knee arthroplasty: Protocol of a single-blind randomized controlled trial

BACKGROUND

Mulligan's mobilization with movement (MWM) aims to enhance the kinematics of the joint. Kinematic impairment of the knee joint is significant following total knee arthroplasty (TKA), which could be managed with Mulligan's MWM. This article describes the study protocol for a single-blind randomized controlled trial investigating the effectiveness of Mulligan's MWM following TKA.

METHODS

A single-blind randomized controlled trial design will be employed to compare two groups: an intervention and control group. Each group will attend a standard post-operative rehabilitation program. The intervention group will additionally receive articular mobilization using a Mulligan's MWM approach. A blinded examiner will assess participants at four points: pre-operation, 3 weeks post-operation (when the intervention starts), 6 weeks post-operation (when the intervention ends), and at 6 months as a long-term follow-up. The two groups will be compared on the basis of knee range of motion (standard goniometry), knee joint pain (Visual Analogue Scales), walking speed using (15-metre walk test), functional mobility (timed up and go test) and participation (Western Ontario and McMaster Universities Osteoarthritis Index questionnaire). A blinded examiner will measure knee joint alignment using a computed tomography scanogram pre-operatively and at 3 months post operation. Mixed model ANOVA will be used to identify any group differences. Ethical approval has been secured from the ethical committee of Kuwait Ministry of Health, and the trial is registered in the ISRCTN registry (ref:13028992).

DISCUSSION

The study findings could inform the optimization of post-operative rehabilitation of patients following TKA.

The Evaluation of Joint Mobilization Dosage on Ankle Range of Motion in Individuals With Decreased Dorsiflexion and a History of Ankle Sprain

CONTEXT

Mulligan's Mobilization with Movement (MWM) is a common intervention used to address dorsiflexion range of motion (DFROM) impairments. However, the treatment dosage of MWMs varies within the literature.

OBJECTIVE

The aim of this study was to examine the effect of serial MWM application on DFROM.

DESIGN

Repeated-measures cohort.

SETTING

A Midwestern University and the surrounding community.

PARTICIPANTS

A total of 18 adults (13 females; age = 29 [12.87] y; DFROM = 30.26° [4.60°]) with decrease dorsiflexion (<40°) participated. Inclusion criteria consisted of a history of ≥1 ankle sprain, ≥18 years old, no lower-extremity injury in the last 6 months, and no history of foot/ankle surgery.

INTERVENTION

Participants completed a single data collection session consisting of 10 individual sets of MWMs.

MAIN OUTCOME MEASURES

DFROM was taken at baseline and immediately after each intervention set (post 1, post 2, … post 10). DFROM was measured with a digital inclinometer on the anterior aspect of the tibia during the weight-bearing lunge test with the knee straight and knee bent. Analysis of variances examined DFROM changes over time. Post hoc analysis evaluated sequential pairwise comparisons and changes from baseline at each time point.

RESULTS

Analysis of variance results indicated a significant time main effect for weight-bearing lunge test with knee bent (P < .001) and a nonsignificant effect for weight-bearing lunge test with knee straight (P < .924). Post hoc analysis indicated improvements in the weight-bearing lunge test with knee bent at each timepoint compared with baseline (P < .005). Post 2 improved compared with post 1 (P = .027). No other pairwise sequential comparisons were significant (P > .417).

CONCLUSIONS

MWMs significantly improved acute knee bent DFROM and indicated that after 2 sets of MWMs, no further DFROM improvements were identified. Future research should investigate the lasting effects of DFROM improvements with variable MWM dosages.

Taping for conditions of the musculoskeletal system: an evidence map review

Background

Taping is a common treatment modality used by many rehabilitation providers. Several types of tapes and taping methods are used in the treatment of musculoskeletal dysfunction and pain.

Purpose

To summarize and map the evidence related to taping methods used for various joints and conditions of the musculoskeletal system, and to provide clinicians and researchers with a user-friendly reference with organized evidence tables.

Data sources

The PEDro, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register for Controlled Trials, PubMed, and PROSPERO databases were searched from inception through October 31, 2019.

Study selection

Eligible studies were selected by two independent reviewers and included either systematic reviews (SRs) or randomized controlled trials (RCTs) and included a musculoskeletal complaint using a clinical outcome measure.

Data extraction

Data was extracted by two investigators independently. Risk of bias and quality were assessed using A MeaSurement Tool to Assess systematic Reviews (AMSTAR) for SRs or the Physiotherapy Evidence Database (PEDro) scale for RCTs. The protocol was registered with PROSPERO (CRD42019122857).

Data synthesis

Twenty-five musculoskeletal conditions were summarized from forty-one SRs and 127 RCTs. There were 6 SRs and 49 RCTs for spinal conditions. Kinesio tape was the most common type of tape considered. Four evidence tables representing the synthesized SRs and RCTs were produced and organized by body region per condition.

Limitations

Inclusion of only English language studies. Also, the heterogeneous nature of the included studies prevented a meta-analysis.

Conclusions

There is mixed quality evidence of effectiveness for the different types of taping methods for different body regions and conditions. All of the SRs and RCTs found during our search of the taping literature have been organized into a series of appendices. A synthesis of the results have been placed in evidence tables that may serve as a useful guide to clinicians and researchers.

Short-term Effects of Mulligan's Mobilization With Movement on Pain, Function, and Emotional Aspects in Individuals With Knee Osteoarthritis: A Prospective Case Series

OBJECTIVE

To evaluate the short-term effects of Mulligan's mobilization with movement (MWM) on pain, physical function, emotional aspects, and proprioceptive acuity after a 2-week treatment period and throughout a 3-week follow-up period.

METHODS

A single group of 30 participants (60.96 ± 5.16 years) with symptomatic knee osteoarthritis (KOA) was evaluated. The protocol involved 5 evaluations moments, before (baseline) and after 2 weeks of intervention (24 hours after the last session), and at 3-week follow-up. The intervention included 3 Mulligan's MWM techniques. The variables evaluated were pain (pressure pain threshold and Visual Numeric Scale), physical function (range of motion, proprioceptive acuity, and the Western Ontario and McMaster Universities Osteoarthritis Index) and emotional aspects (Beck Depression Inventory). Analysis of variance for repeated measures was used considering a significance level of 5%.

RESULTS

At the second evaluation (after intervention), the pressure pain threshold presented higher values for rectus femoris, tibialis anterior, and patellar tendon sites and reduced values for the Visual Numeric Scale, Beck Depression Inventory, and Western Ontario and McMaster Universities Osteoarthritis Index compared with baseline. Also, during the follow-up period, all variables returned close to baseline levels. Proprioceptive acuity and range of motion did not present significant changes.

CONCLUSION

Scores for pain relief, physical function, and emotional aspects improved after a course of MWM in this single group of individuals with KOA. Mobilization with movement had limited outcome during follow-up. It suggests that future clinical trials on the use of MWM for KOA should be considered.

Inferior tibiofibular joint mobilization with movement and taping does not improve chronic ankle dorsiflexion stiffness: a randomized placebo-controlled trial

OBJECTIVE

This study compared the modification of musculoarticular stiffness (MAS) and clinical outcomes after mobilization with movement (MWM) on the inferior tibiofibular joint and a placebo MWM. Moreover, injured and non-injured ankle MAS were compared after MWM therapy.

METHODS

A single-blinded randomized trial was conducted on 75 participants (mean age: 22.3 ± 2.17 years) with chronic self-reported asymmetric perception of ankle dorsiflexion stiffness. Participants were allocated to one of three groups: inferior tibiofibular MWM (ITFMWM), placebo and non-injured. Sinusoidal oscillation methods were used for experimental quantification of the MAS and clinical outcomes were assessed using the weight-bearing lunge test (WBLT), pain and stiffness perception. Three assessments were made: one pre-treatment (T0), one after the manual technique (T1) and one after taping (T2).

RESULTS

Two-way ANOVA showed no significant differences between the groups and no interaction effect for the outcome measures. However, a significant difference for the time effect (T0-T1-T2) was found in the three groups for WBLT dorsiflexion range of motion (p < 0.001, Cohen's d = 0.21) and stiffness perception (p < 0.001, Cohen's d = 0.54) but the minimal clinically important differences were not reached for either value.

DISCUSSION

The results could not support that a single session of ITFMWM modifies MAS or the clinical outcomes compared to placebo treatment. Furthermore, injured MAS does not differ from non-injured MAS in chronic ankle dorsiflexion stiffness. Further studies should assess subjects' responsiveness concerning the Mulligan concept and focus on a medium- to long-term follow-up.

Acute Effects of Hip Mobilization With Movement Technique on Pain and Biomechanics in Females With Patellofemoral Pain: A Randomized, Placebo-Controlled Trial

CONTEXT

People with patellofemoral pain (PFP) present altered lower-limb movements during some activities. Perhaps, joint misalignment in the hip is one of the reasons for altered movement patterns in people with PFP. Some mobilization techniques have been designed to address joint misalignments.

OBJECTIVE

To investigate the acute effects of hip mobilization with movement (MWM) technique on pain and biomechanics during squats and jumps in females with and without PFP.

DESIGN

Randomized, placebo-controlled trial.

SETTING

Movement analysis laboratory.

PATIENTS

Fifty-six physically active females (28 with PFP and 28 asymptomatic) were divided into 4 groups: experimental group with PFP, sham group with PFP, experimental group without PFP, and sham group without PFP.

INTERVENTION(S)

The experimental groups received MWM for the hip, and the sham groups received sham mobilization.

MAIN OUTCOME MEASURES

Pain, trunk, and lower-limb kinematics, and hip and knee kinetics during single-leg squats and landings.

RESULTS

After the interventions, no difference between groups was found for pain. The PFP experimental group decreased hip internal rotation during squats compared with the PFP sham group (P = .03). There was no other significant difference between PFP groups for kinematic or kinetic outcomes during squats, as well as for any outcome during landings. There was no difference between asymptomatic groups for any of the outcomes in any of the tasks.

CONCLUSIONS

Hip mobilization was ineffective to reduce pain in people with PFP. Hip MWM may contribute to dynamic lower-limb realignment in females with PFP by decreasing hip internal rotation during squats. Therefore, hip MWM could be potentially useful as a complementary intervention for patients with PFP.

Do joint mobilizations assist in the recovery of lateral elbow tendinopathy? A systematic review and meta-analysis

STUDY DESIGN

Systematic review.

INTRODUCTION

No consensus exists as to which are the most effective methods to treat the symptoms associated with lateral elbow tendinopathy (LET). Research has suggested that joint mobilizations may assist in the recovery of patients with LET.

PURPOSE OF THE STUDY

To determine if joint mobilizations are effective in improving pain, grip strength, and disability in adults with LET.

METHODS

Searches in 3 databases were performed to identify relevant clinical trials. Reviewers independently extracted data and assessed the methodological quality. Summary measures of quantitative data were extracted or calculated where possible. Appropriate data were pooled for meta-analysis using a random-effects model.

RESULTS

A total of 20 studies met the inclusion criteria; 7 were included in the meta-analysis. Studies were broadly classified into 3 groups: mobilization with movement (MWM), Mill's manipulation, and regional mobilization techniques. Pooled data across all time periods demonstrated a mean effect size of 0.43 (95% confidence interval [CI]: 0.15-0.71) for MWM on improving pain rating, and 0.31 (95% CI: 0.11-0.51) for MWM on improving grip strength, 0.47 (95% CI: 0.11-0.82) for Mill's manipulation on improving pain rating. A mean effect size of -0.01 (95% CI: -0.27 to -0.26) shows Mill's manipulation did not improve pain free grip strength. Functional outcomes varied considerably among studies. Pain, grip strength, and functional outcomes were improved with regional mobilizations.

CONCLUSION

There is compelling evidence that joint mobilizations have a positive effect on both pain and/or functional grip scores across all time frames compared to control groups in the management of LET.

Comparison of two mobilization techniques in management of chronic non-specific low back pain

AIM

The aim of the study was to compare between the effects of Maitland's postero-anterior (PA glide) mobilization and Mulligan's sustained natural apophyseal glide (SNAG) on pain, mobility, muscle activation and functional disability in subjects with chronic, non-specific low back pain.

METHODS

The study was a two arm repeated measure design with random allocation of subjects (n = 33). Subjects in group 1 received Maitland's PA glide mobilization and those in group 2 received Mulligan's SNAG. Along with the respective mobilization technique, individualized exercises were common for subjects in both the groups. Subjects in both groups received treatment for 4 days a week for 4 weeks. The outcome measures were numeric pain rating scale (NPRS) scores, lumbar flexion and extension range of motion, erector spinae muscle activity and Oswestry low back pain disability questionnaire score.

RESULTS

The outcome measure scores showed statistical significance in time effect on NPRS (p = 0.001); lumbar flexion and extension range of motion (p = 0.001); erector spinae muscle activity (0.001); Oswestry low back pain disability questionnaire score (p = 0.001); group effect on lumbar flexion (p = 0.03) and extension range of motion (p = 0.05); and interaction effect (time x group) on lumbar flexion (p = 0.003) and extension range of motion (p = 0.002); and, erector spinae muscle activity (p = 0.05) at the 3rd lumbar vertebral level.

CONCLUSION

The addition of Maitland or Mulligan mobilization techniques of the spine does not show a difference in the improvement of symptoms associated with chronic non-specific low back pain.

Musculoskeletal ultrasound imaging and clinical reasoning in the management of a patient with cervicogenic headache: a case report

Background: Clinical decision-making within the physical therapy treatment process typically follows the hypothetical-deductive method. The accuracy and reliability of clinical tests affect this reasoning process. Musculoskeletal ultrasound imaging (MSK US) is an emerging valid and reliable diagnostic tool in physical therapy. MSK US allows for dynamic visualization of tissues in real time with devices that are often portable.Case Description: The patient was a 55-year-old female, who presented by direct access. She had been suffering from cervicogenic headaches since the age of 18. It was hypothesized that this patient presented with a right rotation positional default of atlas and facet hypomobility at C5-6.Outcomes: After six visits (over 7 weeks) of manual therapy interventions, the patient reported that her headaches and neck pain were no longer present. Her physical therapy goals had been met and she was discharged with the instruction to continue working on her posture correction and self-management.Discussion: This case report describes the use of MSK US imaging as part of the clinical decision-making process when treating a patient with cervicogenic headaches. This case illustrates the successful management using manual therapy to restore position, mobility, decrease muscle tone, and normalize upright posture. Complementary research is necessary to further validate MSK US imaging as the preferred method to objectivize joint mobility and guide decision-making. Additionally, the cause-effect relationship between the treatment and positive outcomes in this case report has to be further validated.

The time-course effects of talus taping on ankle dorsiflexion range of motion

Background/Aims

Talus taping may be an effective physiotherapeutic treatment for equinus (passive dorsiflexion range of motion <10°). However, the time-course effects of this intervention are unknown. The aims of this study were to identify the effect that the application of talus tape for 48 hours during normal functional activities has on dorsiflexion range of motion, and to determine whether any changes in dorsiflexion range of motion persisted until 5 days after removal (study day 7).

Methods

A total of 16 healthy participants (mean age 28.3 ± 8 years) were recruited. Participants' were randomly assigned to control and intervention conditions. Baseline measures of dorsiflexion range of motion were taken in both ankles using the weight-bearing lunge test. The intervention ankle had talus tape applied, which remained in place for 48 hours during normal functional activities. To determine the time-course effects, dorsiflexion range of motion was reassessed in the control and intervention ankles immediately following removal of the tape (at 48 hours) and again 5 days later, on day 7.

Findings

Dorsiflexion range of motion in the taped intervention ankle increased significantly between the baseline and 48-hour measures. However, when reassessed at day 7, participants' dorsiflexion range of motion had returned to baseline levels. There were no significant differences in the control ankle across all three measures.

Conclusions

Applying talus tape for 48 hours during normal functional activities results in immediate but not long-lasting changes in dorsiflexion range of motion.

Effects of mobilisation with movement (MWM) on anatomical and clinical characteristics of chronic ankle instability: a randomised controlled trial protocol

BACKGROUND

Up to 40% of individuals who sprain their ankle develop chronic ankle instability (CAI). One treatment option for this debilitating condition is joint mobilisation. There is preliminary evidence that Mulligan's Mobilisation With Movement (MWM) is effective for treating patients with CAI, but the mechanisms by which it works are unclear, with Mulligan suggesting a repositioning of the fibula. This randomised controlled trial aims to determine the effects of MWM on anatomical and clinical characteristics of CAI.

METHODS

Participants 18 years or over with CAI will be accepted into the study if they satisfy the inclusion and exclusion criteria endorsed by the International Ankle Consortium. They will be randomised into the experimental group (MWM) or the placebo group (detuned laser) and will receive the assigned intervention over 4 weeks. General joint hypermobility and the presence of mechanical instability of the ankle will be recorded during the first visit. Further, position of the fibula, self-reported function, ankle dorsiflexion range, pressure pain threshold, pain intensity, and static and dynamic balance will be assessed at baseline, and at the conclusion of course of intervention. Follow-up data will be collected at the twelfth week and at the twelfth month following intervention.

DISCUSSION

Effectiveness of MWM on clinically relevant outcomes, including long term benefits will be evaluated. The capacity of MWM to reverse any positional fault of the fibula and the association of any positional fault with other clinically important outcomes for CAI will be explored. Proposed biomechanical mechanisms of fibular positional fault and other neurophysiological mechanisms that may explain the treatment effects of MWM will be further explored. The long term effectiveness of MWM in CAI will also be assessed.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry; ACTRN12617001467325 (17/10/2017).

The effectiveness of Mulligan's mobilisation with movement (MWM) on peripheral joints in musculoskeletal (MSK) conditions: A systematic review

Musculoskeletal (MSK) conditions are very common and represent a major concern for the society and global health. The manual therapy technique Mulligan's Mobilisation with Movement (MWM) has shown promising results in treating a variety of MSK conditions. The aim of this review was to systematically review the literature to establish whether MWM treatment is effective for improving pain and function in patients with MSK conditions related to peripheral joints.

METHODS

Seven electronic databases (MEDLINE (through Ovid), EMBASE (through ovid), CINAHL (through EBSCO), Cochrane (CENTRAL), Web of Science, SPORTDiscus (through EBSCO) AND PEDro) were searched up to November 2017 for randomized controlled trials (RCTs). The quality of the evidence was rated using the GRADE approach.

RESULTS

Seven published trials were identified in which all trials presented positive clinical outcome in pain and function of MWM. Moderate quality evidence was found for the effectiveness of MWM in pain and function in patients with chronic ankle instability (CAI) and hip osteoarthritis (OA). There was found low quality evidence for shoulder impingement syndrome (SIS) and low and very low quality evidence for lateral epicondylalgia.

CONCLUSION

Overall MWM interventions applied to peripheral joints seems to be superior to placebo and no intervention controls, but not in comparison with other medical or physiotherapy interventions. There is a need for more high quality trials that investigate the short and long-term effect of a series of MWM interventions.

The effects of a posterior superior iliac spine support device on upper trunk acceleration during gait in individuals with flat lumbar back posture

BACKGROUND

The orientation of the pelvis is of particular importance to the sagittal curve of the spine and has geometric relationships with the top of the spine and lumbar lordosis. Changes in spinal shape or disruptions of sagittal balance in the spine, such as a flattened lumbar spine, have significant negative effects.

OBJECTIVE

The aim of this study was to investigate the effects of the posterior superior iliac spine support device (PSD) on upper trunk acceleration during gait in individuals with flat lumbar back posture.

METHODS

In total, 10 young male subjects with reduced lumbar lordosis (global lumbar lordosis angle (T10-S2): <-20∘) were recruited for this study. Participants walked 7 m with and without wearing a PSD at a self-selected speed while fitted with an accelerometer attached over the T7 spinous process.

RESULTS

The normalized AP acceleration of T7 with PSD (40.57 ± 11.22%) was significantly higher than those without PSD (37.10 ± 10.46%, p= 0.035).

CONCLUSIONS

We found that wearing the PSD immediately improved pelvic physiological movement during walking in individuals with lumbar flat back posture. Our findings may help healthcare professionals manage flat back posture in asymptomatic younger individuals.

The Role and Value of Symptom-Modification Approaches in Musculoskeletal Practice

The diversity of models of care in contemporary musculoskeletal physical therapy can be confusing for patients and practicing clinicians. There is, however, a common theme to many of these seemingly disparate models of care: symptom modification. Symptom modification aims at reducing symptoms and improving function with a variety of clinical approaches. This Viewpoint explores the role of symptom modification in rehabilitation and specifically addresses (1) symptom modification within the kinesiopathological model of pain, (2) symptom modification in clinical practice, and (3) potential commonality in seemingly divergent models of clinical practice. J Orthop Sports Phys Ther 2018;48(6):430-435. doi:10.2519/jospt.2018.0608.