EFFECTIVE OF MULLIGAN MOBILISATION AND TAPING IN LATERAL EPICONDYLITIS

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2 EFFECTIVE OF MULLIGAN MOBILISATION AND TAPING IN LATERAL EPICONDYLITIS Submitted by: POOJA KALARIA (12SPTPT11039) DHARA KAPURIYA (12SPTPT11040) BPT 6 th semester, JULY-2015 Guided by: Dr NAMRATA CHANDRALA Assistant professor, School of physiotherapy, RK University II

3 I CERTIFICATE This is to certify that the project work entitled Effect of Mulligan mobilization and tapingin lateral epicondylitis has been undertaken and written under my supervision and it describes the original research work carried out by Ms. Pooja Kalaria and Ms. Dhara Kapuriya registered at RK University in 6 th semester Bachelors of Physiotherapy. Signature of Guide Name: Dr Namrata Chandrala Degree: MPT ORTHO Designation: Assistant professor III

4 DECLARATION We hereby certify that we are the authors of this project work. We certify to the best of our knowledge, our project does not infringe upon anyone s copyright nor violate any proprietary rights and that any ideas, techniques, quotations, or any other material from the work of other people included in our project published or otherwise, are fully acknowledged in accordance with the standard referencing practices. We declare that this is a true copy of our project, including any final revisions, as approved by my project review committee. Signature.of candidate: Signature.of candidate: Pooja kalaria Dhara Kapuriya Enrolment no.: 12sptpt11039 Enrolment no.: 12sptpt11040 Date: 16 th july 2015 Date: 16 th july 2015 Place: Rajkot Place: Rajkot IV

5 ACKNOWLEGEMENT First and foremost we would like to thank our parents Lalitbhai Kalaria, Jagrutiben Kalaria and Vinodbhai Kapuriya, Sarojben Kapuriya who are my living Gods and our brothers Arjun Kalaria and Neel Kapuriya for their valuable support and encouragement, blessing and love which has always been a source of inspiration and strength in accomplishing this academic task. Our heartfelt gratitude to almighty God who has guided us this far and to whom goes all the honor and glory for the successful completion of this study. We wish to express our regards to our Director Dr Priyanshu Rathod School of Physiotherapy, RK.University for his whole hearted guidance and meticulous suggestions in the completion of this work and for all the facilities and support extended to me during this study. We are extremely thankful for his constant encouragement and inspiration during the course of this study. With due respect, we would like to express our sincere thanks to our guide Dr Namrata Chandrala Senior lecturer of School of Physiotherapy, RK.University, for her judicious information, expert suggestions, valuable guidance, continuous support, incessant reassurance during every stage of this work and interest shown in this dissertation without which this work would not have been possible. we would like to extend our heartfelt thanks to assistant lecturer, Dr Ankur Parekh, Dr Kajal V Anadkat and Dr Vaibhavi Ved for their valuable guidance, constant help and support throughout this study and all the lecturers of my college who have taught me and gave their valuable suggestions during the course of the study. We shall fail our duties if we don t acknowledge my Colleagues and Friends for their suggestions and criticism while assisting us in this study. Last but not the least we would like to thanks all the Individuals in our study without whom this task would not have been possible. Our sincere thanks to all the contributors whose names we might have missed but who truly deserve our gratitude. We would like to thank once again to all who have helped us all the while. Signature: Name: Pooja kalaria Signature: Name: Dhara Kapuriya V

6 LIST OF ABBREVIATIONS 1. MWM: Mulligan s Mobilization with Movement 2. US: Ultrasound 3. PRTEE: Patient Rated Tennis Elbow Evaluation 4. ECRB: Extensor Carpi Radialis Brevis. V VI

7 ABSTRACT BACKGROUND: Lateral epicondylitis is a painful musculoskeletal condition which is considered to be due to over use, over stress or over exertion of wrist extensors(mainly ECRB) of the forearm with production of pain around the common extensor origin. The study is to evaluate the efficacy of taping and Mulligan mobilization in improving the functional ability and reduction of pain in tennis elbow. AIM: 1 To evaluate the effectiveness of taping, US and stretching exercise on pain and disability of patient with lateral epicondylitis. 2 To evaluate the effectiveness of MWM, US and stretching exercise on pain and disability of patient with lateral epicondylitis. 3 To compare the effectiveness of taping and Mulligan mobilization technique on lateral epicondylitis. METHODOLOGY: 1 Study design: Experimental study(pre test and post test). 2 Inclusion criteria: Age of years with symptomatic lateral epicondylitis on side, males and females, positive Cozens test or Mills test confirming lateral epicondylitis. 3 Exclusion criteria: Patient having history of trauma,surgery, acute infection, fractures around elbow complex, Patient who have received steroids injection within last 30 days in elbow joint. 4 Sample size: 30 subjects. 5 sampling: Simple random sampling. 6 Study setting: Various physiotherapy clinics in Rajkot. RESULTS: The result of this study indicate that the mean improvement in hand grip strength when compared in pre and post treatment did not show significant improvement with in the groups with p<0.05. The result of this study indicate that the mean improvement in PRTEE when compared in pre and post treatment shows significant improvement with in and between the groups with p<0.05. VII

8 CONCLUSION: Mulligan mobilization was more effective than taping technique in reducing pain and functional performance. KEY WORDS: Lateral epicondylitis, Mulligan mobilization (MWM), Hand Grip Strength, Patient Rated Tennis Elbow Evaluation (PRTEE). VIII

9 TABLE OF CONTENTS Sr. No. TITLE Page No. 1. INTRODUCTION 1 2. AIMS & OBJECTIVES 6 3. REVIEW OF LITERATURE METHODOLOGY RESULTS DISCUSSION CONCLUSION SUMMARY BIBLIOGRAPHY ANNEXURES 40 IX

10 LIST OF TABLES Sr. No. TABLES Page No. 5.1 Comparison of PRTEE in group A and B(within group) Comparison of Hand Grip Strength in group A and 26 B(within group) 5.3 Comparison of PRTEE between group A and B Comparison of Hand Grip Strength between group A and B 28 X

11 LIST OF GRAPHS SR. No. GRAPHS PAGE NO. 5.1 Comparison of PRTEE in group A and B Comparison of Hand Grip Strength in group A and B 5.3 Comparison of PRTEE between group A and B Comparison of Hand Grip Strength between group A and B 28 XI

12 LIST OF FIGURES SR. NO. FIGURES PAGE NO. 4.1 Lateral epicondylitis Tapping applying method 4.3 Mulligan applying method 4.4 Grip strength measurement 4.5 Material used in study XII

13 INTRODUCTION EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 1

14 INTRODUCTION Tennis elbow or lateral epicondylitis is one of the most common lesions of the forearm. It is a lesion affecting the origin of the tendons of the muscles that extend the wrist joint mainly Extensor Carpi RadialisBrevis (ECRB) 1. The dominant arm is commonly affected among both men and women with prevalence of 1-3 % 2 and in the age group of years 3. Fig 4.1 The commonest causative factor is present at elbow over-use or repetitive concentric and eccentric contractions of the extensor muscles (mainly ECRB) which stabilizes the wrist. These repetitive stresses (heavy lifting, repetitive hammering, scissoring, twisting, and in tennis players with backhand stroke & inadequate forearm extensor power and endurance) produces chronic overload due to biomechanical positional fault resulting in micro tearing & fibrosis of the common wrist extensor origin. This presents as pain on gripping activities, decreased grip strength and tenderness over the outer edge of the elbow 3, 4. The Repeated tensile stress created at the origin of the ECRB may cause microscopic tears at the musculotendinous junction and Angio-fibroblastic hyperplasia response may follow. This leads to inflammation &mucinoid degeneration of the Extensor origin and subsequent changes within the inelastic tendon such as thickening of the tendon s sheath, EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 2

15 nodule formation & adhesions. Additional changes seen microscopically include a reduction in vascularity,fraying & splitting of collagen fibers and an increase in the amount of type III collagen within a tendon which further weakens the tendon causing more microtears and prolong the degeneration process 5, 6. Numerous manual therapy procedures have been developed to assist in the management of Tennis elbow Indications and applications of these numerous manual therapy procedures varies with each author, but the biomechanical effect of radio-humeral gapping remains consistent with each technique 8 A) Mulligan s Mobilization with Movement (MWM): It is a class of manual therapy technique (based on the principle of Kaltenborn i.e. passive accessory mobilization technique applied parallel or perpendicular to the joint plane) that is widely used in the management of musculoskeletal pain. It involves the manual application of a sustained glide by a therapist to a joint, while a concurrent physiological movement of the joint is actively performed by the patient 7.MWM techniques are applied in case of positional fault of the elbow joint Complex & they help to restore normal tracking of the radius on the capitulum. It also prevents the contractile element pathology of the common extensor bundle so that strengthening the forearm muscles can be done without painful symptoms 8. Several researchers have reported decrease in pain and increase in grip strength during or shortly after MWM at the elbow 13. B)Taping: It is a cost effective treatment alternative for many common injuries & overuse syndromes (hillfrank, 1991). Tape is applied across the joint in several layers and is positioned to provide outside support and restrict forces that would apply stress on an injured part. Mulligan taping mainly aims to mainly, to reduce pain, improve function & biomechanics12. It taping aim to control the fascia directly, establish proper structural alignment, improve muscular recruitment & also increase proprioception stimulation enhancing static & dynamic neuro-muscular retraining by balancing the tissue length/tension relationship &motor control 12, 14. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 3

16 NEED OF THE STUDY EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 4

17 NEED OF THE STUDY Mulligan mobilization is the commonest manual therapy procedures used in the treatment of lateral epicondylitis. These techniques help in reduction of pain immediately after the technique is applied for short period 8, 9,10,11,15,16,17. Taping has been found effective in decreasing the pain & restoring the joint play by maintaining & establishes proper structural alignment by balancing the tissue length/tension relationship for prolonged period 12, 14. There are many studies on the effects of Mulligan mobilization in the management of lateral epicondylitis. However not many studies have evaluated the efficacy of using taping technique as an adjunct to manual therapy approach. This study is an attempt to evaluate the efficacy of taping as an adjunct to Mulligan mobilization in improving the functional ability and reduction of pain in lateral epicondylitis. Therapeutic ultrasound and stretching exercises are used to deal with the bio-chemical changes of the condition. This study is to evaluate the efficiency of taping and Mulligan mobilisation in improving the functional ability and reduction of pain in lateral epicondylitis. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 5

18 AIM AND OBJECTIVES EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 6

19 AIM : AIM & OBJECTIVES 1. To compare the effectiveness of taping and Mulligan technique on lateral epicondylitis OBJECTIVES: 1. To evaluate the effectiveness of taping, US and stretching on pain and disability of patient with lateral epicondylitis. 2. To evaluate the effectiveness of MWM, US and stretching on pain and disability of patient with lateral epicondylitis. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 7

20 HYPOTHESIS EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 8

21 HYPOTHESIS ALTERNATIVE HYPOTHESIS: Treatment using Mulligan mobilization and taping shows significant difference in pain and disability in patients with lateral epicondylitis. NULL HYPOTHESIS: Treatment using Mulligan mobilization and taping does not show any significant difference in pain and disability in patients with lateral epicondylitis. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 9

22 REVIEW OF LITERATURE EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 10

23 REVIEW OF LITERATURE 1)Bryan Chung, J ability due Wiley.et.al (2010): Studied the validity of PRTEE. The PRTEE had questionable discriminant ability due to its moderate test-retest reliability and possibly due to low convergent validity with other measures of similar constructs. The PRTEE appears to be sensitive to change, but the margin of difference between a clinically relevant change and no change is very small. 23 2)Tom J. Overend,Jennifer C, Wuori-Fearn, John.F. Kramer.et. at. (1999): Studied the reliability of a questionnaire designs to assess forearm pain function in patient with lateral epicondylitis. The PRTEE or PRFEQ has been found to effective in providing simple, quick and reliable estimations of arm pain functions in patients with lateral epicondylitis. 24 3) Bryan chung, J Preston wileyet. al. (2010): studied validity, responsiveness and reliability of PRTEE.they conclude that it is having questionable discriminant ability due to its moderate test-retest reliability and possibility due to low convergent validity with other measures of similar constructs. 14 4) Won-Hwee Lee, Oh et.at. (2011): Studied the effect of taping on wrist extensor force reproduction and wrist joint position reproduction with or without lateral epicondylitis. The lateral epicondylitis group had a significantly higher FR and JPR errors. Taping significantly improved force reproduction and joint position reproduction error. 16 5) AlirzaShamsoddini, Mohammad TaghiHollisaz, et.al. (2010) studied the initial effect oftaping techniques in subjects with tennis elbow by testing grip strength, wrist extensionmuscleforce and range of motion wrist extension immediately after the application of tapingtechniques. Results showed impressive effect on wrist extension, grip strength and pain. 17 EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 11

24 6) Stasinopoulos, K Stasinopoulu, M I Johanson et. al (2012): Studied the exercise program for the management of tennis elbow. Study described the use and effects of strengthening and stretching exercise program in the treatment of tennis elbow. They concluded that the well designed trial is needed to study the effectiveness of supervised exercise program for tennis elbow consisting of eccentric and static stretching exercise. 19 7) Magnus Peterson, Stephen butler, et. al. (2011): studied randomized controlled clinical trial on the effect of exercise versus expectation on pain, muscle strength, function and quality of life in patients with long standing lateral epicondylosis. They found that exercise group had greater and faster regression of pain, both during muscle contraction and muscle elongation than the reference group. 20 8)MoneetKochar and AnkitDogra(2002): conducted a clinical study on Effectiveness of a specific physiotherapy regimen on patients with Tennis Elbow on 66 patients who were randomized into 3 groups, The first (MM) group was treated with a combination of ultrasound therapy and Mulligan mobilization while the second group was treated with ultrasound therapy alone for ten sessions (completed within three weeks). Both groups followed a progressive exercise regime for a further nine weeks, third group as control group. They were evaluated at weekly intervals from the time of selection until the third week and finally at the 12th week with four outcome measures: visual analogue scale (VAS), isometric grip strength, weight test and patient assessment test. The results conclude that the MM group showed improvement on most parameters than other groups and found that the addition of Mulligan mobilization to a regimen comprising ultrasound therapy and progressive exercises brings about increased and faster recovery in patients with tennis elbow 15. 9)A Binder, G Hodge, A M Greenwood, B L Hazleman, and D P Page Thomas(1985):Conducted a randomized study to determine the effectiveness of therapeutic ultrasound in treatment of soft tissue lesions. They included 76 patients with lateral epicondylitis, 38 were randomly allocated to receive ultrasound treatment and 38 placebo. The conditions of 24 patients (63%) treated with ultrasound and 11 (29%) given placebo improved, the difference being significant at the 1%. Improvement in particular EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 12

25 clinical variables (pain score, weight lifting, grip strength) also showed an advantage for the patients given ultrasound treatment and the result concluded that Ultrasound enhances recovery in most patients with lateral epicondylitis )Pienimaki, Tuomo, Tarvainen.et.al. (2002), Studied the association between changes in pain and grip strength and manual tests among patients with chronic tennis elbow. Pain thresholds at the lateral epicondyle are strongly associated with pain on palpation and with a positive Mill s test. Resisted extension test results reflect decreased grip strength )OritShechtman, Lisa Gestewitz and Christine Kimble have done a study to examine the reliability and validity of the digital DynEx dynamometer. Grip strength testing was conducted on 100 healthy subjects (aged years) using both the Jamar and DynEx dynamometers in the second handle position.the results of this study indicate that concurrent validity between the two instruments was excellent 21. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 13

26 METHODOLOGY EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 14

27 METHODOLOGY Study Design: Experimental study (pre test and post test). Study Setting: Various physiotherapy centres in Rajkot. Sampling Technique: Convenient sampling technique Study Population: Male and Female Study Sample: 30 subjects Study Duration: Training duration: Daily one session Total Study duration - 2 weeks. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 15

28 Fig 4.2: Mulligan Tapping EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 16

29 Fig 4.3:Hand grip strength EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 17

30 Fig 4.4: Mulligan Mobilisation EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 18

31 CRITERIA FOR SELECTION INCLUSION CRITERIA Age group of years with symptomatic lateral epicondylitis on either side. Both males and females. Positive Cozens test or Mills test confirming lateral epicondylitis22, 24, 25. EXCLUSION CRITERIA Patient having history of trauma, surgery, acute infections. Patient who have received steroid injections within last 30 days in elbow joint. Severe neck or shoulder problems with radiating pain to upper limb. Fractures around elbow complex. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 19

32 MATERIALS USED IN THE STUDY Mulligan belt Hand held dynamometer Ultrasound machine frequency 1MHZ Ultrasonic gel couch stool Mulligan elastic adhesive tape pen paper data collection sheet. Patient rated tennis elbow evaluation. Scissors Fig 4.5 EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 20

33 METHOD Patients will be included in the study after the initial assessment and informed consent will be taken. Subjects who fulfil the inclusion criteria will be assigned into two groups based on convenient random sampling. Pre test evaluation will be done before starting treatment which includes pain assessment using PRTEE and pain free grip strength by hand held dynamometer. Group A (n=15) will be given Mulligan s Mobilization With movement on the involved elbow joint, with patient lying in supine position having their elbow extended and forearm pronated. The mulligan belt is kept around the therapist s shoulder and a lateral glide will be given to the proximal part of the patient s elbow joint. During the lateral glide, the patient is asked to perform the pain producing movement (such as gripping or resisted isometric contraction wrist extensor). If the glide is applied correctly then the patient will not feel any pain on Lateral Glide Produced Via The Mobilization Belt Concurrent With Strong Resisted Isometric Wrist Extension. The dosages are 3 sets of 10 pain free mobilizations in each set with one minute rest time between each set 7, 8. Group B (n=15) Mulligan taping: The subjects will be asked to rest the elbow in supported position with the elbow is slightly flexion and pronated and wrist in extended position to contract the ERCB. The tape will be placed on the proximal forearm, starting medially and laterally parallel to the wrist line. This will be repeated 2 or 3 times. The tape is tightened until the subject agrees that it snugs during a contraction of the wrist extensors, but not impending blood flow. The tape should be comfortable when the wrist extensors are relaxed. 2 Both the groups received Pulsed Ultrasound therapy (UST) with a Frequency of 1 MHz & Intensity of 0.5w/cm 2 for 5 min at the musculo-tendinous junction of ECRB on the affected elbow 26, 27. In addition, both the groups will be given stretching exercises. The stretching will be given by flexion of the wrist with forearm pronated and elbow extended. This is held for few seconds and then released. A total of 10 stretches will be given on session per day 20, 28. Each group will be receiving the interventions one session per day up to 2 weeks. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 21

34 At the end of 2 nd week post test evaluation comprising of PRTEE& Pain free grip strength will be conducted for both the groups. The result of pre &post test values of each group is compared & differences in pre &post test values between groups will also be compared. 30 subjects with pre diagnosed tennis elbow will be taken. Consent form will be taken. 2 groups: A and B Pre & post assessment of PRTEE and hand grip strength. Group A : Mulligan mobilization Ultrasound Stretching exercise Group B: Taping Ultrasound Stretching exercise EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 22

35 RESULTS EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 23

36 Result A study was performed in which PRTEE and Hand grip strength was assessed in both groups. The pre and post values for PRTEE and Hand grip strength were collected for both the groups. Statistics was performed using unpaired t test and paired t test for Hand grip strength within and between the groups respectively, whereas Wilcoxson test and Mann Whitney U test was used for PRTEE within and between the groups respectively. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 24

37 Table 5.1 Comparison of PRTEE in group A and B(within group) variable mean s.d. W value P value Result PRTEE pre post Pre Post pre post Group A < Significant Group B < Significant Graph 5.1 The PRTEE comparison within group A and B with pre mean of group A being and post mean being 46.53, whereas for group B pre= and post= The s.d. pre and post value for group A is and respectively. The s.d. pre and post value for group B is and respectively. The pre and post P value for both the groups being p< and p= respectively therefore the result is significant. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 25

38 Table 5.2 Comparison of Hand grip strength in Group A and B(within group) variable mean s.d. t value p value Result Hand grip strength Pre post pre post Group A Not significant Group B Not significant Graph 5.2 The Hand grip stremgth comparison within group A and B with pre mean of group A being 15.37and post mean being 15.99, whereas for group B pre= and post= The s.d. pre and post value for group A is and respectively. The s.d. pre and post value for group B is and respectively. The p value= for group A and for group B, therefore the result is not significant. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 26

39 Table 5.3 Comparison of PRTEE between Group A and B U variable mean s.d. value p value Result PRTEE Pre-post pre-post Pre-post Pre-post Significant Group A: Group B: Group A: Group B: Graph 5.3 The PRTEE between group A and B with pre mean difference of and post mean difference of The pre s.d. difference being and post s.d. difference being The p value=0.0156, therefore the result is significant. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 27

40 Table 5.4 Comparison of hand grip strength between group A and B Variable t p mean s.d. value value Hand grip strength Pre-post Pre-post Pre-post Pre-post Result Not significant Graph 5.4 comparison of hand grip strength between group A & B Group A: 0 Group B: Hand grip strength Pre-post Pre-post Variable mean The Hand grip strength between group A and B with pre mean difference of and post mean difference of The pre s.d. difference being and post s.d. difference being The p value=0.1615, therefore the result is not significant. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 28

41 DISCUSSION EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 29

42 DISCUSSION The present clinical trial was conducted to compare the effectiveness of Mulligan moblisation and taping technique with common treatment of therapeutic ultrasound and stretching exercise in subjects with lateral epicondyitis. Result of the study were focused on improvement of grip strength was measured with the help of hand dynamometer and reduction in function actually improvement scored based on PRTEE for lateral epicondylitis. It was noticed that there was improvement in the above parameters in both groups. AlirzaShamsoddini, Mohammad TaghiHollisaz, et.al. (2010):Studied the initial effect of taping techniques in subjects with tennis elbow by testing grip strength,wrist extensionmuscleforce and range of motion wrist extension immediately after the application of taping techniques.results showed impressive effect on wrist extension, grip strength and pain. 17 MoneetKochar and Ankit Dogra(2002): conducted a clinical study on Effectiveness of a specific physiotherapy regimen on patients with Tennis Elbow on 66 patients who were randomized into 3 groups, The first (MM) group was treated with a combination of ultrasound therapy and Mulligan mobilization while the second group was treated with ultrasound therapy alone for ten sessions (completed within three weeks). Both groups followed a progressive exercise regime for a further nine weeks, third group as control group. They were evaluated at weekly intervals from the time of selection until the third week and finally at the 12th week with four outcome measures: visual analogue scale (VAS), isometric grip strength, weight test and patient assessment test. The results conclude that the MM group showed improvement on most parameters than other groups and found that the addition of Mulligan mobilization to a regimen comprising ultrasound therapy and progressive exercises brings about increased and faster recovery in patients with tennis elbow 15. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 30

43 Mulligan mobilization is the commonest manual therapy procedures used in the treatment of lateral epicondylitis. These techniques help in reduction of pain immediately after the technique is applied for short period 8, 9,10,11,15,16,17. Taping has been found effective in decreasing the pain & restoring the joint play by maintaining & establishes proper structural alignment by balancing the tissue length/tension relationship for prolonged period 12, 14. LIMITATIONS OF THE STUDY Subjects could not be followed up for longer period of time, to see long term benefit. Small sample size was used. Majority of the subjects were females. FURTHER RECOMMENDATION longer duration are recommended with longer follow-up period to assess long term benefits. Conduct the study with larger sample size. Further study should be carried out with acute or chronic injury subjects. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 31

44 CONCLUSION EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 32

45 CONCLUSION The present randomized clinical trial provided evidence to support the use of Mulligan mobilization and taping techniques in relieving pain, improving grip strength and improve functional performance in subject with tennis elbow. In addition, results supported that Mulligan mobilization was more effective than taping technique in reducing pain and functional performance. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 33

46 SUMMARY EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 34

47 SUMMARY The purpose of this study is to determine the effectiveness of Mulligan mobilization and taping in lateral epicondylitis. Individuals (N= 15) were randomly assigned into a group containing 13 females and 2 males in group A and group B containing 12 females and 3 males. Group A was treated with Mulligan mobilization, US and stretching where as group B was treated with Mulligan taping, US and stretching. The measurement used are hand dynamometer and PRTEE. Each subject was measured before and after 2 weeks of treatment. The result of this study indicate that the mean improvement in hand grip strength when compared in pre and post treatment did not show significant improvement within and between the groups with p>0.05. The result of this study indicate that the mean improvement in PRTEE when compared in pre and post treatment shows significant improvement within and between the groups with p<0.05. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 35

48 BIBLIOGRAPHY EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 36

49 BIBLIOGRAPHY 1) Robert A. Donatelli, Michael J. Wooden. Orthopaedic Physical Therapy. 2 nd edition, Churchill Livingstone Inc publications,1994,pp ) D Stasinopulos, M I Johnson, Cyriax Physiotherapy for tennis elbow, Br J of sports medicine. 2004;38; ) S.BrantBrotzman, Kevin. E. Wilk, Clinical Orthopaedic Rehabilitation. 2 nd edition, Mosby pub, ) Ched Starkey, Jeff Ryan. Evaluation of Orthopaedic and Athletic Injuries. 2 nd ed, F A Davis company, ) Pamela K Levangie, Cynthia. C Norkin. Joint Structure & Function, A Comprehensive analysis. 3 rd ed, Jaypee pub ) Peggy.A.Houglum, Therapeutic Exercise for musculo skeletal injuries. 2 nd edition..human Kinetics Publications,2004 7) Brian R Mulligan. Manual Therapy- NAGS, SNAGS, MWMS etc. 4 th ed, Plane view press, Welligton, ) Jack miller,case study: mulligan management of Tennis elbow, published orthpaedic Division Review May/June ) James H Cyriax, The Text book of Orthopedic Medicine, Diagnosis of soft tissue lesion, volume one, 8th edition, A.I.T.B.S Pub ) Rene cailliet. Soft tissue pain & disability, 3 rd edition, F.A.Davis Company, ) James. H Cyriax, The text book orthopedic medicine, Treatment by manipulation, massage and injection, 11th edition, Vol 2, A.I.T.B.S PUB ) Mary Lynn Jocobs, Noelle Austin. Splinting the hand & upper extremity principles & process, 2003, Lippincott Williams &wilkins pub. EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 37

50 13) Carolyn kisner, Lynn Allen Colby. Therapeutic exercises: foundations and technique. 4 th ed. Jaypee publications ) Bill Vicenzino, Jane Brooks bank, Joanne Minto, Sonia offord, Aatitpaungmali, Initial effects of elbow taping on pain free grip strength and pressure pain threshold,, Journal of orthopedic & sports Physical therapy,2003;33: ) Moneet, Kocher Dograankit. Effectiveness of specific physiotherapy regimen on patients with tennis elbow: Clinical Study, Physiotherapy, 2002, vol.88, ) AatitPaungmali, Shaun O'Leary, Tina Souvlis and Bill Vicenzino. Hypoalgesic and Sympatho excitatory Effects of Mobilization with Movement for Lateral Epicondylalgia. Physther 2003; 83: ) D Stasinopulos, M I Johnson, Cyriax Physiotherapy for tennis elbow, Br J of sports medicine. 2004; 38; ) A Binder, G Hodge, A M Greenwood, B L Hazleman, and D P Page Thomas, Is therapeutic ultrasound effective in treating soft tissue lesions.br Med J (Clin Res Ed) February 16; 290(6467): ) Williamson A, Hoggart B, Pain: A review of three commonly used pain rating scales. J Clin. Nurs. 2005, Aug; 14(7): ) D Stasinopoulos, P Manias, A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy,br J Sports Med January; 40(1): ) Orit Shechtman, Lisa Gestewitz and Christine Kimble, Reliability and Validity of the DynEx Dynamometer, Journal of Hand TherapyVolume 18, Issue 3, July-September 2005, ) Pienimaki, tuomo et al,the clinical journal of pain, Association between pain,grip strength and manual tests in the treatment evaluation of chronic tennis elbow.may/june 2002,vol.18,issue 3,pp EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 38

51 23) Won- Hwee Lee, Oh-Yun Kwon, Chung-Hwi Yi, Hye-SeonJeon, Sung-Min Ha. Effects of Taping on Wrist Extensor Force and Joint Position Reproduction Sense of Subjects With and Without Lateral Epicondylitis. Journal.Physiotherapy Therapeutics. Science 2011; (23): ) David J.Magee, Orthopedic Physical Assessment, 4 th edition, Saunders,2002.pp ) Ronald C.Evans, Illustrated orthopedic physical assessment, 2 nd edition,pp316 26) John Low and Reed.Electrotherapy Explained: principles and practice. 3 rd ed. Buttersworth-Heinemann, 1999, 27) Sheila kitchen, Electrotherapy: Evidence Based Practice, 11 th ed. Churchill Livingstone, ) Hillel M. finestone, Deborah L. robinovitch. Tennis elbow no more, practical eccentric and concentric exercises to heal the pain; Can Fam Physician, 2008 Aug; 54(8): EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 39

52 ANNEXURE EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 40

53 ANNEXURE 10.1 CONSENT FORM EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 41

54 ETHICAL INFORMED CONSENT FORM Study title: EFFECTIVENESS OF MULLIGAN MOBILIZATION AND TAPING IN LATERAL EPICONDYLITIS. Subject s Name: Age : Years Sex: Address of the Subject I have been explained in details about the various questions/tests that will be asked/performed is to assess my functional capacity & health status etc. I have also been explained that all the tests are noninvasive and without any side effect. I understand that my participation in the study is voluntary and that I am free to withdraw at any time, without giving any reason, without my medical care or legal right being affected. I understand that the data obtained through the study may be used for research paper publication and I also understand that my identity will not be revealed at any cost. I agree to give my consent for taking my photograph and have no objection against it. I agree to take part in the above study Signature / Thumb impression of the subject Date: Name of Witness: Signature of the Witness: Signature of Investigator Date: EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 42

55 ANNEXURE 10.2 DATA COLLECTION FORM Name: Age: Occupation: Gender: Contact no: Address: Chief complain: Provisional diagnosis: Pain history: Site: Frequency: Aggravating factors: Type: Duration: Relieving factors: Outcome measures: PRTEE: Pre score Post score Hand grip strength: Pre score Post score EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 43

56 ANNEXURE 10.3 MEASUREMENT TOOL Patient rated tennis elbow evaluation (PRTEE) Clinical test: Cozen s test Mill s test Hand dynamometer EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 44

57 ANNEXURE 10.4 SCALES USED IN OUTCOME MEASURES PATIENT-RATED TENNIS ELBOW EVALUATION Name Date Instruction: Please rate the activities in each category according to your difficulty. Circle one for each activity. 1. PAIN in your affected arm Rate the average amount of pain in your arm over the past week by circling the number that best describes your pain on a scale from A zero (0) means that you did not have any pain and a ten (10) means that you had the worst pain imaginable. RATE YOUR PAIN: No Pain Worst Imaginable When your are at rest When doing a task with repeated arm Movement When carrying a plastic bag of groceries When your pain was at its least When your pain was at its worst Pain score = ( ) = /50 EFFECTIVE OF MULLIGUN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 45

58 2. FUNCTIONAL DISABILITY A. SPECIFIC ACTIVITIES Rate the amount of difficulty you experienced performing each of the tasks listed below, over the past week, by circling the number that best describes your difficulty on a scale of A zero (0) means you did not experience any difficulty and a ten (10) means it was so difficultyou were unable to do it at all. No Difficulty Turn a doorknob or key Carry a grocery bag or briefcase by the handle Lift a full coffee cup or glass of milk to your Mouth Open a jar Pull up pants Wring out a washcloth or wet towel B. USUAL ACTIVITIES Rate the amount of difficulty you experienced performing your usual activities in each of the areas listed below, over the past week, by circling the number that best describes your difficulty on a scale of By usual activities, we mean the activities that you performed before you started having a problem with your arm. A zero (0) means you did not experience any difficulty and a ten (10) means it was so difficulty you were unable to do any of your usual activities. Unable To Do 1.Personal activities (dressing, washing) Household work (cleaning, maintenance) Work (your job or everyday work) Recreational or sporting activities Functional score= ( )/2= /50 Total score= = /100 EFFECT OF MULLIGAN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 46

59 ANNEXURE 10.5 MASTER CHART GROUP A MULLIGAN MOBILISTAION, STRETCHING, ULTRASOUND SR NO AGE GENDER PRTEE HAND GRIP STRENGTH(kgs) PRE POST PRE POST SCORE SCORE SCORE SCORE 1 55 F M F M F F F F F F F F F F F EFFECTIVE OF MULLIGAN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 47

60 GROUP B TAPPING,STRETCHING,ULTRASOUND SR NO AGE GENDER PRTEE HAND GRIP STRENGTH PRE POST PRE POST SCORE SCORE SCORE SCORE 1 55 F F F F M M F F F F F F M F F EFFECTIVE OF MULLIGAN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 47

61 EFFECTIVE OF MULLIGAN MOBILISATION AND TAPPING IN LATERAL EPICONDYLITIS Page 47