Estudio Sacroiliaca Mulligan

COMPARATIVE EFFECTIVENESS OF MULLIGAN
MOBILISATION AND MULLIGAN TAPING

TECHNIQUE IN SACROILIAC JOINT
DYSFUNCTION-RANDOMIZED CLINICAL TRIAL
BY
SAMANTHA .F. FERNANDES
Dissertation
Submitted to Rajiv Gandhi University of Health Sciences,
Karnataka, Bangalore
In partial fulfillment of the Regulations for the award of the Degree
of
MASTER OF PHYSIOTHERAPY
MUSCULOSKELETAL DISORDERS AND SPORTS
PHYSIOTHERAPY
UNDER THE GUIDANCE OF:
Dr. GANESH.B.R M.P.T.

ASST PROFESSOR
KLES INSTITUTE OF PHYSIOTHERAPY,

JAWAHARLAL NEHRU MEDICAL COLLEGE CAMPUS,
BELGAUM, KARNATAKA
FEBRUARY 2010
Rajiv Gandhi University of Health Sciences

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation entitled COMPARATIVE
EFFECTIVENESS OF MULLIGAN MOBILISATION AND MULLIGAN
TAPING TECHNIQUE IN SACROILIAC JOINT DYSFUNCTION RANDOMIZED CLINICAL TRIAL is a bonafide and genuine research
work carried out by me under the guidance of Dr. GANESH .B. R,

MPT.
Assistant Professor, KLES Institute of Physiotherapy, Belgaum.
Date:
SAMANTHA .F. FERNANDES,
Place: Belgaum
Post graduate student,

KLES Institute of Physiotherapy, Belgaum
II

CERTIFICATE BY THE GUIDE

This is to certify that this dissertation entitled COMPARATIVE
TAPING TECHNIQUE IN SACROILIAC JOINT DYSFUNCTIONRANDOMIZED CLINICAL TRIAL is a bonafide and genuine research
work carried out by SAMANTHA .F. FERNANDES in partial

fulfillment of the requirement for the degree of Master of
Physiotherapy.
Guide:
Dr. GANESH .B. RMPT

Assistant Professer,
KLES Institute of Physiotherapy,
Belgaum
Date:
Place: Belgaum
III

CERTIFICATE BY THE CO-GUIDE

This is to certify that this dissertation entitled COMPARATIVE
TAPING TECHNIQUE IN SACROILIAC JOINT DYSFUNCTIONRANDOMIZED CLINICAL TRIAL is a bonafide and genuine research
work carried out by SAMANTHA. F. FERNANDES in partial

fulfillment of the requirement for the degree of Master of
Physiotherapy.
Co-Guide:
Dr. VIJAY. B. KAGE MPT

Lecturer,
KLE Societys Institute of
Physiotherapy, Belgaum
Date:
Place:
IV

ENDORSEMENT
This
is
to
certify
that
this
dissertation
entitled
COMPARATIVE EFFECTIVENESS OF MULLIGAN MOBILISATION

AND MULLIGAN TAPING TECHNIQUE IN SACROILIAC JOINT
DYSFUNCTION-RANDOMIZED CLINICAL TRIAL is a bonafide and
genuine
research
work
carried
out
by
SAMANTHA.
F.
FERNANDES under the guidance of Dr. GANESH. B. R,
MPT.
Assistant Professor, KLES Institute of Physiotherapy.
Date:
Dr. SANJIVKUMAR MPT, PM & IR
Place: Belgaum
Principal,
KLES Institute of Physiotherapy,
Belgaum
COPYRIGHT
DECLARATION BY THE CANDIDATE
I hereby declare that the Rajiv Gandhi University of Health

Sciences, Karnataka shall have the rights to preserve, use and
disseminate this dissertation / thesis in print or electronic format for
academic / research purpose.
Place: Belgaum
Date:
SAMANTHA F. FERNANDES
Rajiv Gandhi University of Health Sciences, Karnataka
VI
ACKNOWLEDGEMENT
I take this opportunity to thank all those people who have encouraged me
right from the conception of this work till its present form.
With my heartful salutation and deep sense of reverence, I express my most
humble and profound gratitude to my respected teacher Dr. Sanjivkumar MPT,PM&IR,
Principal, KLES Institute of Physiotherapy, Belgaum for his sympathetic attitude, able
guidance and constant encouragement through out this study.
With great privilege, I also express my most humble gratitude to my Guide
Dr. Ganesh. B. RMPT, Assistant Professor, KLES Institute of Physiotherapy, Belgaum
for her timely guidance, critical suggestions and constant encouragement which went
all the way in successful completion of this work.
I immensely thank Dr. Vijay B. Kage
MPT,
Lecturer for his constant
guidance, suggestions and encouragement, which went all the way in successful
completion of this work.
I immensely thank Mr. R.H. Dhareshwar,
M.SC.
M.Sc. Phil
and Mr. M. D. Mallapur,
Lecturer in Statistics, for his kind help and co-operation in the statistical analysis
of this study.
With great respect, I extend my special thanks and gratitude to all the
Teaching Staff for all the help and advice rendered to me during my study period.
I also sincerely thank to my juniors, Interns and Non Clinical staff for
their co-operation during the study.
VII
I am extremely thankful to my Classmates for their kind understanding and

support during the course of my study.
It would be unfair of me if I fail to thank all the Participants in this study without
whom this study would have been impossible.
I also like to thank Miss. Veena and Mr. Deepak of Sai Xerox & D.T.P
Centre, for Formatting, Printing & Binding of this Dissertation.
I certainly owe my gratitude to my Parents and my brothers for their
never ending love and support.
This task would not have been completed without the grace of ALMIGHTY,
JESUS CHRIST the best healer and to HIM I bow!
SAMANTHA. F. FERNANDES
VIII
LIST OF ABBREVIATIONS USED

BMI
Body mass index
Wt
Weight
Ht
Height
Mts
Meters
Kg
Kilogram
SIJ
Sacroiliac joint
SIJD
Sacroiliac joint dysfunction
MWM
Movement With Mobilisation
SNAGS
Sustained Natural Apophyseal Glides
NAGS
Natural Apophyseal Glides
KT
Kinesio Taping
FABER
Flexion Abduction External Rotation
VAS
Visual Analog Scale
MODQ
Modified Oswestery Disability Questionnaire
TENS
Transcuteneous Electrical Nerve Stimulation
US
Ultarsound
Viz
Namely
IX
ABSTRACT
TITLE
COMPARATIVE EFFECTIVENESS OF MULLIGAN MOBILISATION AND
MULLIGAN
TAPING
TECHNIQUE
IN
SACROILIAC
JOINT

Background and Objectives
The objectives of the present study were to find out the comparative
effectiveness of Mulligan Mobilisation and Mulligans Taping Technique in
Sacroiliac Joint Dysfunction.
Materials and Methods
60 subjects having clinical diagnosis of sacroiliac joint dysfunction (anterior
innominate) were randomly allocated to two study groups. Group A received
therapeutic ultrasound (1 MHZ, 1 watt/cm, 5 minutes) and Mulligan Mobilisation for
ten consecutive days and group B received Therapeutic ultrasound same as group A
and Mulligan Taping Technique by using Kinesio Tex tape, thrice in ten days. The
outcome was assessed in terms of Visual Analog Scale (VAS), and Modified
Oswestery Disability Questionnaire on first and last day of intervention.
Results
The demographic data was well matched in both the groups. Pain intensity in
terms of VAS and Modifed Oswestery Disability Questionnaire decreased
significantly in both the groups after the treatment. Comparing the two groups better
effect was seen in group B (p=0.0357) for VAS and (p=0.0238) for MODQ.
Conclusion and interpretation

The present study demonstrates that both the manual therapy techniques Viz
Mulligan Mobilisation and Mulligan Taping Technique along with Ultrasound
therapy are effective in relieving pain and decreasing disability in Sacroiliac joint
dysfunction. The study also demonstrated that Mulligan Taping Technique were more
effective in decreasing pain and disability as compared to Mulligan Mobilisation.
KEY WORDS
Sacroiliac joint dysfunction, Mulligan Mobilisation, Mulligan Taping
Technique, Kinesio Taping, Therapeutic Ultrasound
XI
CONTENTS
SL. NO.
TOPIC
PAGE NO.
1.
INTRODUCTION
2.
OBJECTIVES
12
3.
REVIEW OF LITERATURE
13
4.
METHODOLOGY
32
5.
RESULTS
39
6.
DISCUSSION
43
7.
CONCLUSION
49
8.
SUMMARY
50
9.
BIBLIOGRAPHY
51
10.
ANNEXURES
ANNEXURE I - TABLES
62
ANNEXURE II - GRAPHS
65
ANNEXURE III - PHOTOGRAPHS
69
ANNEXURE IV - CONSENT FORM
73
ANNEXURE V DATA COLLECTION SHEET
76
ANNEXURE VI MASTER CHART
81
XII
LIST OF TABLES
TABLE NO.
DESCRIPTION
PAGE NO.
1.
Age and Anthropometric Variables
62
2.
Sex Distribution (Chi-square test)
62
Side involvement distribution (Chi-square test)
62
Duration of symptoms
63
Radiation (Chi-square test)
63
VAS score (pairedt test)
63
MODQ score (pairedt test)
64
Statistical analysis (unpairedt test)
64
XIII
LIST OF GRAPHS
FIGURE NO.
DESCRIPTION
PAGE NO.
1.
Anthropometric Variables
65
Sex Distribution
65
Side involvement distribution
66
Duration of symptoms
66
Radiation
67
VAS score (pairedt test)
67
MODQ score (pairedt test)
68
Statistical analysis (unpairedt test)
68
XIV
LIST OF PHOTOGRAPHS
SL. NO.
FIGURES
PAGE NO.
1.
Materials
69
2.
Treatment with Therapeutic Ultrasound Machine
69
3.
Hand placement for MWM for anterior innominate
70
MWM for anterior innominate in prone
70
5.
MWM for anterior innominate in sitting
71
MWM for anterior innominate correction with

walking
71
Mulligan taping for anterior innominate
72
XV
Introduction
INTRODUCTION
It is now incontrovertible that proposition of painful spinal disorder is secondary to
[sacroiliac] joint dysfunction. (mooney).1
The term dysfunction was originally coined by Mennell (1960) to describe
the loss of movement known as joint play or accessory joint movement. It implies
incorrect functioning without trying to state a particular pathology or pinpoint a single
structure. Loss of joint play (dysfunction) can be due to adaptive shortening,
contracture, scaring, adherence or fibrosis.
The sacroiliac joint is an enigma. It is an important set of joints that anchor the
pelvis to the sacrum, which in turn act as a supporting door frame for mobile
lumbar spine and even more mobile legs1
The sacroiliac joint has long been used by anthropologists as a skeletal target
to determine the age of the specimen. It is well accepted that the joint is an extremely
stable structure because of its bony configuration & ligamentous support. The
ligaments of this joint are strongest in the human body.2
Low back pain is very common, affecting approximately 70% of people at
some point in there life.3 SIJ dysfunction is an underappreciated source of low back or
buttock pain.4, 5 It is thought to cause 15% of low back pain.5 The SIJ has been found
to be the pain generator, using controlled fluoroscopically guided diagnostic blocks,
in between 13% and 30% of those with chronic low back pain6
The sacroiliac joint (SIJ) has been implicated as a source of low back pain by
many clinicians and researchers, including Lee (1989, 1992) and Vleeming and
Mooney (1992). There is an interdisciplinary interest in the role of the SIJ and low
back pain and its functional relation to the musculoskeletal system (Vleeming et al
1
Introduction
1992, 1995). The SIJ may cause pain due to disease, inflammation, or movement
dysfunction. Movement dysfunction may exist as hypermobility or hypomobility.
According to Porterfield and DeRosa (1991), the normal SIJ function as a triplane
shock absorber and transfers upper body weight into the pelvis and lower extremities,
and participates in the absorption of the force of heel strike. If the SIJ is hypomobile,
it cannot effectively absorb stress from activities of daily living, and other structures
may be overstressed, thus contributing to musculoskeletal pain and dysfunction7
Pain generated in the SIJ or surrounding structures can present as low back
pain, pelvic pain, or gluteal pain. Patterns of SIJ pain have been identified and can
vary significantly.8 Numbness, popping, clicking or groin pain can occur. Unilateral
pain is more common than bilateral by as much as a 4:1 ratio.9
Athletes involved in sports that require unilateral loading as in kicking and
throwing are at increased risk.SIJ pain has been found to be common in cross-country
skiers and rowers. SIJ pain is more common in pregnant women (possibly as a result
of the release of the hormone relaxin, which allows pelvic expansion and increased
motion). Other factors, such as the trauma of child birth, altered posture, increased
lordosis, and weight gain, also may increase the risk of pain.3
The sacroiliac joint is a unique articulation with a highly individualized and
unique structure.10 It is a combination of synarthrodial and diarthodial joint with a
synovial sacroiliac joint and fibrous sacroiliac joint. According to the anatomist
Grey refers to this joint as synchondrosis and Sabotta states that it is an almost
immovable joint or syndesmosis.11
There have been conflicting studies regarding the mobility of the SI joints. For
some time it was generally accepted that there was motion early in life, but
Introduction
progressively less motion as the degenerative changes of the joint took place, and
many investigators felt that the joints eventually fused. Clinicians now feel that
motion occurs throughout life. Hypocrite first described pregnancy-related motions of
the SI joint in the fifth century BC. In 1589, Dimerbroch 1864, Von Luschka was the
first to categorize the SI joint as a diarthrosis, suggesting the idea of motion. In 1905,
Goldthwaith and Osgood described ST joint overuse and hyper-mobility leading to
lumbar plexus irritation and ischialgia. In 1909, Albee described it as synovial and
mobile. Many of these early studies were conducted on cadavers, and led to
conflicting reports in the literature. In 1920, Halladay was the first to study
unembalmed corpses, and found asymmetrical SI joint movements. He found that
these movements also led to movements in the pubic symphysis, and that back
hyperextension leads to displacement of the sacrum with respect to L5. Much of his
work was the basis for spinal mechanics, further developed by the osteopathic
profession. In 1921, Smith-Peterson described an SI joint arthrodesis that was
effective for ischialgia, and in 1934 Cyriax stated that the SI joint subluxation can be
measured by comparing leg lengths.12
The sacroiliac joint can undergo a small amount of anterio-posterior rotatory
movement (Weisl,1955;Sturesson et al,1989) which appears to range from 2 degrees
(Egund et al,1978) to 12 degrees (Lavignolle et al,1983); movement is now well
accepted, and Vleeming et al,(1990b) state that small movements are indeed possible,
and this is compatible with the findings of small, non-bridging anterior peripheral
osteophytes which are found regularly (Dijkstraet al,1989). Rotation in a paramedian
plane (anterior, posterior,& cranial caudal translation) has been identified, and
rotation in the frontal plane has been shown (Stevens,1992). Under abnormal where
Introduction
the ridges and depression are no longer complementary theoretically causing a
blocked joint (Vleeming et al, 1990).13
The osteopathic profession espouses that there are at least seven described
axes of motion; however, these axes should not be thought of as absolutes, but as
functional axes that occur pending the direction of forces applied through the joint.
These include a left and right oblique axis, a vertical and antero-posterior (AP) axis, a
vertical and sagittal axis, and three horizontal axes. It should be noted that none of
these axes is rigid. The actual axis used depends on the motion and the summation of
forces that move through the joint with a particular action. In the normal gait cycle,
there are combined activities that occur conversely in the right and left innominates,
and function in connection with the sacrum and spine. As one steps forward with the
right foot, at heel strike the right innominate rotates posterior and the left innominate
rotates anterior. During this motion, the anterior surface of the sacrum is rotated to
the left and the superior surface is level, while the spine is straight but rotated to the
left. Toward mid stance, the right leg is straight and the innominate is rotated
anterior. The sacrum is rotated right and side-bent left, while the lumbar spine is sidebent right and rotated left. At left heel strike, the opposite sequence will occur and the
cycle is repeated. Throughout this cycle there is a rotatory motion at the pubic
symphysis, which is essential to allow normal motion through the SI joint. According
to Greenman, pubic symphysis dysfunction in walking is one of the essential or
leading causes of the development of SIJD. In static stance, when one bends forward
and the lumbar spine regionally extends, the sacrum regionally flexes, with the base
moving forward and the apex moving posterior. During this motion, both innominates
go into a motion of external rotation and out-flaring. This combination of motion
during forward bending is called nutation of the pelvis. The opposite occurs in
Introduction
extension, which is called counternutation. As the sacrum goes into extension with
the base moving posterior and the apex anterior, the innominate components
internally rotate and in-flare. This motion is dearly demonstrated and illustrated by
Kapandji.12
MOTION DYSFUNCTION
Hypomobility
As previously noted, throughout later decades of life, the SI joint becomes less
mobile due to adaptive changes in both the joint articulation and connective tissues.
Some believe that these changes are actually the result of hypermobility in the joint
and the bodies own response to this motion. Hypomobility in general appears to be
common in clinical practice, in both acute low back and SI joint pain syndromes.
In the osteopathic profession, SIJD is broken down into iliosacral and SI
dysfunctions. This is primarily a differentiation in terminology for identifying which
part of the anatomy plays the major role in motion restriction. Further, the
dysfunctions are named for their bony position of ease. Somatic dysfunction implies
impaired or altered function of the related components of the somatic (body
framework) system: skeletal, arthrodial, and myofascial structures and related
vascular, lymphatic, and neural elements. There are three types of primary iliosacral
dysfunction: 1) innominate shears, superior and inferior; 2) innominate rotations,
anterior and posterior; and 3) innominate in-flare and out-flare. There are two main
types of dysfunction: 1) sacral torsions, flexion and extension; and 2) unilateral sacral
lesions, flexion and extension. Torsions have both a right and left anterior and right
and left posterior types. These are diagnosed when rotation is the primary component,
although there is an additional side-bending component as well. Unilateral lesions
Introduction
tend to have a primary flexion or extension plus side-bending component, as opposed
to a rotatory component. A bilaterally flexed or extended sacrum is also possible,
which is often found in certain decompensated postures and during pregnancy.
Hypermobility:
Gross SI joint instability is rare, but micro instability is a relatively common
component seen in patients with recurrent SIJD. This micro instability often leads to
chronic pain syndromes and must be treated as part of these complex pain
presentations. Instability often occurs as a result of the loss of the functional integrity
of any of the systems of the lumbosacral and pelvic region that provide stability. The
myofascial or the osteoarticular and ligamentous components may be affected, as with
chronic spondylolisthesis. Understanding this concept is critical, because it implies
that a thorough evaluation of the lumbosacropelvic function must be carried out in the
evaluation for SIJD, regardless of the origin of pain.
Subluxation:
Subluxation indicates gross instability of the SI joint and is quite rare in the
general athletic population. It is primarily described in injuries resulting in significant
energy input, such as car and motorcycle accidents. Some evidence for this
phenomenon has been described in the orthopedic and radiographic literature vis a
joint arthrography with use of contrast, indicating some form of traumatic disruption
of the SI joint.12
There is no true gold standard for the diagnosis of pain originating from the
sacroiliac joint.14,
15, 16
Many practitioners and researchers consider intraarticular
fluoroscopically guided injections to be the closest thing currently available to a gold
Introduction
standard. Most articles and clinicians find joint injections are to be helpful for both
diagnosis and therapeutic purpose.17, 18
There have been numerous functional (motion) and provocative (painproducing) tests reported in the literature; however, none have consistently been
shown to reliably diagnose SI joint dysfunction. We feel that there are two major
flaws in how these studies and others like them have been carried out. Dreyfuss et al.
assumed that pain production is an essential prerequisite to dysfunction. We feel that
SIJD can be diagnosed based on motion restriction and tissue texture changes,
especially in chronic pain syndromes when pain location can very greatly due to
muscle imbalance and other factors. They all focus on assessing each test
individually; however, SI screening tests must always be followed up with segmental
motion testing and tissue palpation. When these tests are used together with a
thorough history to create a clinical picture, they become significantly more reliable,
much like physical exam tests for meniscal tears. Research is currently underway
using SI joint injections under fluoroscopy to compare different provocative tests for
reliability and accuracy. Common tests include standing forward flexion, sitting
forward flexion, stork (Gillet), Gaenslen, supine-to-sit, Patrick (Faber), side-lying
approximation, and supine gapping. In osteopathic medicine, SI joint somatic
dysfunction is diagnosed primarily by the standing and seated flexion tests, stork test,
and asymmetry of pelvic and sacral bony landmarks.8 The likelihood that SIJ
dysfunction is the source of the pain increases markedly if three or more provocation
tests are positive, if the pain is unilateral, if the pain is below L5 without lumbar pain,
or if pain increases with rising from sitting. The differential diagnosis of SIJD is
broad,
and
includes
infection,
inflammation
(arthritic,
metabolic
and
spondyloarthropathies), tumor (primary or metastatic), fractures (stress or traumatic),
Introduction
pregnancy, osteitis condensans illi, radiculopathies, spinal stenosis, facet syndrome,
disco-genic pain, hip disease, and vascular, gastrointestinal, and genitourinary
etiologies.12
There is no specific gold standard imaging test to diagnose SIJD, largely due
to the location of the joint and overlying structures that make visualization difficult.
However, standard radiographs taken at 25 to 30 from the AP axis, and lateral views
may
show
degenerative
changes,
ankylosis,
demineralization
or
fracture.
Degenerative changes are usually first noted on the iliac side of the joint. If sclerosis
involves the lower two thirds of the joint on both sides, sacroilitis is common. It
should be noted that in adolescents, the SI joints can show widening and irregularity,
and consequently can make diagnosis difficult.
Bone scans identify osteoblastic activity, and may signal infection, tumor,
fracture, or a metabolic process. Computerized tomography will identify fractures,
osteoid osteomas, and degenerative changes. Ultrasound Doppler imaging can capture
SI motion in pregnant women with SI pain. Finally, magnetic resonance imaging
(MRI) helps to identify fractures, tumor, soft tissue pathology, and lumbar disc
disease. MRI is most sensitive for identifying inflammatory sacroiliitis.12
Treatment of SIJ dysfunction is based on the etiology, and an integrated
approach using osteopathic medicine, chiropractic, manual physical therapy and
medical management is the best.19 Physical therapy must focus rehabilitation on the
entire abdomino-lumbo-sacro-pelvic-hip complex addressing articular, muscular,
neural, and fascial restrictions, inhibitions, and deficiencies. Correction of leg length
discrepancies, somatic dysfunction, inflexibility, and poor posture is fundamental. SI
belts may be helpful in pregnant patients with hypermobile joints. Prolotherapy of the
lumbo-sacral-iliac region has been shown to be effective in those athletes with chronic
8
Introduction
lumbar and SI joint pain due to instability. In osteopathic medicine, manipulation is
frequently used to treat SIJD. These dysfunctions are termed restrictions, that is,
pelvic and sacral hypomobility. Osteopathic manipulation has been shown to be as
efficacious as standard medical care in the treatment of patients with acute and
subacute low back pain. Sacroiliac joint pain is also since decades known to be treated
by various Electrotherapy Modalities such as Ultrasound, Short Wave Diathermy,
Micro Wave Diathermy, Moist Heat, and Long Wave Diathermy. In chronic cases
pain relief is possible with a TENS unit.4
Ultrasound (US) is defined as a form of acoustic vibration occurring at a
frequency that is too high to be perceived by human ears. For physiotherapeutic
purpose ultrasound with a frequency in the range of 0.5 to 5MHZ is used. Most
commonly 1MHZ and 3MHZ are used. During 1930s lower intensities of ultrasound
were used for the first time in physical medicine to treat soft tissue conditions with
mild heating. Ultrasound therapy is better treatment than most of the other
electrotherapeutic treatment because of its effective depth of penetration. Therapeutics
effects of insonation are pain relief, resolution of inflammation and acceleration of
healing. Hence ultrasound can be used in the treatment of sacroiliac joint
dysfunction.20
The Mulligan Concept (Brian Mulligan FNZSP (Hon), Diploma M.T.)
Mobilisations with Movement:
A new approach. It is stating the obvious that many different manual therapy
concepts and procedures are taught, and all have a place in the treatment of patients.
However, all the techniques in the Mulligan Concept, when indicated, are expected to
bring about an immediate improvement in the patient's condition. This is important in
Introduction
manual therapy, as endless perseverance with no lasting benefit to the patient cannot
be justified. This new approach has been found to be able to restore functional
movements in joints (often in one treatment session), even after many years of
restriction, which questions the text books that speak of adaptive shortening.
Spectacular results are often obtained using mobilisations with movement (MWMS).
Mobilisation With Movement is the concurrent application of pain free accessory
mobilisation with active or passive physiological movement.21 Therapist mobilization
of the SI joint helps to realign the joint. Additionally, self-correction techniques are
presented to the patient so that he/she may assure proper SI Joint alignment
throughout the day.
Ligaments normally provide a great deal stability in sacroiliac joint; a
compromise may require additional external stabilization procedure for example
pelvic belt fixation and special taping technique to assist in providing stability.
Typically the SI joint will stabilize with regular mobilisation, taping/belting, and
exercise over a 6-8 week period of time.22
Kinesio Taping:
In 1973 Dr Kase developed Kinesio Tex, and the Kinesio Taping method.
Kinesio Tapings key differentiator is its ability to aid the lymphatic and muscle
systems, while supporting joints and muscles. For many, the Kinesio Taping
applications are a major breakthrough which substantially reduce recovery times and
improve fitness levels. Kinesio Taping saw worldwide exposure during the 1988
Seoul Olympics. Since then, Kinesio has become one of the fastest growing sport
treatment modalities in the world. The Kinesio Taping Method has taken the
Rehabilitation and Sports Medicine world by storm. Kinesio Taping has become the
gold standard for therapeutic rehabilitative taping. Kinesio taping is a method of
10
Introduction
taping utilizing a specialized type of tape. It differs from traditional white athletic
tape in the sense that it is elastic and can be stretched to 140 % of its original length
before being applied to the skin. It subsequently provides a constant pulling (shear)
force to the skin over which it is applied unlike traditional white athletic tape. The
fabric of this specialized tape is air permeable and water resistant and can be worn for
repetitive days. In contrast to classic taping methods, Kinesio-Taping does not restrict
the patients mobility. In most cases, classic taping methods are applied around joints
and structures in order to immobilize them or to protect them from overloading. This
restriction in movement is connected with known problems of stiffening and a
reduction in muscle mass. Kinesio-Taping offers an effective treatment and
prevention concept while still maintaining full mobility.
Hence, the present study is being undertaken with the intention to determine
the effectiveness of Mulligan Taping Technique along with Mulligan Mobilisation
and Therapeutic Ultrasound as conservative treatment in participants with sacroiliac
joint pain on visual analogue scale, and disability using Modified Oswestery
Disability Questionnaire (MODQ) thus improving their quality of life.
11
Objectives
OBJECTIVES
1. To evaluate the effectiveness of Mulligan Taping Technique
in sacroiliac
joint dysfunction
2. To evaluate the effectiveness of Mulligan Mobilisation in sacroiliac joint
dysfunction.
3. To compare the effectiveness of Mulligan Mobilisation (Movement with
Mobilisation) and Mulligan Taping Technique in sacroiliac joint dysfunction
HYPOTHESES:
1. Null Hypothesis (Ho) :
There will be no significant difference between outcome measure of sacroiliac
joint dysfunction with Mulligan Mobilisation and Mulligan Taping Technique.
2. Alternative Hypothesis (H1) :
There will be significant difference between outcome measure of sacroiliac
joint dysfunction with Mulligan Mobilisation and Mulligan Taping Technique.
12
Review of Literature
REVIEW OF LITERATURE
DEFINITION
Sacroiliac dysfunction is defined as the loss of movement known as joint play
or joint movement (Mennell, 1960).23
Sacroiliac joint region dysfunction is a term used to describe pain in or
around the region of the joint that is presumed to be due to malalignment or abnormal
movement of SIJs.24
HISTORICAL ASPECTS
The joint of the pelvic closed kinematic chain have been steeped in
controversy since Meckel first described them in 1816.25The controversy, involving
the SIJ predominantly, has raised for centuries and centers around several
arthrological features, most significantly its classification, cartilage type, innervations,
propensity for movement, and predilection for causing pain.
For centuries, the SIJ was classified variably as a cartilaginous joint
(amphiarthrosis),4,
a synchondrosis that is
ultimately replaced by bone,18 a
diaarthroamphiarthrodial joint,26 and a cross between a synarthrosis and diarthrosis.27

some concluded that the joint is synovial (diarthridial) but becomes an amphiarthrosis
under certain pathological conditions.28, 29
Researchers as early as 18th and 19th centuries demonstrated that the SIJs are
true synovial joint consisting of joint cavity, synovial membrane and fluid.30, 31, 32, 33 In
the first three quarters of the 20th century, the SIJ was considered exclusively
synovial. The trend today is to include both the iliac and sacral auricular surfaces and
tuberosities in the makeup of SIJ.
13
ANATOMY
The SIJ is reinforced by some of the strongest and the most massive ligaments
in the body. Three ligaments are in intimate contact with the joint, and three others,
though better termed accessory, make important contributions to the joints integrity.
The SIJ capsule is closely attached to the joints margins; ventral and dorsal sacroiliac
ligaments (VSIL, DSIL) cross the joint, and the interosseuss sacroiliac ligament
(ISIL) connects the sacral and iliac tuberosities.34, 35
Hiltons law of nerves states that the nerve that innervates a particular muscle
also innervates the joint moved by that muscle.36 The classical anatomy texts and
various authors report innervation of the SIJ from a variety of combinations of cord
segments and peripheral nerves; the range for the dorsal part of the joint is by
branches of dorsal primary rami of L5-S1-2 and foe the ventral part of the joint by the
superior gluteal and obturator nerves and branches of ventral primary rami L4-5-S1-3.
it has said that unmyelinated, finely myelinated and thickly myelinated fibers are
evident, indicating the potential presence of the full spectrum of joint receptors,
including those that are activated by painful and mechanical stimuli.37
MOTION OF THE SIJ
It is generally agreed that a small amount of movement takes place in response
to nonimpact changes in loading.4 inarguably; the most contentious issue regarding
the SIJ is related to the presence, degree and type of motion to this joint. The
argument has raged for over 2000 years.
It was first believed in 460-377BC that the sacroiliac was capable of motion
but only during pregnancy. Later indirect evidence to the mobility of SIJ was
provided after observing the surface morphology of the joint and it was postulated
14
that the sacrum rotated (nutated/nodded) around a horizontal axis in the vicinity of the
iliac tubersoties.4, 5
It was then suggested that the presence of motion at the SIJ was a normal
condition for both men and women and the SIJ is a primary source of pain
independent of pregnancy. 26, 27, 38,
The normal physiological movements of SIJ region are influenced by lumbar
and hip joint mechanics. Abnormal or asymmetrical forces reaching the hip or lumbar
area are ultimately translated to the pelvis and render the weight-bearing joints
vulnerable to injury.28
The motion was described in 1911by Fick, German anatomist, as being
straight and merely of a rocking type. Weigel in 1955 reported cineradiographic
studies. He described a 5-mm ventral shift of sacrum in relation to the ilium around an
axis of motion located about 10cm below the sacrum. Frigerio and colleagues in 1974
reported a movement of 2.6cm of the iliac crests in relation to the sacrum. Schunke
(1938) observed a pelvic shift when an individual supports his weight on one leg and
suggested the there may be sacroiliac joint motion in stance phase of normal gait.39
Walheim and Olerud used an accurate (0.1mm for translation and 0.1 degree
for rotation) electromagnetic measuring technique in which they affixed two pins to
the pubic line on either side of the pubic symphysis in vivo. This unique experiment
correlated with the radiographic technique of Chamberlain and was successful in
recording motion between the two pins during active straight leg raising, hip
abduction, and one leg standing. In vivo measurements by Waiheim and associates
show vertical translations of 2-3mm and rotations of up to 3o at pubic symphysis
15
motion was the same for males and nulliparous females but was greater in maltiparous
females. 39
A study conducted in Sweden to investigate the SIJ motions in patient in a
truly tree dimensional manner using a stereo radiographic technique. At time of
examination, at least four tatanlum balls were inserted percutaneously, under local
anesthesia, into both the pelvis and sacrum. Stereoroentgeograms were taken with the
patient in five different positions. The author concluded that the hypothesis of hypoand hypermobility causing pain were not supported by the finding of this
investigation.
Miller and co-workers studied the kinematics of the sacroiliac in eight fresh
cadavers specimens aged 59-74. The joints were loaded and displacement of the
sacrum in relation to both ilia was measured. Lateral (X-axis) translation at 0.76mm
SD 1. 41, and anterior (+Z-axis) translation observed to average 2.74 mm (SD1.07).
Lateral rotation to one side (Z-axis) average 1.40 degree (SD 0.71) and axial rotation
(Y axis) in one direction was 6.21degree.39
In 1974, Frigerio used biplanar radiography on cadavers and living subjects to
study the SIJ motion. It was then concluded that the maximum movement between
ilium and the sacrum was 12mm (mean-2.7mm). Maximum movement between the
innominates was 15.5mm.40
MOVEMENT OF SACROILIAC JOINT
The sacroiliac joints are usually stable. However small amount of movement
(combination of linear and angular motion) occur in sacroiliac joint in response to
changes in loading.41 it is generally agreed that the forward rotation of the sacrum is
the dominant feature of SI joint movement in response to the downward force of
16
upper body weight in upright stance. The forward rotation of the sacrum and resulting
movement of the innominate bones is referred to as nutation of the pelvis.
Counternutation is the reverse of nutation back wards rotation of the sacrum resulting
in separation of the posterior aspects of the ilia and drawing together of the ischial
tuberosities.41
The basic motions of the joint of the body and their normal range of motion
values have been established. These data are rudimentary to any evaluation and
treatment. Such data are either lacking or are in dispute when looking at the SIJ.28
In general three type of motion are available to both the innominate bones:
symmetrical motion- symmetrical trunk and hip movements result in paired,
symmetrical movements at the SIJs 29, 30, 31, 32. During trunk flexion or bilateral hip
flexion, the sacrum nutates or rotates anteriorly. The sacrum counternutates, or moves
in its opposite direction, during trunk extension or bilateral hip extension, a second
type of motion occurs at SIJs when asymmetrical forces are applied to the pelvis, as in
static one- legged stance that occurs during gait and asymmetrical falls and
lumbopelvic motion consists of the spine and both innominate bones as a unit around
the femoral heads.
The primary movements available at the SIJs and pubic symphysis are as
follows: innominate anterior rotation, innominate posterior rotation, innominate
internal rotation, innominate external rotation, sacral flexion, sacral extension, sacral
rotation and pubic rotation.42
EPIDEMIOLOGY, INCIDENCE AND PREVALENCE
The incidence, of course, is variable, depending on the diagnostic criteria and
the population studied. Cibuka & associates presented a study in which 81% of 88
17
patients with chronic low back pain demonstrated some evidence of SIJD. In contrast,
in a group of 112 patients who were evaluated for problems other than chronic LBP,
there was a 12% incidence of SIJ.9 A larger study was reported was by Bernard &
Kirkaidy Wilis the authors found SIJD to be a major source of back pain in 22
patients of 1200 patients.43
Studies have shown that there is a relatively high incidence of sacroiliac joint
arthritis in patients undergoing evaluation for Low Back Pain or Sciatica. Hence,
sacroiliac joint arthritis should be considered a possible diagnosis in these patients.44
Bernard and Kikaldy Wilis, reported a larger study. In this consecutive series of
1200 patients referred with chronic low back pain, on a clinical basis, the authors
found sacroiliac dysfunction to be the major source of back pain in 22% of the
patients.43
In US, based on the earlier studies, Andrew L Sherman in his study on
sacroiliac joint injury said, the incidence of low back in humans parallels the common
cold, with a lifetime incidence approaching 95% Goldwaith and Osgood after many
years of work were the first to discuss the possibility of sacroiliac joint as a cause of
low back pain as early as in 1905.45
According to results of the study performed by Schwarzer in 1995, the prevalence of
SI pain would appear to be at least 13% and perhaps as high as 30% in patients with
low back or buttock pain.
PREVELENCE
Up to 40% of low back pain is related to injuries of the SIJ and its supporting
ligamentous structures. Frequently, SIJD co-exists with lumbar disc herniations and
lambar facet syndrome. This occurs because the low back and pelvis rely on many
18
common structures to ensure normal stability and function. Many medical
professionals have attributed low back pain to problem with lumbar disc, thinking that
the SIJ are immobile. Recent studies of the gait cycle and pelvic motion have refuted
this concept of immobility. Additionally, injections of SI joint capsule and ligaments
under x-ray guidance have confirmed that the SIJ can cause localized back and
referred leg pain. The sacroiliac joint has been implicated as a pain generator. Before
1934, the SIJ was thought to be a common source of pain, but once Mixter and Barr
ushered in the dynasty of the disc in their seminal 1934 New England Journal of
Medicine article, the SIJ as a source of pain fell out of fevor.46
ETIOLOGY
Sacral and sacroiliac joint pain, although not as common as low back pain,
occurs in all age group. The pain may be a result of muscular, ligamentous,
neurological, mechanical or bony dysfunction at or sacrum or sacroiliac joint.
Anatomically, numerous muscles, including the sacrospinalis (erector spinae), gluteus
maximus and piriformis attach to the sacrum and could potentially present as a source
of pain if strained or partially avulsed.47 ligamentous structures that attach to the
sacrum and which may cause pain if injured include the sacroiliac, iliolumbar,
sacrospinous and the sacrotuberous ligaments.48pain near the sacrum may also be
neurological
in
origin, as the sacral plexus passes through
the sacral
foramina.47Mechanical pain due to sacroiliac dysfunction may present as sacral pain

and may also refer pain distally. Pain in the sacral region may be of bony origin
secondary to tumor or due to a fracture.
Dysfunction develops when ligaments and joint capsule shorten through
disuse, particularly after injury, when the sprained ligaments or capsules heal in the
shortened position. SIJ pain is probably due to inflammation and / or instability of the
19
interosseous sacroiliac ligaments and / or the posterior sacroiliac ligaments, rather
than to synovial inflammation. According to Frigerio and Di Ambrosia RD SIJD may
be manifested in disease such as ankylosing spondylitis, pagets disease, or
tuberculosis. Mechanical dysfunction like structural and muscular imbalances and
joint hypermobilities also give rise to sacroiliac complaints. It is said that SIJD may
be caused due to 3 types of events namely direct trauma, indirect trauma and
pregnancy.49
ABNORMALITIES OF SACROILIAC JOINTS
Excessive movement of sacroiliac joint stretches the joint capsule, which in
turn, stretches the capsular nerves, resulting in pain. Excessive movement in the
sacroiliac joint may also cause pain due to stretching and impingement of the sacral
spinal nerves pain from these sources are referred to as sacroilitis and is often
misdiagnosed as some form of lower back pain.50 Sacroilitis can occur whenever the
stability of the sacroiliac joint is decreased. In an unstable joint, excessive movement
may cause the contours of the articular surface to interlock in an abnormal position,
which will be reinforced by tension in the supporting ligaments created by the
excessive movement. This form of dislocation of the sacroiliac joint may result in
continuous pain (chronic sacroilitis). The most common form of this condition is
called as anterior dysfunction of the sacroiliac joint in which the sacroiliac joint
becomes locked in an abnormal position with the innominate bone rotated anteriorly
on the sacrum, that is, in a position of counter nutation.50 This occurs especially if the
abdominal and the gluteal muscles are week. In these circumstances one or both
sacroiliac joint may become locked in an abnormals position resulting in unilateral or
bilateral anterior dysfunction. In anterior dysfunction the ability of the sacroiliac joint
20
to assist in shock absorption is severely impaired. The adjacent lumbar segments are
overloaded, which increases the risk of low back pain.41
Motion restriction in sacroiliac joint can occur from shear dysfunction or
muscle imbalance. Shear dysfunction occur when the innominates, sacrum or pubes
have been subjected to excessive shearing forces and have been displaced and locked
in an abnormal position. Muscle imbalances include those conditions in which a
muscle or a group of muscle have an abnormally high resting state of tension,
interfering with normal innominate or sacral motion.51 When there is malalignment in
sagittal plane of the innominate bone, it is referred to as anterior or posterior rotation.
The motion restriction is always in the opposite direction (i.e. the motion restriction
for anterior innominate rotation is posterior rotation). Transverse plane dysfunctions
with positional faults are referred to as inflares. Superior shear dysfunction of the
innominate is called upslip. Upslips result in significant motion restriction on the
ipsilateral contralateral side. Sagittal plane shear dysfunction of the sacrum results in
the sacrum being held in flexion (nutation) or extension (counternutation).52
CLINICAL FEATURES AND DIAGNOSIS
The type of pain that occur with sacroiliac dysfunction are variable. The pain
may be sharp or dull aching, or tingling and so on. Pain is often unilateral and local to
the joint (sulcus) itself but may refer down the leg (usually posteriolaterally and not
below the extremity. Physical findings, common to sacroiliac joint include tenderness
over the sacral sulcus and posterior sacroiliac line. Lumbar spine range of motion may
elicit pain with flexion and lateral bending to the opposite side of the symptomatic
sacroiliac joint. Hamstring tightness is a common associated finding. Neurological
abnormalities, such as numbness weakness reflex changes and nerve root tension
21
signs are usually absent in sacroiliac joint syndrome. 41 In 1994, Laslett and Williams
presented a reliability study using appropriate pain provocation tests. The tests were:
1. Distraction test: pressure is applied directly posteriorly and laterally to both
to stretch anterior sacroiliac ligaments.
2. Compression test: while the patient is lying on one side, pressure is applied to
the upper most iliac crest and directly toward the opposite iliac crest,
theoretically compressing the pelvis.
3. Posterior shear or thigh thrust test: A posterior shearing stress is applied to
the sacroiliac joint of a supine patient by sudden downward force applied to a
90o flexed femur in a neutral position.
4. Pelvic torsion test: with one hip fully flexed onto the abdomen, the other hip
is extended past neutral with the pelvis displaced on the edge of the table to
allow this maneuver (Gaenslens test).
5. Sacral thrust: pressure is applied directly on the sacrum, with the patient in
prone.
6. Cranial shear test: Cranially directed pressure is applied to the coccyx and
sacrum.52
FABERS or Patricks Test is usually in differentiating between hip and
sacroiliac pain. The hip is flexed, abducted and externally rotated, with the lateral
malleolus being allowed to rest on the opposite thigh above the knee. The opposite
anterior superior iliac spine is stabilized and pressure is applied to the other externally
rotated leg at the knee. Pain caused in the groin or anterior thigh is more indicative of
hip pathology. Pain in the sacroiliac joint is indicative of sacroiliac movements.53
22
The key element in sacroiliac dysfunction diagnosis is pain. Many authors
have attempted to define a typical pain pattern associated with the sacroiliac joint.
Several reports describe patients reporting pain on one or both buttocks at or near the
posterior superior iliac spine. Pain radiating to hip, posterior thigh or even calf have
been described.45
A study performed by chamberlain, vertical movement of the pubis was
measured with alternate leg standing and the result showed that more than 2mm of
displacement was abnormal. Incidence of sacroilitis has been reflected, in a study of
222 sports related hip and pelvic injuries in 204 patient, as 15.6% and 6.4% in women
and men respectively.55, 56
MAIN OUTCOME MEASURES
Sacroiliac joint injury leaves the subjects with significant deconditioning and
muscle imbalances. In studies conducted on rehabilitation program for subjects with
sacroiliac joint injury the main outcome measures were decided by consencus as
being pain, function, global assessment for quality of life and return to work.
For this purpose, pain intensity can be measured by means of visual analog
scale (VAS). A 10cm line marked with number 1 to 10 can be used where 0
symbolizes no pain and 10 is maximum pain. Subject is asked to mark his/her pain on
this line as per the severity.57
Scott and Huskis cautioned that providing appropriate functional disability can
be measured using the Modified Oswestry Disability Questionnaire (MODQ). This
index was reported by Fairbank et al in 1980. It is a self administered functional
index comprising of 10 items and includes activities of daily living and pain. Each
item/section contains 6 statements that describe an increasing degree of severity
23
relating to a particular activity. The sections are scored from 0 to 5 points. The point
total from each section is summed and the then divided by the total number of
questions answered and multiplied by 100 to create a percentage disability. The scores
range from 0-100% with lower scores meaningless disability.
Studies have shown MODQ to be responsive to change in patients with low
back pain. Hawson S.T.et al used VAS and Oswestry low back pain disability
questionnaire as measurement tools in the treatment of chronic low back pain.51
Megan Davidson et al said we believe that the MODQ (ICC value =0.84) has
sufficient reliability recommended it as a standardized measure of activity
limitation.51In their original report, Fairbank et al included a test/retest reliability
coefficient of 0.99 and a split half coefficient reported as good.58
TREATMENT
Treatment of SIJ dysfunction is based on the etiology, and an integrated
approach using osteopathic medicine, chiropractic, manual physical therapy and
medical management is the best.46 Many physicians prescribe anti inflammatory
medications in the initial phases. Rest from the aggravating activities is essential
during an acute episode of pain. In case of acute radiculopathy, the use of epidural/
oral steroids is considered. Intra-articular injections of corticosteroids are useful when
the sacroiliac joint is acutely inflamed. A local anesthetic merely conforms the
diagnosis that the sacroiliac is a pain generator. These injections play a role in the
treatment of sacroiliac joint pain but are not functional treatments and a patient with
sacroiliac dysfunction should be treated with a functional approach.59 Sacroiliac joint
strains do exists. A tension sufficient to cause ligamentous strain may not appear on
X-ray. Treatment of mechanical sacroiliac joint dysfunction usually responds well to
24
conservative treatment. Passive mobilisations can be very effective where normal
sacroiliac joint movement is blocked. This has the effect of gently facilitating
normal sacroiliac joint movement, thus removing abnormal stresses on the ligaments
which surround the joint.60
Physiotherapy Approaches
Physical therapy treatment includes, correcting any mechanical asymmetries,
stretching overly tight pelvic muscle and strengthening weak inhibited muscle.
Strengthening exercises helps ensure stability of the sacroiliac joint. Stabilization
exercises take place in a more dynamically functions position and can often include
balance and proprioceptive activities.52 Physical therapy focuses on pain in the acute
phase. Modalities such as ultrasonography with or without phonophoresis, deep and
superficial heat, and superficial cold treatment can reduce pain. Acute sacroiliac
dysfunction frequently responds to a short period of rest, local heat and non steroidal
anti inflammatory drugs(NSAIDs).In chronic cases pain relief is possible with a
TENS unit.59
Ultrasound is used as a therapeutic modality for many soft tissue conditions in
many countries.61 when ultrasound waves enter the body, they can exert effects on the
cells and tissues via thermal and nonthermal mechanism, of which some are still
inconclusive.61, 62
Ultrasound is believed to differ from superficial heating modalities by heating
deeper tissues when applied with appropriate intensity and frequency. Non thermal
effects are claimed to promote healing, although this has not been proved within in
vivo studiesd.62 In the of soft tissue disorder, ultrasound has been used for more than
30 years.63,
64
Increased blood flow, vascular permeability and cell metabolism, of
25
fibrous tissue extensibility and muscle relaxation are the purported physiologic effects
of ultrasound. Ultrasound is proposed to promote healing and regeneration in
inflamed tissue, to reduce pain, and to improve range of motion and this is the
rationale for the use of ultrasound for the management of soft tissue disorders in all
joints, including the sacroiliac joint. 65, 66, 67
Ultrasound is said to remove traumatic exudates and reduce the danger of
adhesion formation. Analgesia produced by ultrasound allows early use of the part.
Accelerate proteins synthesis is believed to stimulate the rate of repair of the damaged
tissues and inflammatory conditions are said to respond to ultrasound due to this
reason.68
Healing of soft tissue injuries have been found to benefit in soft tissue injuries
and sports injuries. Use of Therapeutic Ultrasound is also suggested for low back pain
because there have been favourable reports of pain relief.69
Research has been conducted on the effects of ultrasound in living tissue and
both positive and negative results have been reported. These effects were dependent
on the intensity and frequency of ultrasound applied to the tissue. 65mm and 30mm
for 1MHZ and 3MHZ respectively was found to be an approximate average half value
depth of penetration for US.70 Studies have shown that US delivered at 1 MHZ heats
tissues at depths of 5cm and US delivered at 3MHZ heats tissues at 2cm .71 Several
studies showed that non thermal effects of ultrasound enhance healing of soft tissue
and bone. These non thermal effects can be achieved without raising tissue
temperature by applying ultrasound in the pulsed mode.71
26
Manual Therapy
Manual therapy is hands on treatment form of physiotherapy carried out with
a specific approach involving detailed examination, diagnosis and treatment of a wide
range of condition which causes pain and movement restrictions whereas some
authors suggest manual therapy as the use of the hands in curative and healing
manner, and can be defined as the use of manipulation with their therapeutic content.
Manual therapy has been practiced for centuries. Overtime, it has evolved to
incorporate many disciplines and theories, many of which have been in conflicts for at
least part of their history. In the recent years, there has been a growing acceptance that
no single group is likely to have a monopoly on truth and that each can learn from
others.72
Mulligan is a registered physical therapist who has a private practice in
wellington, Newzealand and is an International Lecturer in manual therapy. His
special interest has always been in manual since being introduced to the field by
Stanley Paris early in the 1960s. He acknowledges as his mentor Freddy Kailtoborn
but has also found invaluable the contributions of James Cyriax, Geoff Maitland,
Robin McKenzie, Robert Elvey etc.73
Brian Mulligans principle techniques are NAGS, SNAGS, and MMWs.
NAGS are natural apophyseal accessory glides applied to the cervical spine with the
patient passive. SNAGs are sustained natural apophyseal accessory glides whereby
the patient attempts to actively move a painful or stiff joint through its range of
motion whilst the therapist overlays an accessory glide parallel with the treatment
plane MWMs are mobilisation with movement is the logical continuance of this
evolution with the concurrent application of both therapists applied accessory and
27
patient generated active physiological movement with the aim of overriding the
obstructions and reestablishing correct alignment. 72, 73, 74
The rationale behind Mulligans technique is that, joint have evolved in a
manner that facilitates free but controlled movement whilst minimizing compressed
forces generated by movement. This balance is maintained by normal proprioceptive
feedback. Alteration of the balance and positioning of structure in and around the joint
that may occur from strain or injury can alter joint tracking resulting in pain or
restriction of movement. It is postulated that these techniques Sedate an agitate,
facilitated nervous system, particularly the dorsal horn, by bombarding it with the
painless normality it has always been patterned to receive.72, 73, 74
The basic concept of Mulligans Mobilisation with Movement is that a
painless gliding translation pressure is applied by the practitioner, almost always at
right angles to the plane of movement in which restriction is noted, while the patient
actively (or sometimes the practitioner passively) moves the joint in the direction of
restriction or pain.75 Mobilisation with Movement enables the therapist to perform
treatments in more dynamic, weight-bearing, functional positions. As the aggravating
movement is used, treatment is specific and the results are often dramatic.76
Mulligan developed his technique to correct joint tracking problems or
positional faults by repositioning them and restoring the normal pain free
motion.77There are an increasing number of reports espousing the clinically beneficial
effects of Mulligan's Mobilisation-with-Movement (MWM) treatment techniques. The
most frequent reported effect is immediate and substantial pain reduction
accompanied by improved function.78
28
The techniques, called "Mobilisation with Movements" (MWM), are claimed
to bring about improvements in pain and function immediately following their
application in the clinic, but there is a lack of experimental data reported in peerreviewed publications. The MWM group of techniques are claimed to achieve this
rapid improvement in persistent musculoskeletal pain states that have been recalcitrant
to other forms of therapy.79
A study by Hall T, Schafer A, Wallin L (2005) on Mulligan bent leg raise
technique concluded that the efficacy of the mulligan bent leg raising technique in
improving straight leg raise 24 hrs after treatment.80
A study by Bill Vicenzino,Aatilt Paungmali & Pamela Teys gives a review of
the current literature performed to synthesize and evaluate claims of effectiveness of
movement with mobilisation(MMW) & speculation about the proposed mechanism of
action. Mulligan Mobilisation with-Movement, positional faults and pain relief:
current concepts from a critical review of literature, provides an overview of literature
concerning the clinical efficacy, effects and putative mechanisms of action of the
MMW approach in treatment of musculoskeletal conditions.81
Ligaments normally provide a great deal stability in sacroiliac joint; a
compromise may require additional external stabilization procedure for example
pelvic belt fixation and special taping technique to assist in providing stability.
Typically sacroiliac joint will stabilize with regular mobilization, taping, exercise over
6-8wks period of time.82
Taping is widely used in the field of rehabilitation as both means of treatment
and prevention of sports-related injuries. The essential function of most tape is to
provide support during movement. Some believe that tape serves to enhance
29
proprioception and, therefore to reduce the occurrence of injuries. The most
commonly used tape applications are done with nonstretch tape. The rationale is to
provide protection and support to a joint or a muscle.83
A study by Mark D. Thelen, Richmond Hill, The Clinical Efficacy of Kinesio
Tape for Shoulder Pain in which they concluded that KT may be of some assistance
to clinicians in improving pain-free active ROM immediately after tape application
for patients.83
A study by Kym Moiler, Toby Hall, Kim Robinson, on The Role of Fibular
Tape in the Prevention of Ankle Injury in Basketball, in which participants were taped
using the method described by Mulligan and they gave preliminary data regarding the
prophylactic effects of fibular repositioning tape on ankle injury in male basketball
players.84
A study by J. McConnell on recalcitrant chronic low back and leg pain- a new
theory and different approach to management and stated that management of chronic
low back and leg pain can be achieved by taping the buttock and down the leg
following the dermatome to shorten the inflamed tissue.85
A case report by H Todd Vaughn & Wanda Nitesch on Ilial anterior rotation
hypermobility in a female collegiate tennis player suggested rehabilitation should
focus on entire abdomino-sacro-pelvic-hip complex, addressing articular, neural, &
muscular inhibition & deficiencies.86
A case report, focus on neuromuscular impairment for examination and
intervention of patients with chronic sacroiliac pain, suggests how the therapist might
use neuromuscular impairments as focus of management of chronic sacral pain.
Although some authors do recommend taping of other areas for pain reduction and
30
increased function .87 No specific research on taping techniques for sacroiliac pain
were found. There have been studies to suggest that taping of knee can influence the
neuromuscular system88, 89It may be that the sacroiliac tape works by changing the
neural input of the pain and proprioceptive pathways of skin, soft tissue and joints that
correspond to the same segmental levels involved in the neuromuscular impairment.14
31
Methodology
METHODOLOGY
It was proposed to study the comparative effectiveness of Mulligan

Mobilisation and Mulligan Taping Technique, in patient with Sacroiliac Joint
Anterior Innominate Dysfunction.
Source of Data
Data was collected from Department of Physiotherapy, KLES Dr. Prabhakar
Kore Hospital and Medical Research Centre Belgaum and KLES Ayurved Hospital
and Research Centre, Belgaum during the study period from November 2008- July
2009.
Method of Data Collection
The method of data collection used for this study was a primary method.
Study design
The study design used for this research was Randomized Clinical Trial.
Ethical clearance was obtained from the institutional ethical committee, KLES
Institute of Physiotherapy, Belgaum before commencement of the study.
Sample size
The sample size used for this research study was sixty (60). It was calculated
on the basis of record of number of participants attended physiotherapy department in
last three years.
32
Methodology
Study sample
The study sample consisted of both male and female referred to the
physiotherapy department with clinical diagnosis of Sacroiliac Joint Anterior
Innominate Dysfunction.
Sampling design
Sampling design used for this study was simple random sampling. For this
purpose the participants were assigned to two groups by lottery method.
Participants
There were 60 participants with clinical diagnosis of sacroiliac joint
dysfunction (anterior innominate).
Inclusion criteria
Participants with clinical diagnosis of sacroiliac joint dysfunction (anterior

innominate).
Pain and tenderness at SIJ.
Positive clinical test for SIJ involvements using the FABERS test.
Those willing to participate in the study.
Exclusion criteria
Subjects with clinical disorder where therapeutic ultrasound is contraindicated

such as metal implants.
Dermatitis
Neoplasm.
Acute tuberculosis.
33
Methodology
Pregnancy.
Hemorrhagic areas
Materials (Annexure-III)
Record or data collection sheet.
Consent
Evaluation chart
Couch
Measuring Tape
Weighing machine
Pencil
Tape cutter
Kinesio Tex Tape
Apparatus and Equipments

1. Measuring Tape:
A measuring tape of total length of 60 inches/152 centimeters was used to
measure the height of each patient. The participant was made to stand against a wall,
head and heel touching the wall and a mark was made on wall at the vertex of the
head. The distance between the floor and the mark was measured in centimeters.
2. Weighing machine:
A standard bathroom-weighing machine with 1 kg increment was used to
measure the weight of each participant in kilograms.
34
Methodology
Therapeutic Modality:
3. Ultrasound machine:
Ultrasound machine, Uniphy, phyaction 190i, made in Germany, was used
(Annexure-III).
4. Kinesio Tex Tape:
KNESIO TEX, Elastic Adhesive Tape (5cm 5m/2 16.4) for Kinesio
Taping Method, EMERGO EUROPE, made in Japan, was used (Annexure-III).
Main Outcome Measures
1. Visual analog scale (VAS)
Pain intensity was measured by means of Visual Analog Scale (VAS). A 10
cm line where; 0 symbolized no pain and 10 as maximum pain. Patient was asked to
mark his/her pain on this line as per the severity. Visual analogue scale was taken preinterventional and post-interventionally.
2. Modified Oswestry Disability Questionnaire (MODQ):
It is a functional index designed to determine the symptoms and limitations
that patient experiences while performing daily activities. This scale consists of 10
items in the form of activities of daily living with each item scoring from 0 to 5 where
0 is no difficulty in performing that activity and 5 is inability to do that activity. This
was used for assessment of the associated disability.
35
Methodology
Interventions
All the participants with sacroiliac joint dysfunction who reported to the
physiotherapy department were screened clinically for SJD with anterior innominate.
By considering inclusion and exclusion criteria, they were requested to participate in
the study. Those willing to participate in the study were given brief idea about the
nature of the study and the intervention. The demographic data including age, gender,
height, weight, side affected, occupation and duration of symptoms were collected
through data collection sheet. Weight (in Kilograms) of the participants was recorded
using a simple bathroom-weighing machine. Height (in centimeters) of the
participants was recorded using a measuring tape, with the height marked on the wall
at the level of the vertex and the heel and the distance between the two points was
measured. Initial evaluation of pain profile using VAS and physical function was
scored by using Modified Oswestry Disability Questionnaire (MODQ).
Then participants were randomly allocated into 2 groups:
Group A: Therapeutic Ultrasound, Mulligan Mobilisation for SIJ.
Group B: Therapeutic Ultrasound, Mulligans Taping Technique for SIJ.
Both the groups received selected treatment for 10 sets for ten consecutive days.
Procedure
Prior to the commencement of the procedure, written informed consent was
taken from the participants.
Group A: Therapeutic Ultrasound, Mulligan Mobilisation for SIJ.
Here the Participants were treated with
1) Therapeutic Ultrasound with the output of 1W/cm2 for 5 min using a pulsed
mode 1:4 mark space ratios with frequency of 1 MHz for this, subjects were
36
Methodology
positioned in prone lying with feet outside the plinth. Ultrasonic gel was applied to
the treatment head as well as to the skin over the area around posterior superior iliac
spine to allow perfect contact and allow maximum transmission of the sonic waves.
2) Mulligan Mobilisation for SIJ: Three sets for ten repetitions for 10 days.
After the detailed assessment, patient were asked to show which movement causes
maximum pain (sit to stand, walking, getting up from prone). Therapist stands at side,
opposite to lesion. Therapist fixates the sacrum with the border of one hand and
places the fingers of other hand under the right anterior superior iliac spine if the right
SIJ is involved. Pull up the ilium on the sacrum and hold this position while the
patient is asked to do painful movement for 10 times, provided these movements are
pain free. Further two sets of 10 were given.
Group B: Therapeutic Ultrasound, Mulligans Taping Technique for SIJ.
1) Therapeutic Ultrasound will be given same as Group A.
2) Mulligans Taping Technique for SIJ
Here the Subjects were treated using Kinesio Tex Tape with Mulligans
Technique for 10 sets for ten consecutive days.
The patient in standing positions with the upper limb crossed across over the
shoulders. Therapist fixates the sacrum with the border of one hand, and places the
fingers of other hand under the right anterior superior iliac spine if the right SIJ is
involved. Pull up the ilium on the sacrum and hold this position while the patient is
asked to do flexion and extension of trunk, provided these are pain free. Then with the
5 cm wide Kinesio tape in front of anterior superior iliac spine was wrapped with
Mechanical correction technique method of application, around obliquely to terminate
over the lumbar spine than secured with a second piece of tape. After this, assessment
37
Methodology
of original painful movement (extension in prone, extension in standing, flexion in
standing) was done. Movement should now have pain free full range of motion and
function. The Kinesio tape was left for 72 hours provided there was no skin irritation.
Patients were advised to avoid any strenuous activity of the back so as to
prevent any stress to joint. At the end of tenth treatment session again Visual Analog
Scale (VAS) and Modified Oswestery Disability Questionnaire (MODQ) readings
were recorded following the same procedure as done on the first day of treatment.
Thus the data collected was taken for further analysis.
38
Results
RESULTS
The result of the study were analyzed in terms of pain relief indicated by
decrease in visual analogue scores, on the day of recruitment and on 10th day of
treatment and the functional Index measured by using Modified Oswestry Disability
Questionnaire (MODQ). Intra and inter group differences were compared so as to
evaluate and compare the effectiveness of two treatment techniques under
consideration in the present study.
Statistical Analysis
Statistical analysis for the present study was done manually as well as using
the statistics software MedCalc version 10.2.0 so as to verify the results obtained. For
this purpose data was entered into an excel spread sheet, tabulated and calculated.
Various statistical measures such as mean, standard deviation and tests of significance
such as chi-square test and paired and unpaired t test, were utilized for this purpose
for all the available scores in all the participants. Nominal data from patients
demographic data i.e. sex, side involved, were analyzed using chi-square test.
Comparison of the pre interventional and post interventional outcome measures
between the groups was done by using paired and unpaired t test. Probability values
less than 0.05 were considered statistically significant and probability values less than
0.0001 were considered highly significant.
DEMOGRAPHIC PROFILE
Age Distribution
The average age of the participants in group A subjects was 44.16 15.99
years, group B subjects was 46.83 14.16 years. There was no significant difference
39
Results
between the mean ages of the participants in both the groups. (p= 0.3185) (AnnexureI, Table No.1, Fig 1).
Sex Distribution
There were total 60 participants participated in the study. Out of which 35
were males and 25 were females. There were 16 males and 14 females in group A, 19
males and 11 females in group B. (2 = 0.6171, p=0.7345) (Annexure-I, Table No. 2,
Fig 2).
Side involvement Distribution
There were total 60 participants participated in the study. There were 15
participants with right side involvement and 15 were with left side involvement in
group A and 18 participants with right side involvement and 12 with left side
involvement in group B. (2 = 2690, p=0.6038) (Annexure-I, Table No. 3, Fig 3).
DURATION OF SYMPTOMS
The mean onset of duration in symptoms in group A were 25.7 21.36 and the
mean onset of duration of symptom in group B were 26.1 20.47. (Annexure-I, Table
No.4, Fig 4).
RADIATION
There were 17 participants who reported of radiating pain and 13 participants
reported absence of radiation in group A whereas in group B 15 had radiating pain
and 15 without radiation. This data was analyzed using chi-square test. (2 = 0.2679,
p=0.8747) (Annexure-I, Table No. 5, Fig 5).
40
Results
ANTHROPOMETRIC MEASUREMENT:
Height
The average height of the subjects in group A was 1.570.09 and in group B
was 1.590.10.
There was no significant difference between the heights of the
subjects in both the groups. (0.0669) (Annexure-I, Table No.1, Fig 1).
Body Weight
The mean body weight of the subjects in group A was 67.79.21 and the mean
body weight of the subjects in group B was 71.69.66. There was no significant
difference in body weight in both the groups. (p=0.112) (Annexure-I, Table No.1,
Fig1).
Body Mass Index
Mean BMI of group A was 27.17 2.99, group B mean BMI was 28.3 3.20.
There was no significant difference between the mean BMI of the participants in both
the groups. (p= 0.1593). (Annexure-I, Table No.1, Fig 1).
OUTCOME MEASUREMENTS:
i) Visual Analogue Scale (VAS) Score
The pre-interventional values of Visual analogue score within the group was
7.74 1.09, 7.48 1.23, in group A, and B respectively whereas post-interventional
values of Visual analogue score was 3.68 1.69 and 2.930 0.8821, in group A, and
B respectively. Changes in the visual analogue scores revealed statistically significant
reduction in pain post interventionally for both the two groups (p < 0.0001). This was
done using pairedt test. (Annexure-I, Table No.6, Fig 6).
41
Results
On comparing the pre session and post session values, the results between the
two groups using unpaired t test revealed that there was statistically significant
difference seen with p values of p=0.4608 and p=0.0357respectively. (Annexure-I,
Table No. 8, Fig 8 ).
ii) Modified Oswestry Disability Questionnaire (MODQ)
The functional recovery was indicated in terms of reduction in Modified
Oswestry Disability Questionnaire score. For this, pre-interventional values of
MODQ score were noted on the first day and the last day for all subjects. However, in
group A the average MODQ score on first day was 60.07 12.78, which reduced to
19.20 8.001 on the last day of treatment. The difference between the first and last
day was found to be statistically significant (p< 0.0001). In group B, the average
MODQ score on first day was 57.714.92, and 24.32 9.021 on last day of
intervention. The difference between the first and last day was found to be statistically
significant (p<0.0001). (Annexure-I, Table No.7, Fig7).
On comparing the pre session and post session values, the results between the
two groups using unpaired t test revealed that there was statistically significant
difference seen in group B with p values p=0.524 and p= 0.0238 compared to group
A. (Annexure-I, Table No.8, Fig8).
42
Discussion
DISCUSSION
Result of the present clinical trial showed that Therapeutic ultrasound along
with Mulligan mobilisation and Mulligan taping technique is effective in reducing
pain and disability.
In the present study Group A received Therapeutic ultrasound, and Mulligan
Mobilisation and Group B received Therapeutic ultrasound, Mulligan Taping with
Kinesio Tex Tape. Both groups had equal number of participants and had shown no
significant difference with respect to their gender distribution, which could have
altered the results of the study.
Analysis of pain relief was done by subjective VAS by statistical mean. Mean
and standard deviation of pain in terms of VAS was done and found that the average
of VAS score for group A on 1st day was 7.48 1.23, and on 10th day was 2.93
0.88. The average VAS score for group B on 1st day was 7.74 1.09 and on 10th day
was 3.68 1.69. The p value for VAS on 1st day for both groups was (p= 0.4608) and
on 10th day was (p= 0.0357). There is significant difference between pre session and
post session within the group for both, group A and group B. When compared
between the groups there was significant difference between pre session and post
session, where group B showed better improvement in terms of VAS. (Annexure-I,
Table No.6, 8).
Analysis of disability was done by subjective MODQ by statistical mean.
Mean and standard deviation of disability in terms of MODQ was done and found that
the average of MODQ score for group A on 1st day was 60.07 12.78, and on 10th
day was 19.20 8.001. The average MODQ score for group B on 1st day
was
57.7 14.92 and on 10th day was 24.31 9.021. The p value for MODQ on 1st day
for both groups was (p= 0.5245) and on 10th day was (p= 0.0238). There is significant
43
Discussion
difference between pre session and post session within the group for both, group A
and group B. When compared between the groups there was significant difference
between pre session and post session, where group B showed better improvement in
terms of MODQ. (Annexure-I, Table No.7, 8).
Pain relief and reduction in disability in both the groups was statistically
significant.
Results after comparison of within the group improvement revealed
significant changes in pre and post interventional values in both the groups. However
Mulligan taping technique along with ultrasound was found to be better in reducing
pain and MODQ score compared to Mulligan Mobilisation along with ultrasound
group.
Ultrasound dosage used in this study was chosen from evidence available.
Pulsed Ultrasound was used since it is preferred for soft tissue repair as affirmed by
Young90 and 1 MHZ was chosen as it is capable of reaching the tissue depth of 5cm
where as 3 MHZ is capable of reaching of only upto upper 2cm
71
pain relief could
have occurred due to the non thermal effects of pulsed ultrasound in the form of
stimulation of histamine release from mast cells and factors from macrophages that
accelerated the normal resolution of inflammation as suggested by Young91 and
Dyson. Naslund found that ultrasound was little effective in RCTs in a review of the
Medline literature in 1999, four of those studies found that ultrasound was no more
effective than placebo US. Baker in a review showed that there was in sufficient
biophysical evidence to provide a scientific foundation for the clinical use of
ultrasound.92
Mulligan (2004) stated that the MWM technique must be pain-free during its
application. This tenet of an MWM is questionable, as it is more of an alteration to
pain with a reduction or elimination, and thus not always pain-free as indicated by
44
Discussion
Mulligan.89 Majority of studies (86%), have reported pain-free application, conversely
other studies review did not state whether their MWM technique reduces or
eliminated pain.94, 95 It is pertinent to the application and effectiveness of an MWM
that a reduction or an elimination of pain are achieved throughout the technique, with
appropriate adaptation of the technique in relation to pain response. Adaptation, or
tweakanology as described by Mulligan, is essential to perform if the technique does
not positively improve pain behavior.96Primarily this includes the direction or angle of
the accessory glide, and the amount of force. This also raises the importance of
adaptation in response to pain behavior during the MWM. Few studies explained the
particular method of adapting the MWM application to alter pain97,
98
and
recommended that MWM is repeated several times, only if there is a substantial

decrease in pain, and if the pain relief has not occurred then glides at different angles
should be attempted; up to a maximum of four times. Abbott et al. also stated that four
attempts of the glide direction are permitted; in order to determine which best
eliminates the pain. If the pain was not eliminated or it returned during treatment, no
further repetitions were performed99 however, the pain relief mechanism was
hypothesized to be due to changes in nociceptive and motor system dysfunction,
possibly implying the role of hypoalgesia.
With respect to the research, the clinical efficacy of Mulligans MWM
techniques has been established for improving joint function, with a number of
hypotheses for its cause and effect. Mulligans original theory for the effectiveness of
an MWM is based on the concept related to a positional fault that occur secondary
to injury and lead to mal tracking of the joint; resulting in symptoms such as pain,
stiffness or weakness.89 Mulligan concept of positional fault would seem more
applicable in alleviating pain with movement of functional activities. It is estimated
45
Discussion
that motor commands play only a minor role in sensory gating. However other non
motor higher centers are more potent modulators of afferent activity.93
The cause of positional faults has been suggested to be due to changes in the
shape of articular surfaces, thickness of cartilage, orientation of fibers of ligaments
and capsules, or the direction and pull of muscles and tendons. MWMs correct this
by repositioning the joint causing it to track normally89,100,101 Thus in present study it
is feasible to postulate that the decrease in pain seen in this study following the
Mobilisation with Movement may be related to a reduction in positional fault at the
sacroiliac joint anterior innominate dysfunction.
Further Mulligan also states that the effects of MWMs can be maintained
further via taping and self MWMs, which may further enhance the possible long
lasting effects.89 Thus in present study it is feasible to postulate that the decrease in
pain seen with Mulligan Taping Technique may be due to correction of the anterior
innominate positional fault of SIJ. Although some authors do recommend Taping of
other areas for pain reduction and increased function,
102
no specific research on
taping technique for sacroiliac joint were found. There have been studies to suggest
that taping of knee can influence the neuromuscular system103,104.
In the present study, Kinesio Tex Tape was used with Mechanical correction
technique method of application was used for Mulligan Taping technique. Kinesio
Tex Tape is designed to give support whilst maintaining full range of motion and it
facilitates lymphatic flow 24 hrs a day. The results of present study when compared
between the two groups, Mulligan Taping group showed better improvement with
reduction in VAS (P=0.0357) and MODQ (P=0.0238). The result would have been
highly significant if combination of other technique of application such as Ligament
46
Discussion
technique and Fascia Technique of application of Kinesio Tex Tape would have been
used.
Various authors have previously reported improvements in function, pain, and
ROM through the use of KT.83 As these reports were either performed on healthy
subjects or were case series, this literature represents low level of evidence; however,
it points to the need for further investigation. Pain modulation via the gate control
theory is one plausible explanation for such a change, because it has been proposed
that tape stimulates neuromuscular pathways via increased afferent feedback.105 under
the gate control theory an increase in afferent stimulus to large-diameter nerve fibers
can serve to mitigate the input received from the small-diameter nerve fibers
conducting nociception.
Another possibility is that reduced pain could be the result of the placebo
effect of the tape, regardless of the direction in which the tape was applied. However,
previous authors have indicated that therapeutic taping had a greater effect on pain
reduction and functional improvement than placebo taping or control conditions.106, 107
Comparison with the other studies lacked due to the lack of details provided in
the abstracts. There is a lack of literature regarding studies on Mulligan Mobilisation
as well as Mulligan Taping Technique in Sacroiliac Joint. The data convincingly
demonstrated in present study that both the Mulligan Mobilisation and Taping
Technique by using Kinesio Tex Tape along with Ultrasound Therapy are effective in
treating sacroiliac anterior innominate dysfunction.
47
Discussion
Limitation of the study
1. One of the weaknesses of this study is the lack of a true control group.
2. Duration of the study was short.
3. Long term effect of intervention was not assessed.
Recommendations
Studies with longer duration on larger sample size with a control group and
with long term intervention are recommended with longer follow up period.
Strength of the study lies in the two Mulligan Technique of intervention used
which have fewer evidence and have been not compared in past and Kinesio
Taping using Mulligan Taping Technique for anterior innominate dysfunction
have not been studied in past.
48
Conclusion
CONCLUSION
In conclusion, this randomized clinical trial which was performed on 60
participants consisting of males and females with a diagnosis of Sacroiliac joint
dysfunction with interventions in the form of therapeutic ultrasound + Mulligan
Mobilisation technique and therapeutic ultrasound + Mulligan Taping Technique
showed that, both the physical therapy regimen can be useful in alleviating the
Sacroiliac joint dysfunction in reduction of pain and improvement in functional
ability in terms of VAS and MODQ respectively. Hence, it can be concluded that both
the interventions are effective therapeutic options in the treatment of Sacroiliac joint
dysfunction (anterior innominate).
49
Summary
SUMMARY
The study was done to compare the effectiveness of Mulligan Mobilisation
and Mulligan Taping technique for patients with clinical diagnosis of Sacroiliac joint
(Anterior Innominate) dysfunction. In present study participants were randomly
allocated in two groups. Group A received Mulligan Mobilisation(3sets, 10
repetitions) along with Ultrasound therapy (1MHZ, 1Watt/cm2,5min) and group B
received Mulligan Taping by using Kinesio tape with correctional method of
application, and Ultrasound therapy (1MHZ, 1Watt/cm2,5min), for ten consecutive
days. The pre interventional and post interventional outcome measure, Visual Analog
Scale (VAS) and Modified Oswestry Disability Questionnaire (MODQ) was taken
and analysis of result was done.
Result of The present study demonstrates that both the manual therapy
techniques Viz Mulligan Mobilisation and Mulligan Taping Technique along with
Ultrasound therapy are effective in relieving pain and decreasing disability in
Sacroiliac joint dysfunction. Pain intensity in terms of VAS and Modified Oswestery
Disability Questionnare decreased significantly in both the groups after the treatment.
Comparing the two groups better effect was seen in group B (p=0.0357) for VAS and
(p=0.0238) for MODQ. Hence based on result of this study it can be concluded that
both the technique used in this study are effective in reducing pain and disability in
patient with anterior innominate sacroiliac dysfunction.
50
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61
Annexure -I
ANNEXURE I : TABLES
TABLE 1: Age distribution and Anthropometric variables
Groups
Mean Age
(Years)
Mean Height
(mts)
Mean Weight
(Kgs)
Mean BMI
Group A
44.166 15.995
1.570.09
67.79.22
27.1 3.02
Group B
46.833 14.1667
1.590.10
71.69.66
28.3 3.18
P value
0.3185
0.6069
0.1121
0.1593
inference
Not significant
Not significant
Not significant
Not significant
TABLE 2: Sex distribution and Chi-square test
Groups
Male
Female
Group A
16
14
Group B
19
11
X2
p value
Inference
0.6171
0.7345
Not significant
TABLE 3: Side involvement distribution and Chi-square test
Groups
Right
Left
Group A
15
15
Group B
18
12
X2
p value
Inference
2690
0.6038
Not significant
62
Annexure -I
TABLE 4: Duration of symptoms
Groups
Duration
Inference
Group A
25.7 21.36
Not significant
Group B
26.1 20.47
Not significant
TABLE 5: Radiation and Chi-square test
Groups
Present
Absent
Group A
17
13
Group B
15
X2
p value
Inference
0.2679
0.8747
Not significant
15
TABLE: 6 Mean changes in VAS score and statistical analysis (pairedt test)
Groups
Visual Analogue Scale (cms)

Pre Treatment
Post Treatment
P value
Inference
Group A
7.74 1.09
3.68 1.69
0.0001
Significant
Group B
7.48 1.23
2.93 0.88
0.0001
Significant
63
Annexure -I
TABLE 7: Mean changes in MODQ score and statistical analysis (pairedt test)
Groups
MODQ
Pre Treatment
Post Treatment
P value
Inference
Group A
60.07 12.78
19.20 8.001
0.0001
Significant
Group B
57.714.92
24.31 9.021
0.0001
Significant
TABLE 8: Statistical analysis unpairedt test)
Groups
VAS
MODQ
Pre treatment
Post
treatment
Pre treatment
Post treatment
Group A
7.74 1.09
3.68 1.69
60.07 12.78
19.20 8.001
Group B
7.48 1.23
2.93 0.88
57.714.92
24.31 9.021
p value
0.4608
0.0357
0.5245
0.0238
Inference
Not Significant
Significant
Not significant
Significant
64
Annexure -II
ANNEXURE II : GRAPHS
GRAPH: 1 AGE, HEIGHT, BMI
GRAPH: 2 SEX DISTRIBUTION
65
Annexure -II
GRAPH:3 SIDE INVOLVEMENT
GRAPH: 4 DURATION O F SYMPTOM
66
Annexure -II
GRAPH :5 RADIATION
GRAPH : 6 VAS PRE AND POST VALUES
67
Annexure -II
GRAPH: 7 MODQ PRE AND POST VALUES
GRAPH: 8 VAS AND MODQ
68
Annexure -II
GRAPH: 8 VAS AND MODQ
69
Annexure -III
ANNEXURE III: PHOTOGRAPHS
MATERIALS
TRETMENT WITH THERAPEUTIC ULTRASOUND MACHINE
69
Annexure -III
HAND PLACEMENT FOR MWM FOR ANTERIOIR INNOMINATE
MWM FOR ANTERIOR INNOMINATE IN PRONE POSITION
70
Annexure -III
MWM FOR ANTERIOR INNOMINATE IN SITTING POSITION
MWM FOR ANTERIOR INNOMINATE CORRECTION WITH WALKING
71
Annexure -III
MULLIGAN TAPING FOR ANTERIOR INNOMINATE DYSFUNCTION
72
Annexure -IV
ANNEXURE IV: CONSENT FORM

COMPARATIVE EFFECTIVENESS OF MULLIGAN MOBILISATION AND
MULLIGAN TAPING TECHNIQUE IN SACROILIAC JOINT
Purpose of study:
The purpose of this study is to compare Mulligan Mobilization and Mulligan
Taping Technique in Sacroiliac joint dysfunction patients.
Procedure:
You will qualify for study only if you are a subject with Sacroiliac joint
dysfunction. You may be included in either the experimental group A, in which you
will receive ultrasound and mulligan mobilization for ten days
or you will be
included in control group B where ultrasound for ten days and Mulligan Taping three
times in ten days. The health care that is provided to you by the therapist will remain
the same regardless of whether you are in study group A or in the control group B.
Baseline data will be assessed on 1st day and 10th day to measure the improvement.
Risks:
There is no risk as a result of participating in this study.
Benefits:
You will be helpful in terms of reducing pain and disability.
Financial Incentive for participation:
You will not receive any payment for participating in this study.
73
Annexure -IV
Alternatives:
If you decide not to participate in the study, physiotherapist will provide the
usual standard care during your treatment with out bias.
Authorization to publish results:
Results of this study may be published for scientific purpose and/or presented
to scientific groups; however you will not be identified.
Sponsors Policy:
K.L.E.S Institute of physiotherapy is the sponsor of this study project in which
you are participating.
Institutional Policy:
The K.L.E.S Institute of physiotherapy will provide, within the limitation of
the laws of the State of Karnataka, facilities and medical attention to participants who
suffer injuries as a result of participating in its project. In the event you believe that
you have suffered any physical injury as the result of his/her participation, you may
contact the principal investigator Samantha Fernandes, Post Graduate student,
9986240928, or Dr. Ganesh B.R Associate Professor,
KIPT, JNMC campus,
Belgaum. Telephone: 0831-2473906.

Voluntary Participation:
Your participation for this study is completely voluntary. Your decision
whether or not to participate will not affect the treatment during your hospital stay.
You are free to discontinue your participation in this study at any time and for any
reason. In case, you need any further information regarding your rights as study
participant you may please contact Dr. Snehal Dharmayat, Assistant Professor, KIPT,
74
Annexure -IV
JNMC campus Belgaum and Member Secretary of KIPT Institutional Ethical
Committee On Human Subject Research , Telephone: 0831-2474727.
Statement of Consent:
I volunteer and consent to participate in this study. I have read the consent
form or it has been read to me. The study has been fully explained to me and I may
ask question at any time.
__________________________
Date;
_________________
Date;
_______________
Signature or Left thumb Impression

(Volunteer Subject)
__________________________
Signature (Witness)
___________________________
Date;
_______________
Signature (Investigator)
75
Annexure -V
ANNEXURE V: DATA COLLECTION SHEET

Title: COMPARATIVE EFFETIVENESS OF MULLIGANS
MOBILIZATION AND MULLIGANS TAPING TECHNIQUE IN
SACROILIAC JOINT DYSFUNCTION: RANDOMIZED CLINICAL TRIAL
DATE: _______________
Name:
Age:
Sex: M
Subject No:
F
I.P / O.P.D NO:
Occupation:
Weight:
Height:
STUDY GROUP: A
BMI:
Address:
Contact no:
Side affected: Right
Left
Bilateral
Duration of symptoms:
Onset: Sudden
Gradual
Tenderness: Present
Absent
FABERS TEST: Positive
Negative
Radiation: Present
Absent
76
Annexure -V
If yes, which side: Right
Left
Have any investigation been done so far?

Yes
No
If yes, specify:
Investigation finding:
Have u taken any treatment for the same in past?

Yes
No
If yes, specify:
Clinical Diagnosis :
Pain Assessment: Visual Analog Scale
First day:
Tenth day:
Functional Index: Modified Oswestry Disability
77
Annexure -V
Questionnaire
(MODQ)
First day:
Tenth day:
____________________
Volunteer Subjects Name
____________________
Witnesss Name
____________________
Investigator Signature
(Samantha .F. Fernandes)
___________________
Signature
___________________
Signature
___________________
Co Guides Signature
(Dr. Vijay Kage)
__________________________
Guides Signature
(Dr. Ganesh B.R)
Date:
78
Annexure -V
79
Annexure -V
80
Annexure -VI
ANNEXURE VI: MASTER CHART
Ultrasound Therapy + Mulligans Mobilization

S.
Name
Age
no
(yrs)
BasavrajReddy
21
MahadevMelage
SEX
Ht
Wt
cms
kgs
BMI
Side
Duration
Radiation
1.57
72
29
Rt
15
Ab
27
1.52
65
28
Rt
30
Dr.DeepaMetgud
32
1.51
59
25.8
Lt
NehaRobinkumar
26
1.49
58
25.8
Prabhakarnaik
40
1.61
91
SarojaPatil
36
1.62
AmbikaPatil
23
SunithaKulkarni
46
PavanKolli
10
FABERS
(days)
VAS
MODQ
pre
post
pre
Post
+VE
8.9
3.9
40.50%
15%
Ab
+VE
7.6
2.6
50%
18%
+VE
6.8
1.2
64%
28%
Lt
+VE
8.4
2.4
50.50%
17.50%
35.5
Rt
45
Ab
+VE
5.1
2.1
62%
20%
70
26.7
Rt
30
+VE
8.1
1.2
44%
15%
1.43
72
35.2
Rt
+VE
8.8
3.4
80%
40.50%
1.66
63
22.9
Lt
15
+VE
4.4
62%
32%
26
1.55
55
22.9
Rt
15
+VE
6.5
2.2
36.50%
8.30%
PatreppaMorali
59
1.55
55
22.9
Lt
20
Ab
+VE
8.6
3.2
59%
15.50%
11
ShobhaPatil
47
1.51
60
26.3
Rt
10
Ab
+VE
8.7
4.2
62%
22%
12
ShripadPatil
51
1.48
62
28.3
Lt
+VE
6.5
2.2
68%
11.60%
13
GirishBalekunchi
35
1.72
82
27.7
Lt
14
Ab
+VE
9.4
3.5
77.50%
27.50%
14
G.R.Jadhav
49
1.52
69
29.9
Lt
+VE
3.4
74%
32%
81
Annexure -VI
15
PrakashBadave
60
1.71
73
25
Lt
21
+VE
7.8
2.2
65%
22%
16
SunilDeshpande
38
1.71
80
27.4
Lt
Ab
+VE
8.7
4.1
62%
17.50%
17
ShradhaBurde
21
1.68
72
25.5
Rt
60
Ab
+VE
5.9
2.3
58%
8.33%
18
PreetiZende
29
1.48
58
26.5
Rt
30
Ab
+VE
7.6
3.4
75%
37.50%
19
SubhadraShidlyali
60
1.51
68
29.8
Rt
40
+VE
8.8
3.2
54%
15%
20
ChandrawwaNandre
62
1.49
56
25.2
Lt
75
Ab
+VE
3.6
46.50%
17.50%
21
B.B.Chandichal
70
1.57
72
29
Lt
15
Ab
+VE
5.6
48%
20%
22
S.G.Mulimani
43
1.66
63
22.9
Lt
+VE
6.9
3.5
62%
11.60%
23
SulochanaTopannavar
49
1.48
58
26.5
Rt
60
Ab
+VE
7.8
2.5
50%
20%
24
NarayanKadam
56
1.68
72
25.5
Rt
65
+VE
7.5
74%
32%
25
A.N.Koli
67
1.71
80
27.4
Rt
30
+VE
4.8
2.2
36.60%
8.30%
26
AllamaSwami
65
1.71
73
25
Lt
+VE
6.9
2.3
85%
33%
27
Gangubikummar
69
1.52
69
29.9
Lt
30
+VE
4.1
74%
27%
28
Hannumanthsingh
34
1.72
82
27.7
Rt
60
Ab
+VE
7.4
4.3
66%
24%
29
AkkataiMagdlim
61
1.48
62
28.3
Lt
45
+VE
7.6
2.4
62%
12%
30
Basappa.S
23
1.51
60
26.3
Rt
Ab
+VE
6.7
2.9
54%
6%
82
Annexure -VI
UltrasoundTherapy+MulligansTaping
S.
Name
no
Age
SEX
(yrs)
Ht
Wt
cms
kgs
BMI
Side
Durati
on
Radiati
on
VAS
FABERS
(days)
MODQ
pre
post
pre
post
PoojaEshgol
26
1.52
63
27.1
Rt
30
Ab
+VE
6.2
3.2
50%
16%
Lankeshdas
26
1.52
63
27.1
Lt
45
Ab
+VE
6.9
2.2
46.50%
26.60%
Daneshwarishivaapuji
57
1.7
72
24.9
Rt
30
+VE
7.1
6.1
46.60%
28%
Madhurijadhav
48
1.73
83
27.7
Lt
30
+VE
8.1
2.9
66%
40%
Madhusaraibagi
52
1.62
70
26.7
Rt
Ab
+VE
6.9
1.9
86%
32%
AnitaBhandi
35
1.49
61
27.2
Rt
30
+VE
8.1
2.7
72%
17.50%
MadivalappaHongal
50
1.75
75
24.4
Lt
75
Ab
+VE
8.9
6.1
45%
16%
BeenaDesai
37
1.55
55
22.9
Lt
75
Ab
+VE
6.1
1.7
50%
26.60%
Prashantsogali
29
1.58
65
26
Rt
30
Ab
+VE
8.6
5.1
66%
28%
10
HirabaiBanajwad
60
1.69
71
24.9
Rt
45
Ab
+VE
8.2
5.2
86%
40%
11
Jayashreewali
33
1.71
80
27.4
Lt
20
Ab
+VE
6.6
70%
32%
12
GangubaiKummar
69
1.51
70
30.7
Rt
15
+VE
8.6
5.5
45%
17.50%
13
R.A.Haveri
53
1.69
74
25.9
Lt
15
+VE
8.9
2.8
50%
16%
14
VeerbadraAralikalti
71
1.76
86
27.8
Lt
60
+VE
8.4
5.3
66%
28%
15
Laxmibaihousanavar
47
1.48
63
28.8
Lt
30
+VE
8.2
2.7
86%
40%
83
Annexure -VI
16
JayantiPatil
50
1.53
71
30.3
Rt
30
+VE
7.6
1.6
70%
32%
17
ShantaDandali
65
1.51
69
30.3
Rt
30
+VE
10
2.3
45%
17.50%
18
NarayanRajgolekar
48
1.49
68
30.6
Rt
Ab
+VE
8.6
2.6
50%
16%
19
ShrikantNargekar
60
1.71
81
27.7
Lt
10
Ab
+VE
2.3
46.60%
26.60%
20
VandannaKaddkar
36
1.51
66
28.9
Rt
60
+VE
7.3
86%
40%
21
SrimantaPatil
48
1.52
80
34.4
Rt
Ab
+VE
6.9
3.9
70%
32%
22
GanapatiDhanawade
27
1.58
60
24
Rt
Ab
+VE
8.9
4.9
45%
17.50%
23
ShobhaPatil
47
1.47
75
34.6
Rt
+VE
6.7
2.1
50%
16%
24
KasturiHegnaik
38
1.47
75
34.6
Rt
Ab
+VE
8.9
5.7
46.60%
26.60%
25
VidhyaDabolkar
52
1.72
89
29.8
Rt
+VE
5.3
3.4
66%
28%
26
AppajiPatil
60
1.65
88
32.3
Rt
30
Ab
+VE
2.1
50.30%
13.30%
27
VithalKoshandar
78
1.42
59
29.3
Lt
21
Ab
+VE
8.3
2.1
36.60%
8.30%
28
MahadevDivate
35
1.48
63
28.8
Lt
10
Ab
+VE
8.4
6.3
45%
17.50%
29
Balichikaldani
30
1.66
63
22.9
Lt
15
Ab
+VE
6.2
1.1
50%
16%
30
RajashreeRajgolekar
38
1.74
91
30.1
Rt
14
+VE
5.1
45%
18%
84

Estudio Sacroiliaca Mulligan

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Estudio Sacroiliaca Mulligan

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COMPARATIVE EFFECTIVENESS OF MULLIGAN

MOBILISATION AND MULLIGAN TAPING

UNDER THE GUIDANCE OF:

Dr. GANESH.B.R M.P.T.

KLES INSTITUTE OF PHYSIOTHERAPY,

Rajiv Gandhi University of Health Sciences

DECLARATION BY THE CANDIDATE

work carried out by me under the guidance of Dr. GANESH .B. R,

Assistant Professor, KLES Institute of Physiotherapy, Belgaum.

SAMANTHA .F. FERNANDES,

Post graduate student,

Rajiv Gandhi University of Health Sciences

CERTIFICATE BY THE GUIDE

work carried out by SAMANTHA .F. FERNANDES in partial

Dr. GANESH .B. RMPT

Rajiv Gandhi University of Health Sciences

CERTIFICATE BY THE CO-GUIDE

work carried out by SAMANTHA. F. FERNANDES in partial

Dr. VIJAY. B. KAGE MPT

Rajiv Gandhi University of Health Sciences

COMPARATIVE EFFECTIVENESS OF MULLIGAN MOBILISATION

FERNANDES under the guidance of Dr. GANESH. B. R,

Assistant Professor, KLES Institute of Physiotherapy.

Dr. SANJIVKUMAR MPT, PM & IR

DECLARATION BY THE CANDIDATE

I hereby declare that the Rajiv Gandhi University of Health

Rajiv Gandhi University of Health Sciences, Karnataka

Lecturer for his constant

and Mr. M. D. Mallapur,

I am extremely thankful to my Classmates for their kind understanding and

LIST OF ABBREVIATIONS USED

Body mass index

Sacroiliac joint dysfunction

Movement With Mobilisation

Sustained Natural Apophyseal Glides

Natural Apophyseal Glides

Flexion Abduction External Rotation

Visual Analog Scale

Modified Oswestery Disability Questionnaire

Transcuteneous Electrical Nerve Stimulation

DYSFUNCTION-RANDOMIZED CLINICAL TRIAL

Conclusion and interpretation

ANNEXURE III - PHOTOGRAPHS

ANNEXURE IV - CONSENT FORM

ANNEXURE V DATA COLLECTION SHEET

ANNEXURE VI MASTER CHART

Age and Anthropometric Variables

Sex Distribution (Chi-square test)

Side involvement distribution (Chi-square test)

Radiation (Chi-square test)

VAS score (pairedt test)

MODQ score (pairedt test)

Statistical analysis (unpairedt test)

Side involvement distribution

VAS score (pairedt test)

MODQ score (pairedt test)

Statistical analysis (unpairedt test)

Treatment with Therapeutic Ultrasound Machine

Hand placement for MWM for anterior innominate

MWM for anterior innominate in prone

MWM for anterior innominate in sitting

MWM for anterior innominate correction with

Mulligan taping for anterior innominate

Many practitioners and researchers consider intraarticular