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Rajiv Gandhi University of Health Sciences,

Bangalore, Karnataka
ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION


1.

Name of the Candidate and
Address

PRIYANKA S. SALUNKE
D/503, SAHYADRI CO-OP HSC,
DEVIPADA, SADGURU NAGAR,
BORIVALI (EAST). MUMBAI- 400 066

2.

Name of the Institution
SHREE DEVI COLLEGE OF PHYSIOTHERAPY,
BALLALBAGH.
MANGALORE- 575003

3.

Course of study and subject
MASTER OF PHYSIOTHERAPY(MPT)

2 YEARS DEGREE COURSE

(MUSCULOSKELETAL DISORDERS AND

SPORTS)

4. Date of Admission to Course 21
st
MAY ,2011
5.

Title of the Topic: THE EFFECTIVENESS OF MULLIGAN MOBILIZATION
WITH MOVEMENT (MWM) AND ULTRASOUND Vs. MULLIGAN
MOBILIZATION WITH MOVEMENT AND TRANSCUTANEOUS ELECTRICAL
NERVE STIMULATION (TENS) ON LATERAL EPICONDYLITIS.

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6.






























Brief Resume of the intended work :
6.1 Introduction:


Lateral Epicondylitis or Tennis Elbow was first described in 1883 by Major, as a

condition causing lateral elbow pain in tennis players. Over the years, this term has become

synonymous with all lateral elbow pain, despite the fact that the condition is most often work

related and many patients who have this condition do not play tennis.
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Lateral Epicondylitis is a painful musculoskeletal condition which is considered to

be due to over-use, over-stress or over-exertion of the wrist extensors of the forearm. Clinical

presentation is characterized by lateral elbow pain, which may radiate into the forearm, with

reproduction of pain onresisted wrist extension and localized palpation around the common

extensor origin.
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Mulligan Mobilization with movement :-

It is developed by Brian Mulligan which is widely used technique for lateral Epicondylitis.
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Mulligan mobilization with movement is a technique in which manual force usually in the

form of a joint glide is applied to a motion segment and sustained while a previously

impaired action is performed.
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This will increase the joint range of motion(ROM), enhancing

the muscle function or treating particular pathologies.
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Ultrasound therapy:

It has become one of the most commonly used treatments in the management of soft tissue

injuries. Therapeutic ultrasound has a frequency ranging from 0.75-3 MHz, with most

machines set at frequency of 1 or 3 MHzs Ultrasound with the frequency of 1MHz is

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absorbed by tissues and is therefore used for deeper injuries whereas 3 MHz is recommended

for more superficial lesions.
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Transcutaneous Electrical Nerve Stimulation(TENS):

Transcutaneous nerve stimulation (TNS or TENS) is the application of a pulsed rectangular

wave current via surface electrodes on the patients skin.
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. TENS may prove to be suitable


intervention for tennis elbow as it may help to reduce pain without the risk of side effects.
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Need for the study:

Mulligan mobilization with movement which is widely used technique in the treatment of

lateralEpicondylitis
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. Literature has also proved that TENS is a suitable intervention for

tennis elbow and it helps in long term management of the condition.
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Other studies have shown that ultrasound also enhances recovery in patients with

Lateral Epicondylitis.
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Therefore; the purpose of this study is to find the combined

effectiveness of Mulligans MWM with ultrasound and Mulligan MWM with TENS in

reducing pain in patients with lateral epicondylitis.

Research Question
Whether the combined treatment of Mulligans MWM with ultrasound bring better
improvement in patients with Lateral Epicondylitis as compared with combined treatment of
Mulligans MWM with TENS?
Null hypothesis
There will be no significant difference in pain reduction following Mulligans

MWM in combination with ultrasound compared to Mulligans MWM in combination with

TENS in patients with lateral epicondylitis.
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Alternate hypothesis

There will be significant difference in pain reduction following Mulligans MWM in

combination with ultrasound compared to Mulligans MWM in combination with TENS in

patients with lateral Epicondylitis.


6.2 Review of literature
Akram Amro et al conducted an experimental design study on 34 patients aged

between 16 and 69 years who underwent 11 sessions of a combination of mulligans

technique and traditional treatment being in experimental group n=17 and traditional

treatment only being in the control group n=17. Pre and post test were performed for both the

groups. They concluded that the combination of Mulligans technique with traditional

treatment leads to better outcomes in the treatment of Lateral Epicondylitis than in traditional

treatment alone.
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Aatit Paungmali et al conducted a study where 24 participants out of which 7 women and 17
men with unilateral chronic lateral epicondylalgia with duration of 8.9 months. The treatment
conditions involved a lateral glide MWM technique for the elbow as described by mulligan.
The placebo condition was applied by same physical therapist and consisted of a firm manual
contact with both the hands of the participants elbow while the participant performing the
pain free gripping action. Whereas the control condition involved the pain free gripping
action by the participant but with no manual force being applied. This study concluded that a
mobilization with movement treatment technique exerted aphysiological effect similar to that
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reported for some spinal manipulation.
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Bill Vicenzino et al published a review of literature in the year 2007 stating the
overview of the literature concerning the clinical efficacy, effects and putative mechanism of
action of the MWM approach in the treatment of musculoskeletal conditions. In the review
author Kochar and Dochar conducted a study in the year 2002 on 66 participants with Quasi-
Randomized controlled trial having lateral epicondylalgia treated with (1) MWM lateral
glide plus ultrasound, (2) Ultrasound alone, (3) Controlled(no treatment). They concluded
that MWM lateral glide plus ultrasound was better than ultrasound alone and control on all
outcomes except grip strength which was only better than control.
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Linda S Chesterton et al conducted a two group pragmatic randomized clinical trial where
240 participants with male and female subjects aged 18 years and above who had consulted
their GP with new clinical diagnosis of tennis elbow. After the completion baseline
assessment patients were allocated in 1:1 ratio for 6 weeks of either primary care
management alone or primary care management with TENS were given. They concluded
that TENS may prove to be suitable intervention for tennis elbow as it may help to reduce
pain.
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Ching- Sung Weng et al conducted a research to evaluate the treatment effect of modulated
frequency mode of acupuncture like TENS on 20 patients suffering from tennis elbow pain.
The subjects were randomly assigned to 3 treatment groups. Each group (n=20) treated with
either 5KHz modulated by 2 Hz frequency mode (LF group), 5 KHz modulated by 100Hz
frequency mode of TENS (HF group) or sham TENS (control group) respectively. The
findings suggest that acupuncture like TENS with modulated frequency maybe good
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treatment choice for patient with tennis elbow.
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A Binder et.al published an article on 16thFebruary 1985 conducting a study on 76 patients
with lateral epicondylitis, 38 were randomly allocated to receive ultrasound treatment and 38
received placebo treatment. The study concluded that patient receiving ultrasound had
recovery in the condition of lateral epicondylitis.
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Ceyda Akin et al. published an article on 2010. They conducted a randomized, single-blind
placebo-controlled prospective study with 60 patients aged between 25-62 years and divided
into 2 groups of 30 patients in a randomized manner as Group-1 (U.S group) and Group-2
(Placebo U.S group) for 5 minutes each. All patients were given static splint to be worn at
night for 3 weeks. In this study it was found that Ultrasound treatment for Lateral
Epicondylitis reduced pain, improved activities of daily living and resulted in high patient
satisfaction.
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6.3 Objectives of the study
1) To find out whether the application of Mulligans MWM with ultrasound can reduce
the pain of the affected extremity in lateral epicondylitis.
2) To find out whether the application of Mulligans MWM with TENS can reduce the
pain of the affected extremity in lateral epicondylitis.
3) To compare the efficacy of Mulligans MWM with ultrasound and Mulligans MWM
with TENS to reduce pain in lateral epicondylitis.
Materials and methods:
7.1 Source of data
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Patients suffering from chronic lateral epicondylitis referred to physiotherapy by
physician/ orthopedics surgeons in and around Mangalore.
7.2 Method of collection of data
Subjects of the above mentioned who meet the inclusion criteria will be selected.
They will be randomly divided into 2 groups:
Group A: Subjects treated with Mulligans MWM and ultrasound.
Group B: Subjects treated with Mulligans MWM and TENS.
Each group consists a minimum of 25 subjects.
Inclusion Criteria:
1) Age group: 25 - 45 years.
2) Unilateral symptomatic lateral epicondylitis.
3) Chronic lateral epicondylitis/tennis elbow (3 months or more than 3 months).
4) Both male and female.
5) Full range of passive elbow extension.
6) Clinically diagnosed positive in Mills or middle finger extension test.

Exclusion criteria:

1) Subject with bilateral lateral epicondylitis.

2) Surgery of lateral epicondylitis within 12 months.

3) History of fracture of radius or ulna.

4) History of rheumatoid disease or neurologic impairment including stroke or head

injury.

5) Medial epicondylitis/ Elbow bursitis.

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6) Severe neck/shoulder problem likely to cause or maintain elbow complaints.

7) Non-cooperative patient.

8) Any deformity in elbow or upper limb.

9) Active infection, ossification, calcification of soft tissues. And patient on anti-

coagulant treatment.

Study Design:
Before After Controlled.
Sampling:
Purposive sampling according to exclusion and inclusion criteria Group A and Group B
subjects are selected by using Simple Random Sampling.
Statistical Test (Statistical Analysis):
The statistical test used will be:
1) Students t-test so as to test if there is any significant difference in the pain experienced
in patients with Mulligans MWM and ultrasound or Mulligans MWM and TENS.
2) Paired t-test for comparing the effects of the 2 techniques.
Study duration:
4 weeks.
Outcome Measure
1) Clinical test: (a) Mills Test.
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(b) Middle Finger Extension Test.
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2) Visual Analog Scale (VAS).
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METHODOLOGY:
50 subjects having Lateral Epicondylitis, satisfying the inclusion criteria will be
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recruited for the study. Informed consent will be obtained from them. Then the subjects will
randomly assigned into two groups i.e. Group A and Group B, with 25 subjects in each
group.
Pretest measurements will be taken for both groups A and B for pain by VAS.
A brief demonstration about Mulligans MWM and Ultrasound will be given to group
A subjects. After the brief introduction, group A will receive Mulligans MWM where a
laterally directed manual pressure to the proximal medial forearm will be given by the
therapist while the subject will be asked to perform the comparable sign motion. Ten
repetitions of Mulligans MWM will be given. It is then followed by Ultrasound which will
be given over the site of lesion. Continuous mode with an intensity of 1.5 Watts/cm
2
will be
given. A very slow, gliding, rotating movement will be made with the transducer over the
lateral epicondyle area. The length of time for each session will be 6 minutes.
A brief demonstration about Mulligans MWM and TENS will be given to group B
subjects. After the demonstration Mulligans MWM will be given as above this will be
followed by TENS. Conventional TENS with a frequency of 65 Hz, pulse duration of 85 pps
and low amplitude of 10 mA with one channel over the extensor surface of forearm will be
given for 10 minutes. The whole program of both the groups is given 3 times per week for a
period of 4 weeks.
On the same assessment parameters post treatment assessment of pain will be taken at
the end of 4 weeks, for both the groups for the comparison with the pre assessment data.
TOOLS AND APPARTUS:

1) Examination couch.

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2) Ultrasound machine.

3) Coupling media (Gel).

4) TENS.

5) Two elastic straps or Velcro fasteners.

6) Cotton, pillow, mackintosh sheet and scissor.

7.3 Does the study require any investigations or interventions to be conducted on
patients or other humans or animals? If so, please describe briefly.
No.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes.




























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List of References:

1) Andrew L. Whaley, Champ L. Baker. Lateral Epicondylitis. Clinical Sports Med 23

(2004) 677-691.

2) Steven Barr, Frances L. Cerisola, Victoria Blanchard. Effectiveness of Corticosteroid

injections compared with Physiotherapeutic interventions for Lateral Epicondylitis: A

Systematic Review. Physiotherapy 95 (2009) 251-265.

3) Wayne Hing et al. Mulligans mobilization with movement: Review of the Tenets and

Prescription of MWMs. NZ Journal of Physiotherapy November 2008, Vol. 36

(3):144-164.

4) Bill Vicenzino, Aatit Paungmali, Pamela Teys. Mulligans mobilization with

movement, positional faults and pain relief: Current Concept from a Critical Review

Of Literature. Manual Therapy 12 (2007) 98-108.

5) C. A. Speed Review of Therapeutic Ultrasound in Soft Tissue Lesions. Rheumatology

2001; 40: 1331-1336.

6) Forster and Palastanga.Claytons Electrotherapy.Aitbs Publishers (INDIA).9
th


Edition. Chapter 3.Electrial Stimulation of Nerve and Muscle.2004; 103.

7) Linda S. Chesterton et al. Transcutaneous Electrical Nerve Stimulation for the

Management of Tennis Elbow: A Pragmatic Randomized Controlled Trial: The TATE

Trial. BMC Musculoskeletal Disorders 2009, 10:156; 1-9.

8) A. Binder, G. Hodge et al. Is Therapeutic Ultrasound Effective in Treating Soft Tissue

Lesions? British Medical Journal Vol. 290 16
th
February 1985; 512-514.

9) AKram Amro, Ina Diener et al. The Effect of Mulligan mobilization with movement

and taping technique on pain, gripstrength, and function in patients with Lateral
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Epicondylitis. Hong Kong Physiotherapy Journal (2010)28, 19-23.

10) Aatit Paungmali, Shaun OLeary. Tina Souvlis and Bill Vicenzino.Hypoalgesic and

Sympathoexcitatory Effects of Mobilization with movement for Lateral

Epicondylalgia.PHYS THER.2003; 83:374-383.

11) Ching-Sung Weng, Shen-HwaShu et al.The Evaluation of two modulated frequency

modes of acupuncture of Tennis Elbow pain. Biomed Eng Appl Basis Comm.,

2005(October); 17:236-242.

12) Cyeda Akin, Oznur Oken et al. Short Term Effectiveness of Ultrasound Treatment in

Patients with Lateral Epicondylitis: Randomized, Single-Blind, Placebo-Controlled,

Prospective Study. Turk J. Rheumatol 2010; 25: 50-55.

13) David J. Magee. Orthopedic Physical Assessment. Elsevier Science (USA). 5
th


Edition. Chapter 6. Elbow. 2008; 379-380.

14) Susan B OSullian, Thomas J Schmitz. Physical Rehabilitation.Jaypee

Publications (Philadelphia).5
th
Edition. Chapter 28.Chronic Pain.2007; 1127.

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9. Signature of the Candidate
10. Remark of the Guide
11. Name and Designation of
(In Block Letters)
11.1 Guide
Dr. LITTY K. CHANDY
ASST. PROFESSOR,
SHREE DEVI COLLEGE OF
PHYSIOTHERAPY, MANGALORE-03.

11.2 Signature
11.3 Co-guide


Dr. JYOTHI PINTO

ASST. PROFESSOR.
11.4 Signature





11.5 Head of Department



11.6 Signature
Dr. VIJAY P
PRINCIPAL,
SHREE DEVI COLLEGE OF
PHYSIOTHERAPY, MANGALORE-03.

12. 12.1 Remark of the
Chairman And Principal

12.2 Signature