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 Table of Contents  
Year : 2015  |  Volume : 3  |  Issue : 2  |  Page : 198-202

Effectiveness of muscle energy technique and Mulligan's movement with mobilization in the management of lateral epicondylalgia

1 Department of Physiotherapy, Global Hospitals and Health City, Chennai, Tamil Nadu, India
2 Department of Physiotherapy, University of Gondar, Gondar, Ethiopia

Date of Web Publication16-Dec-2015

Correspondence Address:
Ravichandran Hariharasudhan
Global Hospitals and Health City, 439, Cheran Nagar, Chennai - 600 100, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-4848.171904

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Aim: To evaluate the therapeutic effectiveness of muscle energy technique (MET) and mobilization with the movement of elbow in subjects with lateral epicondylalgia (LE). Settings and Design: This study was conducted in Global Hospitals and Health City, Chennai 100. Subjects were allocated into group A and B through simple randomization method and double-blinded randomized controlled trial was performed. Materials and Methods: An interventional comparative study was conducted on 30 patients having LE. They were randomly assigned to one of the two groups. Group A (n = 15) was treated using movement with mobilization, group B (n = 15) was treated with MET. Both groups received conventional treatment of therapeutic ultrasound, after corresponding interventions. Visual analog scale (VAS) and elbow functional assessment (EFA) scales were the outcome measures, respectively. Measurements were performed before the beginning of treatment, after 10 days and 3 weeks afterward. Statistical Analysis Used: ANOVA and post-hoc analysis Bonferroni method were used to analyze measurements taken at baseline and follow-up at 10 th day and 3 rd week. Results: Subjects who received mobilization with movement showed a significant improvement in both VAS and EFA than the other group which received MET. Conclusion: We conclude that mobilization with the movement of elbow appears to be more effective manual technique in treating LE in comparison with MET.

Keywords: Elbow functional assessment, lateral epicondylalgia, movement with mobilization, muscle energy technique, visual analog scale

How to cite this article:
Hariharasudhan R, Balamurugan J. Effectiveness of muscle energy technique and Mulligan's movement with mobilization in the management of lateral epicondylalgia. Arch Med Health Sci 2015;3:198-202

How to cite this URL:
Hariharasudhan R, Balamurugan J. Effectiveness of muscle energy technique and Mulligan's movement with mobilization in the management of lateral epicondylalgia. Arch Med Health Sci [serial online] 2015 [cited 2023 Feb 2];3:198-202. Available from: https://www.amhsjournal.org/text.asp?2015/3/2/198/171904

  Introduction Top

Lateral epicondylalgia (LE), or tennis elbow, is a painful condition characterized by pain at the lateral epicondyle, aggravated by resisted muscle contraction of the extensor carpi radialis brevis (ECRB). [1],[2] Subjects with LE exhibit an impaired ability to perform tasks that require gripping, with reduced grip force and weakness of wrist flexion and extension. [3],[4]

The dominant arm is commonly affected, the peak prevalence is between 30 and 55 years of age, with no apparent gender bias. [5]

Even though tennis elbow has well-defined clinical features, no proper treatment intervention has emanated. [6] Different treatment modalities have been described, including nonsteroidal anti-inflammatory drugs, steroid injections, topical glyceryl trinitrate, exercise therapy, manual therapy, ultrasound therapy, laser therapy, extracorporeal shockwave therapy, orthotics, acupuncture, taping, hyaluronan gel injections, botulinum toxin injections, and surgery. [7] Even then, treatment interventions for LE lack scientific validation.

Physiotherapy is a conservative treatment, that is, usually recommended for LE subjects. [8] A wide array of physiotherapy treatments have been recommended for the management of lateral elbow tendinopathy. [9] These treatments have different theoretical mechanisms of action, but all have the major aim: To reduce pain and improve function. Such a variety of treatment options suggests that the optimal treatment strategy is not known, and more research is needed to discover the most effective treatment in patients with LE. One of the most common physiotherapy treatments for LE is an exercise program. The use of manual techniques in the management of musculoskeletal dysfunction has become widespread among physiotherapists in recent years. Most common among these manual techniques are movement with mobilization (MWM), deep transverse friction massage, and muscle energy technique (MET).

MET is a gentle manual therapy intervention targeting the soft tissues primarily, although it also makes a major contribution toward the joint mobilization. It is also described as active muscular relaxation technique (Liebenson, 1989 and 1990). In addition, evidence-based practice standards should be developed and implemented to improve the overall healthcare through value-added care. [10] Mulligan's MWM proposed to correct a positional fault of the joint following an injury or strain. MWM approach combines passive physiological movement applied by the therapist with active movement performed by the subject.

To our knowledge, there have been no studies to investigate the effectiveness of MET and MWM for the management of LE. Therefore, the aim of our study is to investigate the effectiveness of MET and Mulligan's MWM in the management of pain and elbow functional recovery among subjects with LE.

  Materials and Methods Top

From September 2012 to August 2013, 43 subjects who were clinically diagnosed by their Physician or Orthopedician with LE were reviewed to collect age, gender, duration of symptom, hand dominance, medications, and past physiotherapy treatments. Among the 43 subjects 4 of them had bilateral symptoms, 7 of them had steroid injections (2 weeks ago), 2 of them not willing to participate. Hence after going through inclusion and exclusion criteria [Table 1], 30 Subjects were recruited for the study comprising 15 females and 15 males from the ages of 30 to 59 years. This study was conducted in Global Hospitals and Health City, Chennai 100, Tamil Nadu, India.
Table 1: Inclusion and exclusion criteria

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This is a double-blinded randomized controlled study in which all subjects involved in this study were explained about the study and written consent was obtained. They were allocated to group A and B using simple randomization method using random number table. Group A received MWM while group B received MET. All the subjects underwent baseline assessment using a specific Performa.

In this simple randomized double-blinded study, subjects were not aware of the group in which they are allocated and the assessor is not revealed about the subjects group. Baseline and follow-up assessment were performed by a senior physiotherapist with more than 10 years experience. Treatment for subjects was provided by another therapist who is kept blinded regarding baseline and follow-up assessments.

Subjects with group A received MWM technique. The technique involves the application of lateral glide to the proximal forearm laterally while the other hand to glide the distal end of the humerus. The glide was applied and sustained for approximately 5-10 s while the patient performed the pain-free gripping action. Totally, 6 repetitions of the technique were performed during a single treatment session. The period of time between each repetition was no longer than 60 s. This technique was applied in 5 sessions/week for 3 weeks. The fundamental rule that the technique should not provoke pain was followed.

Group B subjects received MET. In this technique therapist stabilizes, the subject's arm distally with one hand, and the subject's forearm was supinated with the therapist's other hand until resistance or discomfort was detected. While the position was held, the subject briefly pronated the forearm (isometric contraction approximately 75% of maximal) against resistance for a period of 5 s, followed immediately by slightly increased supination until resistance was met once again [11] [Figure 1]. After the periods of 5 s of relaxation, the procedure was repeated 5 times during a single treatment session. This technique was applied in 5 sessions/week for 3 weeks.
Figure 1: Subject receiving muscle energy technique

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Both groups followed by the interventions received ultrasound therapy around involved lateral humeral epicondyle (Sonopuls). At a frequency of 1 MHz and pulse ratio of 1:4 was given with an intensity of 1 W/cm 2 . With a frequency of 10 min/session, 5 sessions/week. [12]

Outcome measures were measured in terms of visual analog scale (VAS) and elbow functional assessment (EFA) questionnaire at baseline, 10 th day, and follow-up after 3 weeks.

  Results Top

Data were coded and entered using EPI INFO version 3.5.1 (Centers for Disease Control and Prevention) and exported to Statistical Package for Social Sciences (SPSS) version 16 (SPSS Inc). Within group analysis was performed using post-hoc - Bonferroni test. Data were described as mean and standard deviation according to its normality. A total of 30 (100%) individuals were taken in this study were randomly divided into groups A and B. Mean age with a standard deviation of group A and B was 41.73 ± 8.319 and 40.20 ± 6.19. A total of 13 (43.3%) female and 17 (56.7%) males participated in this study. There is no significant difference between the age distribution of group A and B.

Visual analog scale for pain intensity

ANOVA for repeated measures shows that there is a significant decrease in VAS scores from the baseline to 3 weeks in both the groups. F (2, 56) = 171.9, P < 0.01. Pairwise comparison of VAS across different periods within group A and group B using post-hoc analysis - Bonferroni test was done. Multiple comparison of VAS at baseline - day 10, baseline - follow-up, and day 10 - follow-up was analyzed and found P < 0.01, which is highly significant in group A [Table 2].
Table 2: Pairwise comparison of VAS scores across different periods within group A and B using post-hoc analysis — Bonferroni test

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Elbow functional assessment scale

ANOVA for repeated measures shows that there is a significant decrease in EFA scores from the baseline to follow-up in group A. Pairwise comparison of EFA across different periods within group A and group B using post-hoc analysis - Bonferroni test was done. The P value among baseline - day 10, baseline - follow-up (after 3 weeks), and baseline - follow-up were 0.00, which is highly significant (P < 0.01). Multiple comparison shows that the difference is highly significant from the baseline to day 10 and day 10 to follow-up in group A than group B [Table 3].
Table 3: Pairwise comparison of EFA scores across different periods within group A and B using post-hoc analysis — Bonferroni test

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  Discussion Top

The results of this randomized controlled study showed that both techniques had their share of positive influences in VAS, and EFA in participants of both the groups. Subjects treated with mobilization with movement therapy showed significant outcomes than those treated with MET. In our recent work, we examined the effects of MET with strain counter strain in mechanical low back pain and found out that MET was effective in alleviating mechanical low back pain in terms of pain, increase in ROM, and reducing disability. [13] This is by means of mechanism expressed as "increased tolerance to stretch." According to Chaitow MET is an active muscular relaxation method, normal blood circulation is restored which wipes out nociceptive stimulants from the site of pain which relieves pain. [14] However, the literature on MET intervention for the management of LE is nonexistent. Even in this study though MET seems to have a prognostic effect but still lacked a statistical significance when compared with MWM in this study. This is because MET targets mainly soft tissues and primarily muscles. Whereas MWM works primarily on articular and the same time targets muscular structures too. Our study showed that the treatment of LE with MET is a good adjunctive therapy along with effective MWM.

Statistical analysis of VAS depicts that pain declined significantly in MWM group. According to Paungmali et al. (2003) MWM produces sensory input sufficient to recruit and activates descending pain inhibitory systems that result in some or all of the pain relieving effects. It produces hypoalgesic effects during and following its application, as well as sympatho excitatory effect. [15]

Vicenzino et al. (2007) hypothesized that mal-positioning of the ulna and radius occurs in relation to humerus in tennis elbow, the reduction of pain could be due to repositioning of the ulna and radius with respect to humerus achieved by lateral glide to elbow joint. [16] In MWM group, a significant improvement occurs in the functional outcome which was depicted in the statistical analysis of EFA scale. Hence, the improvement in the ability to do their usual work occurs. The pain reduction resulted in the performance of activities, which were painful previously. Both groups were provided ultrasound therapy to reduce pain and inflammatory response after interventions.

Normal function of hand provides us the ability to perceive and manipulate objects in the environment, [17] to achieve normal function of hand; proximal joints and musculatures should be optimal enough to stabilize the hand and wrist which helps to obtain precision and prehensile functions. In LE due to ECRB tendinitis, hand grip and movements are severely compromised. In any rehabilitation of the upper limbs complete recovery must be achieved, if not, it can limit the quality of life and functional independence. [18]

In view of the results obtained, MWM is more effective than MET. This is due to the fact that MWM addresses the pathology directly by correcting faulty position which was not obtained with MET. Hence, MWM should be the sole treatment approach in the management of LE complimented by MET and other interventions.

  Conclusion Top

In MWM group, a significant improvement occurs in functional outcome. Hence, the improvement in the ability to do their usual work occurs. This result proves the fact that Mulligan's MWM favors a biomechanical thesis citing correction "positional fault" that aggravates LE. Even though MET is a gentle manual technique, it fails to achieve significance immediately as compared to MWM.

  Acknowledgment Top

The authors wish their gratitude to Dr. V. Vijayanarasimhan (MS Ortho) and Dr. Clement joseph (MS Ortho) full fledge to complete this study. We are thankful to all the therapist and referral physicians for their support. We also wish to express our gratitude to our family members and friends.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Johnson GW, Cadwallader K, Scheffel SB, Epperly TD. Treatment of lateral epicondylitis. Am Fam Physician 2007;76:843-8.  Back to cited text no. 1
Luk JK, Tsang RC, Leung HB. Lateral epicondylalgia: Midlife crisis of a tendon. Hong Kong Med J 2014;20:145-51.  Back to cited text no. 2
Alizadehkhaiyat O, Fisher AC, Kemp GJ, Vishwanathan K, Frostick SP. Upper limb muscle imbalance in tennis elbow: A functional and electromyographic assessment. J Orthop Res 2007;25:1651-7.  Back to cited text no. 3
Slater H, Arendt-Nielsen L, Wright A, Graven-Nielsen T. Sensory and motor effects of experimental muscle pain in patients with lateral epicondylalgia and controls with delayed onset muscle soreness. Pain 2005;114:118-30.  Back to cited text no. 4
Shiri R, Viikari-Juntura E, Varonen H, Heliövaara M. Prevalence and determinants of lateral and medial epicondylitis: A population study. Am J Epidemiol 2006;164:1065-74.  Back to cited text no. 5
Nagrale AV, Herd CR, Ganvir S, Ramteke G. Cyriax physiotherapy versus phonophoresis with supervised exercise in subjects with lateral epicondylalgia: A randomized clinical trial. J Man Manip Ther 2009;17:171-8.  Back to cited text no. 6
Coombes BK, Bisset L, Vicenzino B. A new integrative model of lateral epicondylalgia. Br J Sports Med 2009;43:252-8.  Back to cited text no. 7
Stasinopoulos D, Johnson MI. Cyriax physiotherapy for tennis elbow/lateral epicondylitis. Br J Sports Med 2004;38:675-7.  Back to cited text no. 8
Stasinopoulos D, Johnson MI. Effectiveness of extracorporeal shock wave therapy for tennis elbow (lateral epicondylitis). Br J Sports Med 2005;39:132-6.  Back to cited text no. 9
Demeke S, Balamurugan J, Alemie GA, Abebe E. In-hospital mobility and associated factors. Br J Med Med Res 2015;5:780-7.  Back to cited text no. 10
Sucher BM, Glassman JH. Upper extremity syndromes. Phys Med Rehabil Clin N Am 1996;7:787-810.  Back to cited text no. 11
Haker E, Lundeberg T. Pulsed ultrasound treatment in lateral epicondylalgia. Scand J Rehabil Med 1991;23:115-8.  Back to cited text no. 12
Hariharasudhan R, Balamurugan J. A randomized double-blinded study of effectiveness of strain counter-strain technique and muscle energy technique in reducing pain and disability in subjects with mechanical low back pain. Saudi J Sports Med 2014;14:83-8.  Back to cited text no. 13
  Medknow Journal  
Chaitow L. Advanced Soft Tissue Techniques - MET. Churchill Livingstone: 2 nd ed; 1996. p. 4-10.  Back to cited text no. 14
Paungmali A, O'Leary S, Souvlis T, Vicenzino B. Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Phys Ther 2003;83: 374-83.  Back to cited text no. 15
Vicenzino B, Paungmali A, Teys P. Mulligan's mobilization-with-movement, positional faults and pain relief: Current concepts from a critical review of literature. Man Ther 2007;12:98-108.  Back to cited text no. 16
Balamurugan J, Hariharasudhan R. Screening of subclinical sensory impairment in hand among diabetic blinds. Int J Curr Res Rev 2012;4:167-75.  Back to cited text no. 17
Balamurugan J, Arunachalam R. Effect of repetitive unilateral and bilateral arm training using students designed manual reach equipment (MRE) in improving motor function of the hemiplegic subjects. Int J Health Sci Res 2012;2:52-8.  Back to cited text no. 18


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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