Immediate effects of Maitland mobilization versus Mulligan Mobilization with Movement in Osteoarthritis knee- A Randomized Crossover trial

Abstract

Background

Maitland Mobilization or Mulligan Mobilization with Movement (MWM) approaches have been widely used clinically for pain relief and improving mobility in Osteoarthritis knee. However the experimental evidence supporting the usage of these mobilization techniques as sole interventions in management of Osteoarthritis knee is insufficient.

Objective

To determine from Maitland Mobilization and Mulligan MWM, which mobilization technique will be more effective in reducing pain and improving mobility and function in OA knee immediately after the intervention.

Study design

Randomized Crossover trial.

Materials and methods

30 subjects with osteoarthritis knee were recruited and 15 each were randomly allocated to two intervention sequences-one sequence was where Maitland was given first followed by Mulligan and the other was where Mulligan was given first followed by Maitland with a washout period of 48 h in between the two interventions. Numeric Pain Rating Scale (NPRS), Timed Up and Go (TUG) test and Pain free Squat Angle were the outcome measures measured before and immediately after both interventions.

Results

Using Repeated Measures ANOVA for analysis of outcomes between and within interventions, no significant differences were seen between Maitland Mobilization and Mulligan MWM, for NPRS, TUG and Pain free Squat Angle (p = 0.18, p = 0.27,p = 0.17) respectively whereas within the interventions both Maitland and Mulligan all outcome measures showed significant changes (p < 0.001).

Conclusion

Thus it can be seen that Maitland mobilization and Mulligan MWM, both are equally effective in osteoarthritis knee in reducing pain and improving functional mobility and pain free squat angle immediately post treatment.

Introduction

Osteoarthritis (OA) also known as degenerative joint disease, is associated with degradation of articular cartilage, subsequently affecting the underlying bone causing osteophyte formation at the joint margins (Altman et al., 1991, Larmer et al., 2014). OA knee has an increasing prevalence noted in the middle ages and women are more predisposed than men (NICE, 2008). Prevalence of OA knee in India is 30% and maximum of OA knee affected population were individuals aged between 40 and 60 years and 19–30% of the total affected population were sedentary or unemployed (Pal et al., 2016). The management of OA knee is witnessing a rise in economic burden in terms of long term medications like NSAIDs or opioid analgesics, intra articular injections of steroids or more recently used cartilage analogue injections and surgeries like chondroplasties and widely performed knee arthroplasties. Physical therapy has known to play a vital role in pain relief and restoration of mobility and function in OA knee which includes-range of motion exercises for knee, strengthening (isometric or dynamic resistance training) of muscles around hip and knee (Quadriceps, Hamstrings, Gluteus Maximus, Gluteus Medius and Minimus); flexibility exercises (Iliotibial Band, Hamstrings, Gastro-soleus and Rectus femoris); aerobic conditioning, aquatic exercises; patellar taping; electrotherapy modalities like thermotherapy, electrophysical modalities (Transcutaneous Electrical Nerve Stimulation, Interferential Therapy or Faradic Stimulation to the surrounding muscles, Ultrasound therapy) and more recently manual therapy techniques (Page et al., 2011).

Manual therapy includes hands-on soft tissue or joint mobilization techniques which modulate pain and also improve extensibility of contractile tissues and movement of joints (French et al., 2011). Its neurophysiological effects are – mechanoreceptor mediated pain gate analgesia blocking nociception at spinal cord dorsal horn; periaqueductal grey matter and rostroventral medulla mediated descending pain inhibition mostly through activity of noradrenaline and to some extent opioids and serotonin causing reduction in maladaptive cognitive-affective mechanisms observed in pain neuromatrix (Vicenzino et al., 2001, Skyba et al., 2003, Zusman, 2002, Mosely, 2003). An RCT, where subjects with OA knee were allocated into four groups to receive-usual care provided by a general practitioner, manual physiotherapy, multi-modal exercise physiotherapy and combined exercise plus manual physiotherapy (Abbott et al., 2015) showed that Western Ontario & McMaster Universities Arthritis Index (WOMAC) scores improved similarly for manual therapy group as well as exercise therapy group as compared to usual care group; however there were no additional improvements seen on combining exercise therapy and manual therapy rather an antagonistic interaction was seen between exercise therapy and manual therapy. Manual therapy is frequently used in combination with other interventions such as conventional exercise or electrotherapy in OA knee, hence its individual effect in OA knee is not clear (NICE, 2008, RACGP, 2009). A systematic review done on manual therapy in OA hip and knee concluded that there is inconclusive scientific evidence substantiating effectiveness of manual therapy in reducing pain or improving function in OA hip and knee (French et al., 2011).

Mulligan Mobilization with Movement (MWM) is based on the concept that minor position faults occur in articulating surfaces of joints following injury or strains resulting in movement restriction and pain exacerbated by active contraction of muscles within the faulty positions of the joint (Mulligan, 2011). Thus, MWM involves passive accessory glide as a corrective technique, applied by the therapist perpendicular to the joint plane to correct the positional fault combined with the offending movement being performed actively by the subject and sustained for several repetitions, the pain should always be reduced and/or eliminated during the application and pain-free function should be restored (Mulligan, 2011).

Maitland mobilization includes continuous analytical assessment of the nature of the disorder which mainly involves identifying the pain mechanisms driving the dysfunctional movement patterns and utilizing clinical reasoning to integrate theoretical concepts with the clinical presentation of the disorder, in order to formulate a dynamic working diagnostic hypothesis, with the appropriate intervention addressing all components of the disorder, according to the priority of presentation. In Maitland mobilization, passive physiological and accessory oscillatory movements are applied to the joint to gain range of motion, lost due to pain or stiffness, and to restore optimal kinematics between the joint surfaces, where the grade, frequency and dosage of mobilization is determined by Severity, Irritability and Nature (SIN) of the disorder (Hengeveld and Banks, 2014).

Most of the studies of manual therapy in OA knee have utilized Maitland mobilization techniques effectively. In an RCT done, Maitland joint mobilization including antero-posterior (AP) glide of tibia on femur, and patella glides in all directions was given in addition to control treatment of stretching, isometric quadriceps, closed-kinetic chain exercise and static bicycling; which resulted in better reduction in pain in the experimental group ( Nor Azlin and Su Lyn, 2011). When OA knee participants were given 6 min of knee joint mobilization, and after a gap of 1 week they received only cutaneous input intervention, it was seen that there was a global increase in pressure pain threshold, significantly lowered baseline pain, significantly enhanced Continuous Passive Motion (CPM) ranges and increased vibration perception threshold acuity following in subjects receiving joint mobilization but not after cutaneous input intervention (Courtney et al., 2016). Mulligan MWM though clinically claimed to be effective in pain relief and improving joint mobility in OA knee; there is lack of published literature on effectiveness of MWM in the management of OA knee. In an RCT, experimental group where Mulligan MWM was applied in addition to trunk stabilization exercises and electrotherapy modalities (thermotherapy, ultrasound and interferential therapy) in subjects with OA knee had better WOMAC scores and more significant pain reduction than in the control group which received only trunk stabilization and electrotherapy (Nam et al., 2013).

The literature available, to date, shows that there are very few high quality studies comparing Maitland Mobilization and Mulligan MWM applied independently without any conventional interventions in OA knee and hence it is difficult to determine their effectiveness individually. Most of the studies done so far have focused on the long-term effects of repeated joint mobilization sessions along with exercise or electrotherapeutic interventions. Thus, less emphasis has been given to immediate or short-term effects of a single mobilization session. Short term or immediate effects of mobilization if turn out positive and significant seem more appropriate to determine; considering long standing morbidity and economic burden involved in OA knee due to which repeated sessions of intervention might be difficult to undergo for the OA knee subjects. Thus, the objective of this study was to determine between Maitland Mobilization and Mulligan MWM, which mobilization technique will be more effective in reducing pain and improving mobility and function in OA knee immediately after the intervention.