ARTICLE INFO. Key Words: Mulligan s MWM, MIMG protocol, myofascial mobilization, myofascial manipulation, WOMAC scale, patellar mobilizations.

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1 International Journal of Therapies and Rehabilitation Research [E-ISSN: ] IJTRR 2015, 4: 4 I doi: /ijtrr Original Article Open Access Effect of Mulligan s MWM versus Macquarie Injury Management Group (MIMG) protocol on pain and function in osteoarthritis of knee: a randomized clinical trial Swathi Kandada 1, Anand Heggannavar 2 ARTICLE INFO Article History: Received: June 30, 2015 Accepted: July Published: July 21, 2015 Key Words: Mulligan s MWM, MIMG protocol, myofascial mobilization, myofascial manipulation, WOMAC scale, patellar mobilizations. AUTHORS AFFILIATIONS 1 (MPT), KLE University Institute of Physiotherapy, Belagavi. 2 MPT, Assistant Professor, KLE University Institute of Physiotherapy, Belagavi. ABSTRACT Objective: Compare the effectiveness of Mulligan s MWM and MIMG protocol on pain and function in knee osteoarthritis. Background: Osteoarthritis is a disorder of the diarthrodial joint, a slow degenerative disease clinically characterized by pain, loss of functional mobility. On a radiograph seen as reduced joint space, formation of osteophytes, sclerosis of bone and deformity. Manual therapy has proved to be an effective treatment method in knee osteoarthritis (OA), but there is a need to investigate effectiveness of different manual therapy techniques. There is limited evidence on effect of Mulligan s MWM and MIMG protocol in knee OA. Participants: 64 subjects (mean age 52.42±6.95 years) with the diagnosis of knee OA stage II and III on Kellegren Lawrence classification were recruited from tertiary health care hospital, Belagavi, Karnataka. Methods: A randomized clinical trial was conducted on 64 subjects, were randomly allocated into two groups, Group A (n=32) receiving Mulligan s MWM (6 sessions) +conventionaltherapy (14sessions) and Group B (n=32) receiving MIMG protocol (6 sessions) +conventional-therapy (14 sessions) for a period of 2 weeks. The outcome measures were Visual Analogue Scale (VAS), Range of Motion (ROM) and WOMAC scale. The outcomes assessed on day 1 pretreatment and day 14 post-treatment. Results: Pre and post mean difference values in Group A were 5.38±1.07cm, 8.75± and 40.31±7.24 for VAS, ROM flexion and WOMAC respectively. While the pre and post mean difference values for Group B were 5.28±1.11cm, 12.19± and 41.41±12.62 for VAS, ROM flexion and WOMAC respectively. The intra group comparison was statistically significant with p= < Inter- group comparison is not statistically significant. Conclusion: Both Mulligan s MWM and MIMG protocol are effective in treating OA knee. Hence can be suggested as one of the treatment regime. INTRODUCTION Osteoarthritis is characterized by decoupling of degenerative and repair process resulting in degeneration of the joint 1. Degeneration of the articular cartilage, results in alteration of its biomechanical properties leading to focal loss of articular cartilage, loss of joint space, osteophyte formation, focal area of synovitis, periarticular bone remodelling and subchondral cysts. 2

2 Knee joint is the most frequently affected in OA and results in pain and mobility impairment in the elderly. 3 Symptomatic knee osteoarthritis has high prevalence among older people in the Asian region both in rural and urban areas. 4 OA knee has a multifactorial etiology which includes increased mechanical stress, obesity, age, genetic predisposition and greater bone density. 5 Other risk factors of OA are female gender, geographic factors, smoking, occupational kneeling or squatting, lifting heavy weights, ethnicity, joint trauma, immobilization. 1,6 OA knee is generally classified as primary (idiopathic) and secondary. Signs and symptoms of OA knee are pain during weight bearing, limited knee range of motion, crepitus, occasional effusion, and variable degrees of local inflammation. 7 Sequence of pathological events in OA usually begins in the antero-medial compartment of the knee joint leading to fibrillation, sclerosis, eburnation and osteophyte formation are the sequence of events in OA. 8 The Kellegren and Lawrence method is a validated method to classify OA into 4 grades based on level of destruction on radiographic images; grade I shows early changes and grade IV shows severe radiographic disease. 9 Electrical modalities are used to relieve pain; other treatment methods are exercises, patellar taping, thermal modalities and aerobic walking 10. Shortwave (SW) diathermy can be used to reduce pain and swelling, accelerate the inflammatory process, and promote healing in tissues with chronic inflammation. 11 Exercise consistently yields better improvements in pain, physical function and also helps to improve quality of life in osteoarthritis. 12 Manual therapy includes many techniques of which the most common is joint mobilization and manipulation. Manual therapy combined with stretching and strengthening exercises to the effected components of the full kinematic chain of lower extremity i.e., the ankle, knee, hip and the lumbar segments along with the knee joint had proved beneficial effects. 13 MIMG knee protocol is a chiropractic approach which includes two techniques myofascial mobilization and myofascial manipulation. It was introduced by the MIMG group, Australia. Brian Mulligan s Mobilization with Movement (MWM) for peripheral joints is a widely used to restore functional movements in joints even after many years of restriction. 15 Mobilization with Movement is the concurrent application of pain-free accessory mobilization with active and/or passive physiologic movement. Passive end-range over pressure may now be applied without pain as a barrier. 16,17 The present clinical interest is to investigate the effectiveness of manual therapy and chiropractic techniques in peripheral joints as there is little evidence in this region. Pain and functional limitation is the major concern in OA knee, manual therapy techniques were proved to be effective in improving pain and function. Both MWM and MIMG have evidence that these techniques are effective in reducing pain, improving range and function in participants with knee OA. 14,18-20 The aim of this study is to compare the effectiveness of MWM and MIMG on pain and function in OA knee. MATERIAL AND METHODS A total of 70 participants were screened for primary osteoarthritis, out of which 6 were excluded as they did not meet the inclusion criteria. 64 subjects with knee OA were recruited in the study as per the following inclusion criteria 1)both female and male subjects aged between 40 to 60 years, 2) subjects with primary knee osteoarthritis, Grade II and III by Kellegren Lawrence. Subjects were excluded if they had 1) any surgical procedure done for lower extremity in past 6 months, metal implants in lower limb, 2)any infection or neoplastic disorder,3)post traumatic knee stiffness, 4)secondary knee oa,5)peripheral vascular disease. Demographic data was recorded and physical examination will be carried out prior to intervention. Participants were recruited and randomly allocated into control group (A) or experimental group (B). The study was carried out in tertiary health care hospitals, Belagavi after the approval from Institutional Ethical Committee and informed consent was obtained from the subjects. OUTCOME MEASURES: Outcome measurements were VAS for pain, ROM was calculated using a goniometer and WOMAC index to assess function was taken on 1 st day before intervention and 14 th day after intervention. Knee pain is measured on Visual Analogue Scale by asking the subject to mark on a 10 cm scale based on the severity of pain where 0 is signifies as no pain and 10 as worst pain. ROM measured using a Goniometer with subject in supine position and asking the subject to flex his knee while the range is measured and functional assessment is assessed with WOMAC index, a well validated and self administered scale which consists of a total of 24 items in 3 domains. Pain- 5 items, Stiffness -2 items, Physical function- 17 items. Total score ranges from 0 to 96. Each item is scored 0(none), 1(mild), 2(moderate), 3(severe) and 4(extreme). Average of the score is obtained by dividing the total score with 96 and multiplying with 100. Procedure: The subjects were randomly allocated into 2 groups using card method, with 32 subjects in each group.group (A) received Mulligan s MWM and conventional therapy. MWM includes a medial glide, lateral glide (photograph 2) applied with a belt and maintained and the subject asked to flex his knee actively and rotation glide (photograph 1) with subjects knee in flexed position in supine and the therapist internally rotates tibia on femur and fibula is moved ventrally when the glide is maintained, mobilizations given for 6 sessions in two weeks. 15

3 Photograph 1: Rotational Glide Photograph 4: Myofascial Manipulation STATISTICAL ANALYSIS Statistical analysis for the present study was done using SPSS version 21. Demographic data i.e. age, gender, BMI, duration of symptoms were analyzed using chi-square test and t-test. Within group comparison for VAS intervention was done by Wilcoxon matched pairs test and between group comparison with Mann-Whitney U test. Range of Motion (ROM) and WOMAC (function) were analyzed by paired t-test. Level of significance was set at p<0.05. Photograph 2: Lateral Glide Group B received MIMG protocol+ conventional therapy. MIMG chiropractic knee protocol consists of a non-invasive myofascial mobilization (photograph 3) procedure and an impulse thrust (photograph 4) procedure. The mobilization procedure directs a small, sustained load and specific force to the patellofemoral articulation in a pre-determined direction of movement. This load was achieved through the active extension and flexion of the knee in the range starting from 90 of knee flexion to available full extension. During this movement, the patella is actively mobilised in a supero-inferior direction in a plane directed tangentially to the patella 17 for 6 sessions in 2 weeks. 14 Conventional therapy 13 is given 1 session/day for 14 days; includes Short Wave Diathermy, contralateral method for 15 minutes duration, stretchings for gastrocnemius, hamstrings and quadriceps muscle 3 repetitions of 30-sec hold, and strengthening exercises for quadriceps 1 set of 10 repetitions, range of motion exercises two 30sec bouts with 3 sec hold at end range and patellar mobilizations( grade III and IV) 2-6 bouts of 30 sec. Photographh 3: Myofascial Mobilization RESULTS 64 participants were included in the study through random sampling method into either groups and received intervention for 2 weeks. Demographic Profile: Each group had 32 participants. The mean age of participants in group A was 50.13±6.94 and group B was 54.72±6.25. Other details such as BMI, gender, duration of symptoms and knee affected were shown in table 1. Outcome measures: The intra group comparison for VAS, ROM and WOMAC had shown statistical significance (p< ) (table 2). The mean values of VAS score reduced from 7.72±0.92 to 2.34±0.65 with a difference 5.38±1.07 in group A and from 7.56±1.13 to 2.28±1.08 with a difference 5.28±1.11 in group B (fig.1). In group A WOMAC reduced from 63.73±10.27 to 23.42±40.31 with a difference 40.31±7.24, in group B from 66.03±12.04 to 24.62±13.09 with a difference 41.41±12.62(fig.3). In group A ROM increased from ±10.92 to ±6.65 with a difference 8.75±7.41 and in group B from ±13.59 to ±6.69 with a difference 12.19±10.47(fig.2). Between groups comparison showed no statistical significance in VAS, ROM and WOMAC with p-values , and respectively (table 3) TABLE: 1 Shows the Baseline Characteristics DISCUSSION The present study was to compare the effects of Mulligan s MWM mobilizations and MIMG protocol of myofascial mobilization and manipulation in osteoarthritis knee. It showed improvement in various parameters assessed in both the groups compared to their baseline values in terms of pain (VAS), ROM and function (WOMAC) pre treatment and after 2 weeks of treatment.

4 Table 1 Variables Group A Group B t-value p-value Mean Std.Dev. Mean Std.Dev. Age (yrs) * BMI (kgs/m 2 ) * Duration of symptoms (days) chi-square p-value Gender Male (%) Female (%) Knee affected Right (%) Left(%) p 0.05 TABLE 2: Intra group comparison of VAS, ROM and WOMAC Variables Group Pre-treatment Post-treatment Difference p-value VAS a Group A 7.72(0.92) 2.34(0.65) 5.38(1.07) * Group B 7.56(1.13) 2.28(1.08) 5.28(1.11) * ROM b Group B (13.59) (6.69) (11.5) * Group A (10.92) (13.59) -8.75(7.41) * WOMAC b Group B 66.03(12.04) 24.62(13.09) 41.41(12.62) * Group A 63.73(10.27) 23.42(8.17) 40.31(7.24) * p 0.05; a. Wilcoxon matched pairs test; b. Paired t-test Table 3: inter group comparison of VAS, ROM and WOMAC Variables Group Pre-treatment Post-treatment Difference VAS a Group A 7.72(0.92) 2.34(0.65) 5.38(1.07) Group B 7.56(1.13) 2.28(1.08) 5.28(1.11) p-value ROM b Group B (13.59) (6.69) 12.19(10.47) Group A (10.92) (6.65) 8.75(7.41) WOMAC b Group B 66.03(12.04) 24.62(13.09) 41.41(12.62) Group A 63.73(10.27) 23.42(8.17) 40.31(7.24) p 0.05; a: Mann-Whitney U test; b: paired t-test Women aged above 50 years had a high incidence of OA knee compared to men of same age group; hence proved age and gender are the risk factors for OA knee. Studies have shown that osteoarthritis is common and is more prevalent in people aged above 50 years. Women aged 50 years have high prevalence compared to men, in male population people aged 60 and more have high prevalence of OA. 21, 22 Patients in MWM group had shown reduced pain and improved function and range. MWM group had shown short-term benefits of pain reduction and improved range and function, long term follow-up benefits could not be assessed; literature supports immediate effects and short-term benefits of Mulligan s MWM in OA knee on pain and disability. The mechanism of pain reduction in MWM supports the involvement of biomechanical and neurophysiological mechanism, eventhough there is low evidence in support to the statement. Biomechanically correction of positional fault could relieve pain and neurophysiological mechanisms include changes in descending pain inhibitory systems and changes in central pain-processing mechanisms.

5 Group A Group B pre post difference Figure 1. VAS scores Group A Group B pre post difference Figure 2. ROM scores Group A Group B pre post difference Figure 3. WOMAC scores

6 The large movement done actively by the patient when glide is maintained passively by the therapist there may be alterations in concentration of inflammatory mediators and results in deactivation of silent nociceptors activated by such inflammatory mediators. 16,18-20 A study done by Dimitrova E has proved that MWM is feasible and efficacious in individuals with knee osteoarthritis. 23 The MWM concept has the potential to produce immediate and long-lasting effects, even in patients that had not previously responded to other treatment for an extended period of time. 24 The long term benefits of MWM could not be assessed as a follow up could not be done, future studies are needed to assess for the long term benefits. Patients in MIMG group had shown immediate relief of pain and improved range which was maintained till the next session and improved function in few sessions, this can be attributed use of SWD prior to mobilization. Heat dissipated from SWD increases the pain threshold as a response of deep action of heat upon free nerve endings or on the nerve trunk that supplies the affected area, heat also reduces the muscle spasm as it directly acts on the muscle spindles and in turn reduces pain. 25 Application of SW diathermy to the involved tissues may increase vascular circulation and change tissue temperature, which directly results in vascular dilatation, an increase in pain threshold, and a decrease in pain and swelling. Such vascular improvement also accelerates the inflammatory process by increasing nutrition and oxygen supply and by removing metabolic and waste products. 11 Pollard H and Chiro GD et al studied that the MIMG had benefits in a short term period on self reported pain and knee function after a 2 week treatment period, their study used placebo effect of TENS where intensity was set at zero. 19 The mobilization procedure stretches the joint capsule in the sagittal plane and likely loosens adhesions of the patellofemoral articulation. In addition, the anterior thigh musculature is effectively mobilized so that the tight myofascial thigh structures are released. Manipulation involves an impulse type thrust directed in the caudal direction, delivered to the knee of the patient with the object of this procedure is not to produce joint cavitation, more so to mobilize the joint. 14 There is a need to investigate the immediate effects of MIMG as subjects showed a better improvement after 10 sessions of treatment. They also reported reduced pain and improvement in functional activities such as walking; standing more than hour, reduced stiffness in mornings and evenings. Literature supports the immediate effects of MWM in knee OA and in other peripheral joints. An immediate effect of MWM was shown in pain reduction and improved range of motion also improved functional performance. 18 Quadriceps weakness is known to be a risk factor in OA knee and is considered to be one of the reason for disease progression, 26 taking this factor into consideration quadriceps strengthening program had been included as a part of conventional therapy. This could be one of the reasons for early recovery of subjects in this study. The combined effect of SWD, mobilizations and exercises could be a reason for early recovery in most of the subjects. Studies support quadriceps strengthening as a treatment regime in OA knee. Limitation of the study is long term effects could not be assessed as follow-up was not done after the intervention period. FUTURE SCOPE A similar study with long-term follow up can be undertaken. Combination of other modalities can be considered for comparison. A future study needs to investigate the immediate effects of MIMG protocol. CONCLUSION This study has investigated effectiveness of Mulligan s MWM mobilization and MIMG protocol in osteoarthritis knee and the study shows that significant improvement is seen in both the groups. The present study supports the use of both Mulligan s MWM and MIMG protocol as physical therapy measure as both techniques are effective in treating OA knee. ACKNOWLEDGEMENT: We would like to thank all the participants of the study for their co-operation throughout the study. We would like to thank KLES DR. Prabhakar Kore s Hospital and MRC and KLES Ayurveda Hospital. CONFLICT OF INTEREST: None REFERENCES 1. Siddharth Kumar Das; Osteoarthritis. Best Practice And Research Clinical Rheumatology. 2008: 22(4): Mahajan A, Verma S, Tandon V. Osteoarthritis. J Assoc Physicians India 2005; 53: Corti M. C. and Rigon, C. Epidmiology of osteoarthritis: prevalence, risk factors and functional impact. Aging Clinical and Experimental Research Oct;15(5): Kinsella K, He W (2009) An Ageing World: U.S. Census Bureau, Washington, DC. 5. World Health Organisation. The Bone and joint Decade Marlene Fransen, Lisa Bridgett, Lyn March, Damian Hoy, Ester Penserga And Peter Brooks. The epidemiology of osteoarthritis in Asia. International journal of rheumtic diseases 2011;14: Symmons d, Mathews C, and Pfleger B. 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