2.1 Passive Joint Mobilization (PJM) : Page - 14

CHAPTER- 2 REVIEW OF LITERATURE
We explored the previous empirical evidences related to our research from different
search engines and databases and explained it in two subheadings as follows,
2.1 Passive Joint Mobilization (PJM)
Passive joint mobilization is a technique in which oscillatory movements

(Arthrokinematics) are performed using different grades in the synovial joint to ease
pain and to increase range of motion in joint disorders. Empirical evidences related to
PJM are as follows,
Nathan PW et al 1974 conducted an experimental study in 7 male of age group

between 28- 60 years to prove the pain gate theory. They induced the pain in subjects
having by heating the small area of skin and after that the peripheral nerves were
stimulated in the same subjects by electrical stimulation. Subjects were instructed to
inform to the researchers once they felt pain. Authors concluded that subjects felt
pain while their skin tissue prone for heat, but the moment peripheral nerves (large
diameter myelinated A fibers) were stimulated by electric current, Pain sensation
which is carried by small unmyelinated C fibers was reduced and at some time not
perceived. They suggested the gating theory forms the basis for treating much acute
and chronic pain and the same principle can be used to treat the same. 27
Bini G et al 1984 conducted a psychophysical experiment in 16 humans to determine

how low intensity mechanical and thermal skin stimuli interfere with the sensation of
pain. Moderate or intense pain was induced by low frequency (2 Hz) electrical
stimulation within cutaneous fascicles of the median nerve at wrist level, and
vibration, pressure, cooling or warming were applied for short periods (usually 20-60
set) within or outside the skin area to which the pain was projected. Vibration within
the area of projected pain reduced the sensation of pain more efficiently than vibration
outside that area. Moderate pain was sometimes completely inhibited but intense pain
was only moderately reduced. Pressure and cooling produced some pain relief
whereas mild warming had an ambiguous effect. They concluded that activity in low
threshold mechanoreceptive and cold sensitive units suppresses pain at central
(probably segmental) levels.28
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Garvice G et al 1985 determined the effects of passive joint mobilization and active
exercise in 20 patients with adhesive capsulitis of shoulder. Twenty patients with
painful knee were randomly placed in one of two groups. The experimental group
received mobilization and active exercises two to three times per week for 4 weeks.
The controls received only active exercises. Pain questionnaires were answered and
isolated knee mobility measurements were taken initially and at weekly intervals
during the 4 weeks of treatment. Pain scores decreased more in the mobilization
group; however, the difference between the groups was not significant. They
suggested that joint mobilization and exercises were clinically effective in the
treatment of adhesive capsulitis of shoulder.29
Suhn-yeop K 1996 stated that Type 1, II, III are regarded as "true" joint receptors,
type IV is considered a class of pain receptor. Type 1, II and III mechanoreceptors,
via static and dynamic input, signal joint position, intra articular pressure changes,
and the direction, amplitude, and velocity of joint movements. Type 1
mechanoreceptor sub serve both static and dynamic physiologic functions. Type 1 are
found primarily in the stratum fibrosum of the joint capsule and ligaments. Type 1
receptors have a low threshold for activation and are allow to adapt to changes
altering their firing frequency. Type II receptors have a low threshold for activation.
These dynamic receptors respond to joint movement. Type II receptors are thus
termed rapidly adapting. Type II joint receptors are located at the junction of the
synovial membrane and fibrosum of the joint capsule and intra articular and extra
articular fat pads. Type III receptors have been found in collateral ligaments of the
joints of the extremities. Morphologically similar to Golgi tendon organ. These
dynamic receptors have a high threshold to stimulation and are slowly adapting. Type
IV receptors possess free nerve ending that have been found in joint capsule and fat
pads. They are not normally active, but respond to extreme mechanical deformation of
the joint as well as to direct chemical or mechanical irritation. Small amplitude
oscillatory and distraction movements (joint mobilization) techniques are used to
stimulate the mechanoreceptors that may inhibit the transmission of nociceptors
stimuli at the spinal cord or brain stem levels. 30
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Humphries SA et al 1996 investigated a prediction derived from gate control

theory-that there would be a pulse of pain as a pain stimulus was being ramped off
due to the rapidly transmitting, inhibitory large fiber activity falling away sooner at
the spinal level than the excitatory activity of the slow-transmitting, small nociceptive
afferents. Fourteen subjects had the pain stimulus of iontophoretically applied
potassium ions (K+) applied to an upper and a lower site on the dominant arm. In a
threshold detection task using the double random staircase method, subjects were
asked to indicate whether they could detect a pulse of additional pain during this
ramp-off phase. The average rate of stimulus ramp-off in order to detect a pain pulse
was statistically greater for the upper-arm site (14.3 micrograms K+/sec) than for the
lower-arm site (9.4 micrograms K+/sec). These results were consistent with gate
control theory. 31
Vicenzino B et al 1998 conducted a randomized, double blind and placebo controlled

study in 24 patients with chronic epicondylalgia to assess the hypoalgesic and
sympatho excitatory effect produced by manipulative therapy by activating the
descending pain inhibitory system. Manipulative treatment produced hypoalgesic and
sympatho excitatory changes significantly greater than those of placebo and control (p
<0 .03). Authors concluded that Manual therapy produced a treatment-specific initial
hypoalgesic and sympatho excitatory effect beyond that of placebo or control through
activation of central control mechanism. 32
Conroy DE et al 1998 determined the effect of joint mobilization in 14 patients with

shoulder impingement syndrome. Patients were divided into 2 groups, Group A who
received joint mobilization and Group B received hot packs and soft tissue
mobilization. Visual analogue scale for pain and Range of motion of joint were
measured before and after treatment. It was concluded that Group A showed better
results than Group B patients in terms of pain and ROM. 33
Toni G et al 2001 conducted a randomized controlled trial with blinded assessors

to investigate the effect of a specific joint mobilization, the anteroposterior glide on
the talus, on increasing pain-free dorsiflexion and 3 gait variables: stride speed (gait
speed), step length, and single support time in 41 patients with acute ankle inversion
sprains (,72 hours). Subjects were randomly assigned to 1 of 2 treatment groups. The
control group received a protocol of rest, ice, compression, and elevation (RICE). The
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experimental group received the anteroposterior mobilization, using a force that

avoided incurring any increase in pain, in addition to the RICE protocol. Subjects in
both groups were treated every second day for a maximum of 2 weeks or until the
discharge criteria were met, and all subjects were given a home program of continued
RICE application. Outcomes were measured before and after each treatment. The
experimental group had greater improvement in range of movement before and after
each of the first 3 treatment sessions. 34
Sterling M et al 2001 conducted a placebo-controlled, double blind, repeated

measures design in 30 subjects with mid to lower cervical spine pain to investigate the
proposal regarding the spinal manual therapy and descending inhibitory pathways
from the dorsal periaqueductal gray area of the midbrain (dPAG) by including a test
of motor function randomized. They concluded that the cervical mobilisation
technique produced a hypoalgesic effect as revealed by increased pressure pain
thresholds on the side of treatment and decreased resting visual analogue scale scores.
The treatment technique also produced a sympathoexcitatory effect with an increase
in skin conductance and a decrease in skin temperature. 35
Sluka KA et al 2001 stated that application of a manual therapy technique will

produce antihyperalgesia in an animal model of joint inflammation and that the
antihyperalgesia produced by joint mobilization depends on the time of treatment
application. To prove the above statement, Capsaicin (0.2%, 50 ml) was injected into
the lateral aspect of the left ankle joint and mechanical withdrawal threshold assessed
before and after capsaicin injection in Sprague-Dawley rats. Joint mobilization of the
ipsilateral knee joint was performed 2 h after capsaicin injection for a total of 3 min, 9
min or 15 min under halothane anaesthesia. Control groups included animals that
received halothane for the same time as the group that received joint mobilization and
those whose limbs were held for the same duration as the mobilization (no halothane).
Capsaicin resulted in a decreased mechanical withdrawal threshold by 2 h after
injection that was maintained through 4 h. Both 9 and 15 min of mobilization, but not
3 min of mobilization, increased the withdrawal threshold to mechanical stimuli to
baseline values when compared with control groups. The antihyperalgesic effect of
joint mobilization lasted 30 min. Thus, joint mobilization (9 or 15 min duration)
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produces a significant reversal of secondary mechanical hyperalgesia induced by

intra-articular injection of capsaicin.36
Skyba DA et al 2003 conducted a study to determine which spinal neurotransmitter

receptors mediate manipulation-induced antihyperalgesia. Rats were injected with
capsaicin (50 μl, 0.2%) into one ankle joint and mechanical withdrawal threshold
measured before and after injection. The mechanical withdrawal threshold decreases 2
h after capsaicin injection. Two hours after capsaicin injection, the following drugs
were administered intrathecally: bicuculline, blocks γ-aminobutyric acid (GABAA)
receptors; naloxone, blocks opioid receptors; yohimbine blocks, α2-adrenergic
receptors; and methysergide, blocks 5-HT1/2 receptors. In addition, NAN-190,
ketanserin, and MDL-72222 were administered to selectively block 5-HT1A, 5-HT2A,
and 5-HT3 receptors, respectively. Knee joint manipulation was performed 15 min
after administration of drug. The knee joint was flexed and extended to end range of
extension while the tibia was simultaneously translated in an anterior to posterior
direction. The treatment group received three applications of manipulation, each 3
min in duration separated by 1 min of rest. Knee joint manipulation after capsaicin
injection into the ankle joint significantly increases the mechanical withdrawal
threshold for 45 min after treatment. Spinal blockade of 5-HT1/2 receptors with
methysergide prevented, while blockade of α2-adrenergic receptors attenuated, the
manipulation induced anti hyperalgesia. NAN-190 also blocked manipulation-induced
antihyperalgesia suggesting that effects of methysergide are mediated by 5-HT1A
receptor blockade. However, spinal blockade of opioid or GABAA receptors had no
effect on manipulation induced-antihyperalgesia. Thus, the antihyperalgesia produced
by joint manipulation appears to involve descending inhibitory mechanisms that
utilize serotonin and noradrenaline.37
Sluka KA et al 2006 hypothesized that joint mobilization would reduce the bilateral
hyperalgesia induced by muscle and joint inflammation. Mechanical hyperalgesia was
measured by examining the mechanical withdrawal threshold of the rat‟s paw before
and after induction of inflammation with 3% carrageenan (gastrocnemius muscle) or
3% kaolin/carrageenan (knee joint), and for 1 hour after knee joint mobilization. The
mobilization consisted of rhythmically flexing and extending the knee joint to the end
of range of extension while the tibia was simultaneously moved in an anterior to
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posterior direction. A bilateral decrease in mechanical withdrawal thresholds occurred

1, 2, and 4 weeks after inflammation of the knee joint or muscle. In animals with
muscle inflammation, mobilization of the knee joint increased the mechanical
withdrawal threshold bilaterally when given 1, 2, or 4 weeks after inflammation.
However, in animals with knee joint inflammation, mobilization of the knee joint at 4
weeks increased the mechanical withdrawal threshold but had no effect when
administered 1 or 2 weeks after inflammation. Therefore, joint mobilization reduces
hyperalgesia induced by chronic inflammation of muscle and joint. 38
Suraj et al 2006 conducted a study to find out the effects of joint mobilization on
pain and range of motion of joint in 30 osteoarthritis knee patients. They were divided
into 2 groups control and experimental. Control group patients received conventional
treatments like ultrasound therapy, TENS and exercises, where as experimental group
received joint mobilization. Authors concluded that pain reduced in both groups but
experimental group patients reduced pain better than control group. 39
Moss P et al 2007 conducted a double blind controlled study in 38 subjects to find

out the initial effects of knee joint mobilization on osteoarthritic hyperalgesia. They
compared the AP mobilization of the tibio-femoral joint with manual contact and
no-contact interventions and pressure pain threshold were measured before and after
treatment. Authors concluded that accessory mobilization of an osteoarthritic knee
joint immediately produces both local and widespread hypoalgesic effects and It may
be used as an treatment option to reduce pain in osteoarthritis knee patients. 40
Kahanov L et al 2007 stated that joint mobilization can be effective for pain
reduction and increased range of motion. More over this technique chosen for
treatment of a particular joint should be based on the type of mechanoreceptor
present.41
Johnson AJ et al 2007 compared the effectiveness of anterior versus posterior glide

mobilization techniques for improving shoulder external rotation range of motion
(ROM) in 20 patients with adhesive capsulitis. All subjects received 6 therapy
sessions consisting of application of therapeutic ultrasound, joint mobilization, and
upper-body ergometer exercise. Treatment differed between groups in the direction of
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the mobilization technique performed. Shoulder external rotation ROM measured

initially and after each treatment session was compared within and between groups. A
posteriorly directed joint mobilization technique was more effective than an anteriorly
directed mobilization technique for improving external rotation ROM in subjects with
adhesive capsulitis. Both groups had a significant decrease in pain.42
Annina S et al 2008 conducted a systematic review to assess the consistency of

evidence supraspinal systems in mediating the effects of passive cervical joint
mobilization and concluded that passive joint mobilization applied to the joint
produce the hypoalgesia through activation of descending pathways in central nervous
system and joint mechanoreceptors.43
Pollard H et al 2008 conducted a study randomized controlled trial to determine

whether a manual therapy technique knee protocol can alter the self reported pain
experienced by a group of chronic knee osteoarthritis sufferers . 43 participants with
a chronic, non progressive history of osteoarthritic knee pain, aged between 47 and 70
years were randomly allocated following a screening procedure to an intervention
group(n=26; 18 men and 8 women, mean age 56.5 years) or a control group (n=17; 11
men and 6 women, mean age54.6 years). Participants were matched for present knee
pain intensity measured on a visual analogue scale. The intervention consisted of the
Macquarie Injury Management Group Knee Protocol whilst the control involved a
non-forceful manual contact to the knee followed by interferential therapy set at zero.
Participants received three treatments per week for two consecutive weeks with a
follow up immediately after the final treatment. Post-treatment Participants
completed11 questions including present knee pain intensity and feedback regarding
their response to treatment utilizing a visual analogue scale. Prior to the intervention,
there was no significant differences in age or present knee pain intensity. Following
treatment, the intervention group reported a significant decrease in the present pain
severity (mean 1.9) when compared to the control group(mean 3.1). Response to
treatment questions indicated that compared to the control group, the intervention
group felt the intervention had helped them (intervention mean 7.0; control mean 3.4),
felt it decreased their knee symptoms such as crepitus (intervention mean 6.0;control
mean 3.4) and improved their knee mobility(intervention mean 6.4; control mean 3.4)
and their ability to perform general activities (intervention mean6.5; control mean 3.8).
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Importantly the MIMG Knee Protocol intervention group reported no adverse

reactions during treatment. Authors concluded that a short-term manual therapy knee
protocol significantly reduced pain suffered by participants with osteoarthritic knee
pain and resulted in improvements in self-reported knee function immediately after
the end of the 2 week treatment period. 44
Denham F et al 2008 conducted a randomized clinical trial in 60 patients. Patients

were divided into 3 groups with 20 patients each. Group 1 patients received topical
capsaicin; Group 2 received knee mobilization; and Group 3 received knee
mobilization with capsaicin. All groups were treated 6 times over 3 weeks. The
primary outcome measure was the Western Ontario and McMaster Universities
Osteoarthritis Index (WOMAC). Secondary measures included the Short-Form
McGill Pain Questionnaire (SFMPQ), Numeric pain rating scale (NPRS), and
goniometry (ROM). The Kruskal-Wallis tests compared among groups; Friedman's
T-test were used to compare within group change. After analyzing the results
statistically, authors suggested that manipulative therapy, particularly combined
manipulative therapy with capsaicin, may be helpful in short-term treatment of
kneeosteoarthritis.45
Kanlayanaphotporn R et al 2009 conducted a triple-blind, randomized controlled

trial to determine the immediate effects on both pain and active range of motion
(ROM) of the unilateral postero-anterior (PA) mobilization technique on the painful
side in mechanical neck pain patients presenting with unilateral symptoms. Pain
intensity, active cervical ROM, and global perceived effect were measured at baseline
and 5 minutes post treatment. And the authors conclude that after mobilization, there
were no apparent differences in pain and active cervical ROM between groups.
However, within-group changes showed significant decreases in neck pain at rest and
pain on most painful movement with a significant increase in active cervical ROM
after mobilization on most painful movement. 46
Maher S et al 2010 explored the effects of tibio-femoral (TF) manual traction on

pain and passive range of motion (PROM) in 13 individuals with unilateral motion
impairment and pain in knee flexion. All participants received 6 minutes of TF
traction mobilization applied at end-range passive knee flexion. PROM measurements
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were taken before the intervention and after 2, 4, and 6 minutes of TF joint traction.
Pain was measured using a visual analog scale with the TF joint at rest, at end-range
passive knee flexion, during the application of joint traction, and immediately
post-treatment. There were significant differences in PROM after 2 and 4 minutes of
traction. A significant change in knee flexion of25.9 0, was noticed and pain got reduce
after application of tibiofemoral traction.47
Nor Azlin MN et al 2011 conducted a controlled, single blinded experimental study

in 22 patients aged 40 and above with mild and moderate OA knee to determine the
effects of passive joint mobilization on pain and stairs ascending-descending time in
subjects with knee osteoarthritis (OA knee). Patients were divided into experimental
group who received passive knee mobilization plus conventional physiotherapy and
control group who received conventional physiotherapy alone. Both groups received 2
therapy sessions per week, for 4 weeks. Pain was measured with Visual analogue
scale and stairs ascending-descending time with Aggregated Locomotor Function test,
at baseline and at week 4. There was a significant reduction in pain among subjects in
the experimental group (18.07 mm, t = 3.48, p = 0.01) compared to the control group
(6.66 mm, t = 0.44, p = 0.67). Non-significant clinical difference was found in stairs
ascending-descending time between the two groups (i.e. 6.25s in the experimental
group versus 6.78 s in the control group, F(1,10) = 0.70, p = 0.42). No significant
correlation was found between pain score and stairs ascending-descending time, r =
0.34, p = 0.16. Authors concluded that the addition of passive joint mobilization to
conventional physiotherapy reduced pain but not stairs ascending-descending time
among subjects with knee osteoarthritis. 48
Sambandam CE et al 2011 conducted a study to find out the effectiveness of

mobilization technique either Mulligan‟s Mobilization or Maitland Mobilization for
improving the unilateral tibiofemoral joint ROM and functional performance in 60
patients with osteoarthritis of Tibiofemoral joint. They were divided into 3 groups
Group A received Mulligan mobilization, Group B received Maitland Mobilization
and Group C received conventional treatment. ROM was measured by Goniometry
and functional performance was measured by WOMAC scale pre and post treatment
by blinded tester. In this study all groups have shown significant difference in
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improving ROM, and improving functional performance but mulligan group showed
better improvement than Maitland group and control group.49
Jansen MJ et al 2011 conducted a meta-analysis of randomised controlled trials in

adults with osteoarthritis of the knee. Strength training alone, exercise therapy alone
(combination of strength training with active range of motion exercises and aerobic
activity), or exercise with additional passive manual mobilisation, versus any
non-exercise control were used as interventions. Comparisons between the three
interventions were also sought. Outcome measures like pain and physical function
were examined. Results suggested that exercise therapy plus manual mobilization
showed a moderate effect size on pain compared to the small effect sizes for strength
training or exercise therapy alone. They concluded that to achieve better pain relief in
patients with knee osteoarthritis physiotherapists or manual therapists might consider
adding manual mobilisation to optimise supervised active exercise programs. 50
Villafane JH et al 2012 investigated the effect of passive accessory mobilization in

28 patients with thumb carpometacarpal (CMC) osteoarthritis (OA). Outcome
measurements like pressure sensitivity and pinch grip force in the were measured.
Patients were divided into control and experimental group. The experimental group
received passive accessory mobilization to the CMC OA, and the control group
received intermittent ultrasound on the affected side for 4 sessions over 2 weeks.
There was no significant difference noted between groups and the authors concluded
that pain pressure threshold is increased but with no effect in motor control. 51
Kadu SS 2013 determined the effectiveness between supervised clinical exercise

with Maitland mobilization and an home exercise program in treating osteoarthritis of
knee for the period of 4 weeks. Patients were divided into control and treatment
group. Control group patients received only exercise, where as exercise with Maitland
mobilization was given to treatment group. 6 minutes walk test and Western Ontario
McMaster Universities Osteoarthritis Index (WOMAC) were used as outcome
measuring tool. They concluded that both groups showed clinically and statistically
significant improvements in the 6-minute walk distances and WOMAC scores at 4
weeks By 4 weeks, WOMAC scores had improved by 52% in clinic treatment group
and by 26% in home exercise group. Average 6-minute walk distances had improved
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about 10% in both groups but on comparing both groups experimental group patients
results were better than control group.52
Arguello Prada EJ et al 2013 conducted a experiment in which a novel

neuron-model known as the Neuroid, which emphasized the functional rather the
physiological character of nerve cells, was used as the main building block to
replicate the Gate Control System (GCS). Two Aβ-fibre models were built: one model
that preserved the paradoxical relation between the activation threshold and the F-I
curve slope, and one model based on the hypothetical average response across the
receptive field. They suggested that the average response of the Aβ-fibres does not
increase monotonically but reaches a plateau for high intensity stimuli. In addition, it
was seen that activation of C-fibres does not necessarily imply the activation of
projection neurons and, therefore, the onset of pain sensation. Also, we observed that
the activation of Aβ-fibres may both, decrease and increase the activity of the
projections neurons, an aspect which has not been directly described in previous
works.53
Ghanbari A et al 2013 conducted a Quasi experimental study to investigate the

immediate effect of a single session of tibiofemoral joint mobilization on quadriceps
muscle strength in healthy young women. Grade 4 mobilization in a posterior-anterior
direction was performed at the knee joint for 3 minutes while the individual was
seated with the joint in 90° flexion. Before and 30 minutes after the intervention,
quadriceps strength was measured as maximal voluntary isometric contractions
(MVIC)(in Newton) by a digital dynamometer with the participant seated and the
knee joint at 90° flexion. MVIC were significantly larger than the pre-mobilization
value immediately (P=0.0001) and 30 minutes post joint mobilization (P=0.0001).
Authors concluded that mobilization increased quadriceps strength and the increase
persisted for 30 minutes. Increasing knee joint mobility may remove neuromuscular
inhibition on the quadriceps and thus enhanced muscle strength. 54
Vernon H 2013 stated that join mobilization reduce pain, reduce muscle
hyperactivity, induction of reflexes in autonomic system, increase mobility of joint
and improve proprioception of joint applied. 55
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Villafane JH et al 2013 conducted a double blind randomized controlled trail to

examine the effectiveness of a manual therapy and exercise approach relative to a
placebo intervention in 60 individuals with carpometacarpal (CMC) joint
osteoarthritis (OA). Patients were randomly assigned to receive a multimodal manual
treatment approach that included joint mobilization, neural mobilization, and exercise,
or a sham intervention, for 12 sessions over 4 weeks. Outcome measurements like
pain, pain pressure threshold and pinch grip was examined. The study concluded that
combination of joint mobilization, neural mobilization, and exercise is more
beneficial in treating pain than a sham intervention in patients with CMC joint OA. 56
Kenkampha K et al 2013 investigated the immediate effects of Sacroiliac joint

(SIJ) mobilization on lumbar spinal flexibility, pain perception, and pressure pain
threshold (PPT) in 16 patients (8 males and 8 females) with non-specific low back
pain (NSLBP) associated with sacroiliac joint dysfunction SIJD. Patients were
randomly assigned into two groups. Experimental group was treated with SIJ
mobilization 30 oscillations/ set, 3 sets/ one side (total within 4 minutes). The control
group was instructed the same starting position (rest in side lying for 2 minutes/ side)
as of the experimental group but just with the sham method. Both groups were
immediately pre and post-treatment assessed lumbar spinal flexibility, pain perception
level, and pressure pain threshold tested by Modified-modified Schober‟s test, Visual
analog scale (VAS), and algometry. They concluded that SIJ mobilization increases
lumbar spinal flexibility, reduces pain, and improves pain threshold than the control
group.57
Shum GL et al 2013 conducted a experimental study to find the effect of

posteroanterior mobilization on back pain and the associated biomechanical changes
in the lumbar Spine in 19 low back pain patients. Pain intensity, active lumbar range
of motion, the magnitude of the posteroanterior mobilization loads, bending stiffness
of the lumbar spine, and the lordotic curvature of the lumbar spine were assessed
before and after 3 cycles of posteroanterior mobilization. Posteroanterior mobilization
was found to bring about immediate desirable effects in reducing spinal stiffness and
the magnitude of back pain.58
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Martins DF et al 2013 in their experimental study, investigated the contribution of

the adenosinergic system on the anti hyperalgesic effect of ankle joint mobilization
(AJM) in mice (25–35 g) which was submitted to plantar incision surgery. The mice
were subjected to AJM for 9 minutes. Withdrawal frequency to mechanical stimuli
was assessed 24 hours after plantar incision surgery and 30 minutes after AJM,
adenosine, clonidine, or morphine treatments. The adenosinergic system was assessed
by systemic (intraperitoneal), central (intrathecal), and peripheral (intraplantar)
administration of caffeine. The participation of the A1 receptor was investigated using
a selective adenosine A1 receptor subtype antagonist. In addition, previous data on the
involvement of the serotonergic and noradrenergic systems in the anti hyperalgesic
effect of AJM were confirmed. This study demonstrated the involvement of the
adenosinergic system in the anti hyperalgesic effect of AJM in a rodent model of pain
and provides a possible mechanism basis for AJM-induced relief of acute pain.59
Syed S at al 2014 conducted a study to compare the effectiveness of Maitland‟s

mobilization and Myofascial mobilization in reducing pain and improving functional
disability among 68 patients aged between 40-70 years with knee osteoarthritis .
Patients were divided into 2 groups A and B randomly. VAS and WOMAC scale
were used to measure pain and functional activities respectively. They concluded that
both Myofascial mobilization and joint mobilization presented more
beneficial effects on knee OA on a short term basis. 60
Joshi S et al 2014 conducted a experimental study to compare the effectiveness of

maitland compression technique with medial glide and conventional therapy in 30
patients with patellofemoral osteoarthritis. Patients age group was between 45 yrs to
65 yrs. Using random sampling method the 30 subjects were divided into 2 equal
groups with 15patients each. Both the groups were given conventional physical
therapy as a baseline treatment. Along with conventional therapy the experimental
group received Maitland Compression technique with medial glide . 3 series of 15
compressions per session for 5 days per week, whereas the control group received
only the conventional physical therapy. The study was performed for
3weeks.Evaluation was done before starting the treatment and then after 3 weeks.
Outcomes scores were evaluated using KOOS Scale and VAS scale . Subjects
received Maitland Compression Technique with Medial Glide showed significant
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reductions in pain and other symptoms with an improvement in quality of life.(t of

KOOS =10.52 ,tof VAS = 8.064 ). Authors concluded that Mailtland mobilization
with medial glide yielded better results in patients with patellofemoral osteoarthritis. 61
Kappetijin O et al 2014 evaluated the efficacy of passive knee extension

mobilization in addition to exercise therapy on extension range of motion (ROM) in
patients with osteoarthritis (OA) of the knee and determined changes in pain and
functional abilities in 34 patients with knee OA complain of pain, limited range of
motion, and impaired activities. Thirty-four participants with persistent knee pain, a
positive radiography for knee OA, and a passive extension deficit were included.
Seventeen participants (mean age±SD, 59.8±6.1 years)were treated with an exercise
protocol and were additionally given manual mobilizations to improve passive
extension ROM. The other group (mean age±SD, 61.5±7.3 years) with equal
characteristics was treated with an identical exercise therapy protocol only. Prior to
participation, detailed ROM measurements were recorded next to muscle function
tests, pain (VAS), six-minute walking tests (6MWTs), a condition-specific
questionnaire, and the patient-specific function scale (PSFS). Participants in both
groups completed 16 treatment sessions each. Passive mobilization significantly
improved extension ROM in the intervention group (5.2 versus 8.6°, p = 0.017). The
manually mobilized group also had better physical capacities as assessed by 6MWT,
less pain, and a lower PSFS score. A combined protocol including exercise therapy
and passive mobilization was beneficial for patients with OA of the knee complaining
of pain, decreased extension ROM and decreased limited abilities. 62
Tavakkoli M 2014 conducted a blind clinical trial in 30 patients. They were divided
into 3 groups 1) Mobilization with exercise therapy, 2) Exercise therapy and 3)
Mobilization. In addition , >0.2 W/Cm2 ultrasound was used as placebo for 3 minutes
for all groups. The duration of treatment was 10 sessions in 3 weeks. To evaluate joint
stiffness WOMAC questionnaire was used. Evaluation was done before and after
treatment and approximately one week after the last session of treatment. Data
analysis indicated a significant difference between first and second groups (P =
0.008); while, there was no significant difference between other groups. Comparison
of joint stiffness after treatment to that before the treatment showed a significant
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decrease only in the second group (P = 0.016); no significant change was observed in
other groups. Variations in joint stiffness was not significant in the follow-up session
compared to that before the treatment in any of the groups. This study showed that
type 1 mobilization of a patellofemoral joint is not effective on reduction of joint
stiffness caused by type 2 or 3 knee osteoarthritis, where as it is used to relieve pain
according to previous empirical evidences. 63
Lee NY et al 2015 investigated the effect of the manual joint mobilization in

osteoarthritis knee patients and also determined the effect of pain, range of motion,
body function and balance after applying it in thirty participants with knee pain .
They were randomly assigned to control (Con) group (n=15) that received the general
physical therapy and experimental (Exp) group (n=15) that received the applied the
manual joint mobilization and the general physical therapy three times per week, 30
minutes per day for four weeks. It measured the visual analogue scale (VAS), the
range of motion (ROM), body function (WOMAC) and balance. Results showed that
there was significant different between the control group and experiment group in
VAS, ROM and WOMAC. After 4 weeks, the experiment group was significantly
different from other group in VAS, ROM and WOMAC. But the measurement of
balance did not show the significantly difference within group and between groups.
Authors suggested that Manual joint mobilization was effective in pain, ROM,
function in patient with knee osteoarthritis. 64
Rangey PS et al 2015 conducted a study in which they compared the immediate

effectiveness of two different Maitland protocols on pain, pressure threshold (PPT) and
range of motion (ROM) in 24 patients. They were selected according to the American
College of Rheumatology criteria and divided into group A and B randomly, receiving
3 repetitions of Maitland mobilization of the knee joint each of1 minute duration and 1
repetition of 3 minutes duration respectively. Patients with lower limb surgery,
inflammatory or neurological conditions, experienced altered sensation over the knee
or exhibited cognitive difficulties were excluded. PPT and ROM were measured by
pressure algometer and goniometer respectively. Level of significance was kept at 5%.
Results showed statistically significant difference within both groups for both PPT
(groupA p=0.002, groupB p=0.002) and ROM (groupA p=0.003, groupB p=0.003).
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Mann Whitney U test showed statistically significant difference between the groups for
ROM (p=0.045) but no difference for PPT (p=0.356).Authors concluded that both the
protocols may be used for pain relief and improvement in ROM for subjects with
osteoarthritis. For a greater improvement in the ROM, Maitland mobilization may be
given for three repetitions of 1 minute each with a 30 second break between each
repetition.65
Moon GD et al 2015 compared the Maitland mobilization and Kaltenborn

mobilization techniques in 20 patients with frozen shoulders to assess its effects on
pain and range of motion of shoulder joint. Patients were divided into 2 group, where
one group receives Maitland mobilization and other group Kaltenborn mobilization
techniques. Grade III anteroposterior oscillation and posterior translation were used
for the Maitland and Kaltenborn mobilization groups, respectively. Pain and range of
motion of external and internal rotation were evaluated pre- and post-intervention in
both groups. Paired t-tests was used to compare the pre- and post-intervention results
in both groups, and independent t-tests were used to compare groups. Both groups
exhibited significant decreases in pain post-intervention. Moreover, the range of
motion of internal and external rotation increased significantly post-intervention in
both groups. Authors concluded that the posterior Maitland and Kaltenborn
mobilization techniques are effective for improving pain and range of motion in
frozen shoulder patients.66
T Sousa et al 2015 conducted a study in 15 male Wistar rats to find out the effects of
peripheral joint mobilization on nociception and motor activity. Fifteen male Wistar
rats were induced with joint inflammation through an injection (0.1 mL) of kaolin and
carrageenan (3%) in the left knee. Three days after induction of inflammation, joint
mobilizations grade 1 (n=5) or grade 3 (n=5) were performed, whereas control
animals (n=5) received no interventions. Authors concluded that rats which received
joint mobilization showed reduction in pain and improvement in motor activity than
control group rats.67
E. Kaya Mutlu et al 2015 conducted a randomized control trail study in 48

osteoarthritis knee patients to compare the effects of 2 different mobilization
techniques . Fourty-eight participants with osteoarthritis of the knee were randomly
assigned to a MWM group (n=23) or a PJM group (n=25). Participants in MWM
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group received Movement with mobilization (MWM) and exercise. MWM consisted
of a sustained manual glide of the tibia (medial, lateral, or rotation) during active knee
flexion and extension (three sets of 10 repetitions). The participants in (Passive Joint
mobilization) PJM group received PJM techniques and exercise. Passive joint
mobilization includes knee distraction, dorsal glide, ventral glide and patella glides in
all directions. The duration of treatment was a maximum of 5 weeks (12 sessions) in
both groups. The subjects were assessed before and after treatment using a Visual
Analogue Scale (VAS) for pain, and the Range of Motion (ROM) was measured using
a digital goniometer. The Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC) was used to assess function activities. They concluded that patients
with osteoarthritis of knee gained clinically benefit from mobilization techniques on
pain, ROM and function.68
Young NL et al 2015 investigated the effects of the manual joint mobilization in 30

osteoarthritis knee patients. Patients were randomly divided into control (Con) group
(n=15) that received the general physical therapy and experimental (Exp) group
(n=15) that received the applied the manual joint mobilization and the general
physical therapy three times per week, 30 minutes per day for four weeks. Visual
analogue scale (VAS), the range of motion (ROM), body function (WOMAC) and
balance (TUG) was used as outcome measuring tools. Experimental group patients
showed significantly better improvement than the control group in terms of pain,
ROM and WOMAC scores and authors suggested that Manual joint mobilization was
effective in pain, ROM, function in patient with knee osteoarthritis. 69
Bezelga C et al 2015 conducted a randomized controlled trail to find out the effects of
joint mobilization in 40 patients with hip osteoarthritis (OA). Patients were divided
randomly into two groups 20 each, where movement with mobilization was given to
one group and other group received sham intervention. Outcome measures like Pain
was recorded by numerical rating scale (NRS) and hip flexion and internal rotation
ROM, and physical performance like timed up and go, sit to stand, and 40m self
placed walk test were assessed before and after the intervention. They concluded that
Pain, hip flexion ROM and physical performance immediately improved after the
application of movement with mobilization in elderly patients suffering hip OA. 70
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Taeseong Ju et al 2015 investigated the effects of hip mobilization on pain,

function, and psychological factors in 40 patients suffering from chronic low back
pain with limited range of hip joint motion. Patients were randomly assigned to
experimental (n=20) or control groups (n=20). Both groups received conventional
physical therapy for forty minutes, three times a week for six weeks. Experimental
group was performed additional hip mobilization for fifteen minutes, three times a
week for six weeks. All of the patients were evaluated for pain, function, and
psychological factors before and after intervention. This study confirmed that hip
mobilization brings positive effects on pain, function and psychological factors for
patients with chronic low back pain. 71
Frantz A et al 2015 conducted a study to determine the effect of joint mobilization in

8 patients with pain in shoulder joint and conclude that joint mobilization can be used
to ease painful shoulder joint.72
Ahmad A et al 2016 conducted a comparative study in 50 osteoarthritis knee

patients. Patients were grouped into control who received only conventional physical
therapy interventions and experimental group who received only joint mobilization.
Both groups were received their programs for 8 weeks; two sessions per week. Pain
and function activities were measured using visual analogue scale (VAS) and Index of
severity of osteoarthritis (ISOA).Both groups showed significant improvement in
ISOA score and VAS and authors concluded that Manual joint mobilization improves
the effectiveness of the treatment program in treating symptoms of knee OA and
improves function in elderly people with knee OA. 73
Park SJ et al 2016 investigated the effects of joint mobilization and kinesio taping on
pain, range of motion and knee function in 30 patients with knee osteoarthritis. They
were divided into three groups: group 1 was treated with joint mobilization, group 2
was treated with kinesio taping and group 3 was treated with joint mobilization and
kinesio taping. Joint mobilization was performed for 20 minutes three times a week
for a period of 4 weeks, after which tape was applied for the same period of time and
it was not exceeded 24 hours. Pain, range of motion and knee function were then
assessed to identify the effectiveness. A visual analog scale (VAS) was used for pain
assessment, while active and passive range of motion (AROM, PROM) were assessed
using smart phones application, and knee injury and osteoarthritis outcome score
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(KOOS) was used to assess knee function. After intervention, the joint mobilization
group and kinesio taping group showed significant improvements in VAS, AROM,
PROM and KOOS (Symptom, Pain, ADL, QOL), whereas no significant difference
was found in sport/recreation. The joint mobilization with kinesio taping group
showed significant improvements in all items, and a significant increase was found in
AROM and PROM compared to the other two groups. Authors found that joint
mobilization and kinesio taping effectively improved pain, range of motion and knee
function in patients with knee osteoarthritis, but that application of joint mobilization
with kinesio taping was most effective. 74
CourtneyCA 2016 examined the effect of joint mobilization in 40 patients with mild
to moderate osteoarthritis. Patients were randomized to receive 6 minutes of knee
joint mobilization (intervention) or light manual cutaneous input only, one week
apart. They concluded that Joint mobilization may act via enhancement of descending
pain mechanisms, in patients with painful knee OA. 75
Ropero Pelaez FJ et al 2016 conducted a study in which they modified the Melzack
and Wall circuit slightly by using strictly excitatory nociceptive afferents (in the
original arrangement, nociceptive afferents were considered excitatory when they
project to central transmission neurons and inhibitory when projecting to substantia
gelatinosa).The results of their neuro computational model are consistent with
biological ones in that, nociceptive signals are blocked on their way to the brain every
time a tactile stimulus is given at the same locus where the pain was produced. It
relieved pain in other painful conditions like phantom limb pain, wind-up and
wind-down pain, breakthrough pain, and demyelinating syndromes like
Guillain-Barre and multiple sclerosis.76
.
Xu q et al 2017 conducted a systematic review and meta-analysis on the effectiveness
and adverse events (AEs) of manual therapy compared to other treatments for
relieving pain, stiffness, and physical dysfunction in patients with knee osteoarthritis
(KOA). Two reviewers independently conducted the search results, identification,
data extraction, and methodological quality assessment. The methodological quality
was assessed by PED scale. They included14 studies involving 841 KOA patients and
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suggested that manual therapy might be effective and safe for improving pain,
stiffness, and physical function in KOA patients. 77
Kulkarni AV et al 2017 conducted a study to determine the effectiveness of

mulligan‟s mobilization with movement techniques on pain in 30 knee osteoarthritis
patients. Patients were divided randomly into control and experimental group with 15
patients in each group. Conventional treatment (TENS and exercise) was given to
control group, where as experimental group received conventional treatment and joint
mobilization techniques. VAS (Visual Analogue Scale) and 6 minutes walk test was
used as outcome tools. Authors after 3 days of treatment session, concluded that joint
mobilization is effective in reducing pain in patients with knee osteoarthritis.
Statistically significant reduction in VAS (pain) and marked improvement in the
distance covered by the subjects was observed in the experimental group post
treatment.78
Gonclaves Tavares FA et al 2017 evaluated the effects of joint mobilization on pain

intensity and incapacity in 60 chronic low back pain patients. They were divided into
control and experimental groups with 30 patients in each group. Control group
received no interventions, where as joint mobilization technique was received by
experimental group. They concluded that experimental group patients showed better
improvement in their symptoms than control group. 79
Nawaz MS et al 2017 conducted a quasi experimental study to determine the outcome

of isometric exercises (Quadriceps) alone and in combination with grade 1-2 Knee
joint mobilizations to manage pain and to improve physical functioning in 80 patients
of knee Osteoarthritis. The study was conducted in the physiotherapy department of
Fatima Memorial Hospital Shadman. Patients were divided in two groups
(Mobilization group and Combination group). There was no significant difference
between age, education, co-morbidities and initial WOMAC score in different
domains (pain, stiffness, physical function) and total WOMAC score of the two
treatment groups before treatment. WOMAC scale was used as an assessment tool to
measure the outcome of treatment in different groups before and after treatment
(follow up 2weeks). There was significant improvement seen in all 3 domains of
WOMAC scale (pain, stiffness and physical activity) in Combination group in Grade
1-2 knee Osteoarthritis. According to Paired t test mean difference between post-Pre
Page | 33
values of both groups was highly significant (p=0.000) in all domains. Combination
of Grade1- 2 Maitland and Isometric of Quadriceps showed better improvement in
pain, stiffness and physical activity in Grade 1- 2 Osteoarthritis than the quadriceps
isometrics alone.80
Vaishnavi KS et al 2017 compared the effectiveness between Maitland‟s
mobilization with ultrasound and Proprioceptive exercises with ultrasound, to reduce
pain (VAS) and improve functional ability (WOMAC) in OA knee. Subjects were
screened as per inclusion and exclusion criteria with knee OA. A written informed
consent was signed by the subject and was rehabilitated for alternate days for 2
weeks. These subjects were randomly divided in two groups. Group A (n=10) Treated
with ultrasound and Maitland‟s mobilization. Group B (n=10) Treated with ultrasound
and Proprioceptive exercise program. In comparison with VAS-pain and
WOMAC-pain, stiffness and difficulty scores, Group A shows significant
improvement of all the parameters than Group B. Group A with VAS of pre
intervention score being 8 and post intervention 2.5. Group B with VAS of pre
intervention score being 5.7 and post intervention 3.6. Group A with WOMAC pain,
stiffness and difficulty of pre intervention being 8.6, 3.1and 32.1 respectively and post
intervention 3.7, 1.5and 11.3. Group B with WOMAC pain, stiffness and difficulty of
pre intervention being 13.4, 4.6 and 41.9 respectively and post intervention 6.5, 2.2
and 21.7. Following the intervention, at the end of 2nd week result showed clinically
and statistically improvement in the VAS and WOMAC scores in Group A compared
to Group B. Authors suggests that Maitland‟s mobilization with ultrasound therapy
eased the symptoms of OA knee patients. 81
Jiao Xu et al 2017 conducted a single blind, prospective, randomized study to find

out the effect of joint mobilization in 120 patients with unilateral total knee
arthroplasty. Patients were randomized into an intervention group, a physical modality
group, and a usual care group. The intervention group underwent joint mobilization
manipulation treatment once a day and regular training twice a day for a month. The
physical modality group underwent therapy once a day and regular training twice a
day for a month. The usual care group will perform regular training twice a day for a
month. Primary outcome measures was based on the visual analog scale, the knee
joint Hospital for Special Surgery score, range of motion, surrounded degree, and
adverse effect. Secondary indicators were manual muscle testing, 36-Item Short Form
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Health Survey, Berg Balance Scale function evaluation, Pittsburgh Sleep Quality
Index, proprioception, and muscle morphology. The authors concluded that joint
mobilization techniques was effective in early knee replacement people to reduce pain
and improving functional activities of knee joint. 82
Megha M et al 2017 conducted a study to find out the effects of Patellofemoral

Mobilization, Stretching and Strengthening on walking Ability and Stair Climbing in
30 Subjects with Osteoarthritic knee, where patients were divided into 3 group with
10 patients each. group 1 received patellar mobilization in all directions plus isometric
exercise of quadriceps, group 2 received strengthening exercise of quadriceps,
hamstrings and hip abductors plus isometric exercise of quadriceps and group 3
received stretching exercise of rectus femoris, hamstrings, hip adductors, pyriformis,
posterior knee joint capsule, IT band, calf muscle plus isometric exercise of
quadriceps. Total duration of treatment was 5 days in a week for 4 weeks. Authors
concluded that though all groups showed better results, mobilization effects were a
head in relieving pain in case of osteoarthritis. 83
Ujwal L Y et al 2017 conducted a randomized controlled trail to find the effect of

mobilization in 30 patients with adhesive capsulitis of shoulder. Patients were divided
into 2 groups into Group A (15) undergoing movement with mobilization (MWM)
intervention and Group B (15) undergoing supervised exercises only for 1 week.
Range of motion, pain using Numerical Pain Rating Scale (NPRS); and Shoulder Pain
and Disability Index (SPADI) were measured pre and post treatment. Authors
concluded that patients treated with MWM showed marked reduction in pain, increase
ROM and SPADI.84
Farooq MN et al 2018 determined the effect of mobilization and routine

physiotherapy on pain, disability, neck range of motion (ROM) and neck muscle
endurance (NME) in 68 patients having chronic mechanical neck pain (NP). Patients
were divided into 2 groups, one group with 34 patients who received conventional
physical therapy treatment and other group with 34 patients who received joint
mobilization. Visual analogue scale (VAS), neck disability index (NDI), neck flexor
muscle endurance test and universal Goniometer were used as measuring tools before
the treatment. 10 treatment sessions over a period of four weeks were given to
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patients and at the end of 4th week all outcomes were measured again. The authors
concluded that joint mobilization on combining with conventional physiotherapy
yielded better results than conventional therapy alone. 85
Migule EE 2018 conducted a randomized controlled trail to compare the effectiveness

of high, medium and low mobilization forces for increasing range of motion (ROM)
in 60 patients with hip OA and to analyze the effect size of the mobilization. Rom and
pain level was measured using Goniometer and WOMAC scale. Authors concluded
that A high force long-axis distraction mobilization in open packed position
significantly increased hip ROM in all planes of motion compared to a medium or low
force mobilization in patients with hip OA. A specific intensity of force mobilization
appears to be necessary for increasing ROM in hip OA. 86
Dhinu J et al 2018 investigated the effects of joint mobilization in 499 patients with
patellofemoral pain and concluded that joint mobilization drastically reduced pain and
improved functional activities. 87
Rao RV et al 2018 conducted a randomized cross over trail to determine whether

Maitland Mobilization or Mulligan movement with mobilization (MWM), will be
more effective in reducing pain and improving mobility and function in OA knee
immediately after the intervention. 30 subjects with osteoarthritis knee were recruited
and 15 each were randomly allocated to two intervention sequences- one sequence
was where Maitland was given first followed by Mulligan and the other was where
Mulligan was given first followed by Maitland with a washout period of 48 hours in
between the two interventions. Numeric Pain Rating Scale (NPRS), Timed Up and Go
(TUG) test and Pain free Squat Angle were the outcome measures measured before
and immediately after both interventions. Using Repeated Measures ANOVA for
analysis of outcomes between and within interventions, no significant differences
were seen between Maitland Mobilization and Mulligan MWM, for NPRS, TUG and
Pain free Squat Angle (p=0.18, p=0.27,p=0.17) respectively whereas within the
interventions both Maitland and Mulligan all outcome measures showed significant
changes (p<0.001). Authors concluded that that Maitland mobilization and Mulligan
MWM, both are equally effective in osteoarthritis knee in reducing pain and
improving functional mobility and pain free squat angle immediately post treatment. 88
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2.2 Proprioceptive Neuromuscular Facilitation (PNF)
Proprioceptive Neuromuscular Facilitation (PNF) stretching is an advanced technique

used to treat neuromusculoskeletal dysfunction. Empirical evidences related to PNF
are as follows,
Etnyre BR et al 1986 stated that the most common stretching method comparisons
are between static stretching (SS) and one or more Proprioceptive Neuromuscular
Facilitation (PNF) technique(s). The two most frequently implemented PNF
techniques are: contract-relax (CR); and contract-relax-antagonist-contract (CRAC).
Previous comparative investigations among stretching methods have primarily
observed changes in straight-leg hip flexion as a result of lengthening the hamstrings,
a two-joint muscle. The present study observed gains in range of motion among three
stretching methods (SS, CR, CRAC) of a joint limited by a single joint muscle, the
soleus. Twelve subjects performed each of the three methods on separate days.
Significant differences were observed among all methods (p = .001). Further analysis
revealed the CRAC method was superior to the CR method (p less than .01), and the
CR method was superior to the SS method (p less than .01). Significant
pre-post-treatment gains in range of motion were observed as a result of the CR and
CRAC methods, but not the SS method. Authors suggests that previous
investigations for two-joint muscles in which PNF techniques were more effective
than static stretching for increasing range of motion. Also, a reciprocal activation
(CRAC in the present study) was the most effective for increasing range of motion. 89
Osternig LR et al 1987 investigated the effect of three common PNF stretching

techniques on hamstring muscle activation and knee extension. Three PNF techniques:
stretch-relax (SR), contract-relax (CR) and agonist contract-relax (ACR) were applied
to ten male and female subjects aged 23-36 years who were stabilized to isolate knee
extension measurements. Knee joint position and EMG activity from quadriceps and
hamstring muscles were computer processed throughout technique application. The
mean hamstring EMG activity increased 8-43% within a given trial of ACR and CR
respectively, and did not diminish across trials. SR produced a 11% decrease in mean
hamstring EMG activity. ACR produced 3-6% greater knee extension values than CR
Page | 37
and SR respectively, in spite of 71-155% greater hamstring EMG activity during ACR.
The data suggest that CR and ACR do not evoke sufficient relaxation in muscles
opposing knee extension to overcome tension facilitation generated by stretch. Thus,
increases in ROM are achieved while the hamstrings are under considerable tension. 90
Robertson RN et al 1990 investigated the effects of sustained stretch and two

common proprioceptive neuromuscular facilitation (PNF) stretch techniques on
hamstring muscle activation and knee extension range of motion (ROM) in different
athletic populations. Three stretch techniques: stretch-relax (SR), contract-relax (CR),
and agonist contract-relax (ACR) were applied to 10 endurance athletes (EN), 10 high
intensity athletes (HI), and 10 control subjects (C). The results revealed that ACR
produced 89-110% greater hamstring EMG activity (P less than 0.05) and 9-13%
more knee joint ROM than CR and SR, respectively. This same pattern was evident
for the individual subject groups. Comparisons of mean data among the three subject
groups revealed that the EN athletes generated 58-113% more hamstring EMG
activity (P less than 0.05) than the HI and C groups, respectively, across all stretch
conditions, whereas the EN group attained significantly less ROM than the HI and C
groups for CR and ACR conditions. It was postulated that high intensity-short term
activity training necessitates less hamstring resistance to knee extension than long
term endurance training. The overall findings concludes that PNF stretch techniques
improves knee extension ROM and the performance of the muscles also increased. 91
Worrell TW et al 1994 determined the most effective stretching method for

increasing hamstring flexibility and the effects of increasing hamstring flexibility on
isokinetic peak torque in 19 subjects. A two-way analysis of variance was used to
compare two stretching techniques: proprioceptive neuromuscular facilitation stretch
and static stretch. A one-way repeated measures analysis of variance was used to
compare hamstring isokinetic values pre- and post stretching. No significant increase
occurred (p > .05) in hamstring flexibility even though increases occurred with each
technique: static stretch (+21.3%) and proprioceptive neuromuscular facilitation
(+25.7%). Significant increases occurred in peak torque eccentrically at 600/sec (p
<.05, +8.5%) and 1200/sec (p < .05, + 13.5%) and concentrically at 1200/sec (p < .05,
+ 11.2%). No significant increase occurred at 6O0/sec (p > .05, +2.5%). Authors
concluded that most effective method to increase length and flexibility of hamstring
muscle is proprioceptive neuromuscular facilitation stretching.92
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R.Ferber et al 2002 conducted a study to find the effects of proprioceptive

neuromuscular facilitation (PNF) stretch techniques on older adults and examined the
EMG activity in older adults. Three PNF stretch techniques: static stretch (SS),
contract–relax (CR), and agonist contract–relax (ACR) were applied to 24 older adults
aged 50–75 years. The subjects were tested for knee extension range of motion (ROM)
and knee flexor muscle EMG activity. The results indicated that ACR produced
29–34% more ROM and 65–119% more EMG activity than CR and SS, respectively.
Authors concluded that PNF stretch techniques can increase ROM in older adults and
can be used for the same purpose.93
Godges JJ et al 2003 conducted a randomized controlled 2-group, pretest-posttest,

multivariate study in patients with shoulder musculoskeletal disorders aimed to
evaluate the immediate effect of soft tissue mobilization (STM) with proprioceptive
neuromuscular facilitation (PNF) to increase glenohumeral external rotation at 45° of
shoulder abduction and overhead reach. Twenty patients (10 males, 10 females; age
range, 21-83 years) with limited glenohumeral external rotation and overhead reach of
1 year duration or less served as subjects. The subjects were randomly assigned to a
treatment group, which consisted of soft tissue mobilization to the subscapularis and
proprioceptive neuromuscular facilitation to the shoulder rotators, or a control group.
Goniometric measurements of glenohumeral external rotation at 45°abduction and
overhead reach were taken preintervention and immediately post intervention for the
treatment group and for the control group. The treatment group improved by a mean
of 16.4° of glenohumeral external rotation, as compared to less than a 1° gain in the
control group. Overhead reach in the treatment group improved by a mean of 9.6 cm
in comparison to a mean gain of 2.4 cm for the control group (P = .009). Authors
suggest that a single intervention session of STM and PNF was effective for
producing immediate improvements in glenohumeral external rotation and overhead
reach in patients with shoulder disorders.94
Feland JB et al 2004 conducted a randomized controlled trail in 72 male subjects

aged 18–27 to determine if submaximal contractions used in contract-relax
proprioceptive neuromuscular facilitation (CRPNF) stretching of the hamstrings yield
comparable gains in hamstring flexibility to maximal voluntary isometric contractions
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(MVICs).Subjects were qualified by demonstrating tight hamstrings, defined as the

inability to reach 70˚ of hip flexion during a straight leg raise. Sixty subjects were
randomly assigned to one of three treatment groups: 1, 20% of MVIC; 2, 60% of
MVIC; 3, 100% MVIC. Twelve subjects were randomly assigned to a control group
(no stretching). Subjects in groups 1-3 performed three separate six second CRPNF
stretches at the respective intensity with a 10 second rest between contractions, once a
day for five days. Goniometric measurements of hamstring flexibility using a lying
passive knee extension test were made before and after the stretching period to
determine flexibility changes. Paired t tests showed a significant change in flexibility
for all treatment groups. A comparison of least squares means showed that there was
no difference in flexibility gains between the treatment groups, but all treatment
groups had significantly greater flexibility than the control group. CRPNF stretching
using submaximal contractions is just as beneficial at improving hamstring flexibility
as maximal contractions.95
Marek SM 2005 et al conducted a randomized, counterbalanced, cross-sectional,

repeated- measures design to examine the short-term effects of static and
proprioceptive neuromuscular facilitation stretching on peak torque (PT), mean power
output (MP), active range of motion(AROM), passive range of motion (PROM),
electromyographic (EMG) amplitude, and mechano myographic (MMG) amplitude of
the vastus lateralis and rectus femoris muscles during voluntary maximal concentric
isokinetic leg extensions at 60 and3000. S-1.Ten female (age, 23 6 3years) and 9 male
(age, 21 6 3 years) apparently healthy and recreationally active volunteers were
included in this study. Four static or proprioceptive neuromuscular facilitation
stretching exercises to stretch the leg extensor muscles of the dominant limb during 2
separate, randomly ordered laboratory visits. The PT and MP were measured at 60
and3000. S-1. EMG and MMG signals were recorded, and AROM and PROM were
measured at the knee joint before and after the stretching exercises. Static and
proprioceptive neuromuscular facilitation stretching reduced PT (P =0.051), MP
(P=0.041), and EMG amplitude (P=0.013) from pre stretching to post stretching at 60
and3000. S-1.(P <0 .05). The AROM (P <.001) and PROM (P =0.001) increased as a
result of the static and Proprioceptive neuromuscular facilitation stretching. The
MMG amplitude increased in the rectus femoris muscle in response to the static
stretching at 600. S-1 (P =0.031), but no other changes in MMG amplitude were
Page | 40
observed (P >0.05). Both static and proprioceptive neuromuscular facilitation

stretching caused similar deficits in strength, power output, and muscle activation at
both slow (600. S-1) and fast (3000. S-1) velocities and range of motion of joint. 96
Kofotolis N et al 2006 examined the effects of 2 proprioceptive neuromuscular

facilitation (PNF) programs on trunk muscle endurance, flexibility, and functional
performance in subjects with chronic low back pain (CLBP). Eighty-six women who
had complaints of CLBP were randomly assigned to 3 groups: rhythmic stabilization
training, combination of isotonic exercises, and control. Methods. Subjects trained
with each program for 4 weeks with the aim of improving trunk stability and strength.
Static and dynamic trunk muscle endurance and lumbar mobility were measured
before, at the end of, and 4 and 8 weeks after training. Disability and back pain
intensity also were measured with the Oswestry Index. Multivariate analysis of
variance indicated that both training groups demonstrated significant improvements in
lumbar mobility (8.6%–24.1%), static and dynamic muscle endurance (23.6%–81%),
and Oswestry Index (29.3%–31.8%) measurements. Authors concluded that Static and
dynamic PNF programs may be appropriate for improving short-term trunk muscle
endurance and trunk mobility in people with CLBP. 97
Sharman MJ et al 2006 stated that Proprioceptive neuromuscular facilitation (PNF)

stretching techniques are commonly used in the athletic and clinical environments to
enhance both active and passive range of motion (ROM) of joint. Moreover an
98
„active‟ PNF stretching technique achieves the greatest gains in ROM.
Yuktasir B et al 2009 conducted a study to investigate the long-term effects of two

different stretching techniques on the range of motion (ROM)and on drop
jump(DJ).DJ scores were assessed by means of a contact mat connected to a digital
timer. ROM was measured by use of a goniometer. The training was carried out four
times a week for 6 weeks on 10 subjects as passive static stretching (SS),and on 9
subjects as contract–relax PNF(CRPNF) stretching. The remaining nine subjects did
not perform any exercises(control group).One-way Analysis of Variance(ANOVA)
results indicated that the differences among groups on DJ were not statistically
different . ROM values were significantly higher for both stretching groups, while no
change was observed for the control group. Authors concluded that static and
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Proprioceptive neuromuscular facilitation (PNF) stretching techniques improved the

ROM, but neither of the stretching exercises had any statistically significant effect on
the DJ scores.99
Mahieu NN et al 2009 examined the mechanism of effect of PNF stretching on

changes in the ROM in 62 healthy subjects. They were randomized into two groups: a
PNF stretching group and a control group. The PNF group performed a 6-week
stretching program for the calf muscles. Before and after this period, all subjects were
evaluated for dorsiflexion ROM, passive resistive torque (PRT) of the plantar flexors
and stiffness of the Achilles tendon. The results of the study revealed that the
dorsiflexion ROM was significantly increased in the PNF group. The PRT of the
plantar flexors and the stiffness of the Achilles tendon did not change significantly
after 6 weeks of PNF stretching. These findings provide evidence that PNF stretching
results in an increased ankle dorsiflexion. 100
O’Hora J et al 2011 investigated the efficacy of several repetitions of proprioceptive

neuromuscular facilitation stretching(PNF) and static stretching (SS).Authors also
compared the effectiveness of a single bout of a therapist-applied 30-second SS vs. a
single bout of therapist-applied 6-second hamstring (agonist) contract PNF. Forty-five
healthy subjects between the ages of 21 and 35 were randomly allocated to 1 of the 2
stretching groups or a control group, in which no stretching was received. The
flexibility of the hamstring was determined by a range of passive knee extension,
measured using a universal goniometer, with the subject in the supine position and the
hip at 900 flexion, before and after intervention. A significant increase in knee
extension was found for both intervention groups after a single stretch Both
interventions resulted in a significantly greater increase in knee extension when
compared to the control group The PNF group demonstrated significantly greater
gains in knee extension compared to the SS group. Authors concluded that the
hamstring (agonist) contract PNF is more effective in improving hamstring length
than an SS in a single stretching session. 101
Khodayari B et al 2012 investigated the effect of different intensity of PNF

stretching on improve hamstring flexibility in seventy five male students with age
18-26 years. They were selected randomly and divided in five groups: first group was
Page | 42
as control, second, third, fourth and fifth groups exerted maximal voluntary of muscle
isometric contraction sequently at 20, 40, 60 and 80 percentages. Experimental groups
take a part in CR PNF training for 5 days. Research findings showed that there are
significant differences between experimental groups in compare with control group
after CR PNF training, but there are no significant differences between experimental
groups in range of flexibility. Authors concluded that use of sub-maximal CR PNF
training on Hamstring led to more flexibility, also when muscles stretched in this
range will be decreased muscles damages probability. 102
Lee JH et al 2013 examined the effects of treatment using PNF extension techniques
on the pain, pressure pain, and neck and shoulder functions of the upper trapezius
muscles of myofascial pain syndrome (MPS) patients. Thirty-two patients with MPS
in the upper trapezius muscle were divided into two groups: a PNF group (n=16), and
a control group (n=16). The PNF group received upper trapezius muscle relaxation
therapy and shoulder joint stabilizing exercises. Subjects in the control group received
only the general physical therapies for the upper trapezius muscles. Subjects were
measured for pain on a visual analog scale (VAS), pressure pain threshold (PPT), the
neck disability index (NDI), and the Constant-Murley scale (CMS). None of the VAS,
PPT, and NDI results showed significant differences between the groups, while
performing postures, internal rotation, and external rotation among the CMS items
showed significant differences between the groups. Exercise programs that apply PNF
techniques can be said to be effective at improving the function of MPS patients.103
Lee CW et al 2014 compared two methods for the muscle stabilization of the trunk of
patients with chronic low back pain. The methods comprised combination patterns of
proprioceptive neuromuscular facilitation (PNF) and ball exercise. The subjects were
40 volunteers who had low back pain. All subjects were randomly assigned to either a
group which received proprioceptive neuromuscular facilitation or a group which
performed ball exercise. Measurements were taken four times in total, at
pre-intervention, two weeks later, four weeks later, and six weeks later. The main
measurement methods used were the visual analogue scale (VAS) for pain and
electromyography (EMG) for muscle activity. VAS and EMG activity were
significantly reduced in the PNF combination pattern group and the ball exercise
group. A comparison of the groups showed significant differences. In VAS and EMG
Page | 43
activity; in particular, the combination pattern group using PNF increased EMG
activity more than the ball exercise group did after six weeks of intervention. Authors
conclude that PNF combination pattern training for six weeks was more effective for
patients with low back pain than performing ball exercise. 104
Kaur M et al 2014 conducted a study to find out the effect of static stretching and
PNF stretching in 30 subjects with hamstring tightness. Subjects were randomly
divided into two groups Group A, received static stretching and Group B received
PNF stretching. Range of motion was assessed pre and post treatment. Authors
concluded that though both groups showed statistically significant results, subjects
who received PNF stretching yielded better results in terms of increase ROM of knee
joint.105
Lim KI et al 2014 investigated the effects of two different stretching techniques on

range of motion (ROM), muscle activation, and balance in 48 adults with reduced
range of motion of knee joint due to hamstring tightness. Patients were randomly
divided into three groups: a static stretching group (n=16), a PNF stretching group
(n=16), a control group (n=16). ROM of knee joint was measured using Goniometer
before and after stretching. It was noticed that patients who received PNF stretching
showed increased ROM of knee joint than the other groups without decrease in
muscle activation, but no group showed effect on balance. 106
Aras D et al 2015 determined the effect of a combination of administration of Hold

relax (HR) and glucosamine in reducing the levels of COMP through decreased pain,
increased muscle strength and Range of motion (ROM) in 40 patient with
Osteoarthritis knee joint. Patients were divided into 2 group, Group 1 received 3 times
treatment of HR in one day with one glucosamine capsule per day for 1 week,
whereas Group 2 received 6 times treatment of HR in one day with one glucosamine
capsule per day for 2 weeks. Pain level, muscle strength and ROM was assessed pre
and post treatment and it was noticed that Group 2 patients showed better results than
Group 1 patients.107
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Shirazi SA et al 2015 compared the flexibility of muscles around the knee joint in 23
patients with knee osteoarthritis with 23 healthy individuals. Proprioceptive
neuromuscular facilitation stretching was applied to quadriceps, hamstring, iliotibial
band, adductor and gastrocnemius muscles and was evaluated with a goniometric
device. Pain intensity was assessed with a visual analogue scale and concluded that
flexibility of knee joint muscles helps to reduce pain. 108
Ahmed AR et al 2016 conducted a randomized control trail to compare the

effectiveness of neurodynamic and static stretching techniques on hamstring
flexibility in 40 healthy male subjects with hamstring tightness. They were randomly
divided into two equal groups: The neurodynamic group and the static stretching
group. Treatment was given for 5 consecutive days and the outcomes were measured
using Active knee Extension Test and Straight Leg Raising. There was a significant
improvement in hamstring flexibility following application of both neurodynamic and
static stretching but the improvement in the neurodynamic group (p<0.001) was better
than that of the static group (p<0.02). Authors concluded that a neurodynamic
stretching could increase hamstring flexibility to a greater extent than static stretching
in healthy male subjects with a tight hamstring muscles.109
AK Singh et al 2017 compared the effectiveness of PNF (hold-relax) and

Neurodynamic sliding technique for improving hamstring flexibility in 60 participants
with hamstring tightness were allocated into two groups (30 participants in each
group). The outcome measure used was AKE (Active Knee Extension) test. Subjects
of group A were treated with PNF hold relax stretching, whereas the subjects of group
B were treated with Neurodynamic sliding technique. For both experimental groups,
the technique was performed three times a week for a total training period of four
weeks. Authors concluded that PNF (Hold-Relax) stretching technique was more
effective than Neurodynamic sliding technique for improving hamstring flexibility. 110
Golpayegani M et al 2017 aimed to determine the effect of PNF stretching exercise

on in 20 female volunteers with Patello femoral pain syndrome (PFPS). They were
randomly assigned to PNF and control groups. The experimental group accomplished
their own specific treatment protocols for 8 weeks, whereas the control group did not
follow the treatment plan. Pain and functional disability were assessed by visual
Page | 45
analogue scale (VAS) and Kujala questionnaire respectively, before and after
exercise. It was noticed that PNF stretching may have positive effects on PFPS. in 132
osteoarthritis knee patients. Patients were randomly divided into four groups (I–IV)
with 33 patients in each group. The patients in Group I received isokinetic muscular
strengthening exercises, Group II received bilateral knee static stretching and
isokinetic exercises, Group III received proprioceptive neuromuscular facilitation
(PNF) stretching and isokinetic exercises, and Group IV acted as controls. Outcomes
were measured by changes in Lequesne‟s index, range of knee motion, visual analog
pain scale, and peak muscle torques during knee flexion and extension. Patients in all
the treated groups experienced significant reductions in knee pain and disability, and
increased peak muscle torques after treatment and at follow-up. However, Group III
patients showed the beat results in relieving symptoms of osteoarthritis. 111
Harini G et al 2018 conducted a study to find out the immediate effect of

contract-relax antagonist-contract (CRAC) method on iliopsoas muscle and hamstring
muscle stretching on chronic non specific low back pain (NSLBP) in 30 patients of
both gender age between 20-30 years with chronic NSLBP of more than 3 months,
iliopsoas muscle tightness at least one side (“positive” from modified Thomas test).
Pain intensity at least 3/10 on a 10 cm visual analog scale (VAS). Hamstring tightness
with a minimum of 6 cm (male), 10 cm (females) done by sit and reach test. CRAC
technique and hamstring stretching were administered to the patients and concluded
that CRAC stretching technique combined with hamstring stretching reduced back
pain.112
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CHAPTER- 2 REVIEW OF LITERATURE

2.1 Passive Joint Mobilization (PJM)

Passive joint mobilization is a technique in which oscillatory movements

Nathan PW et al 1974 conducted an experimental study in 7 male of age group

Bini G et al 1984 conducted a psychophysical experiment in 16 humans to determine

Humphries SA et al 1996 investigated a prediction derived from gate control

Vicenzino B et al 1998 conducted a randomized, double blind and placebo controlled

Conroy DE et al 1998 determined the effect of joint mobilization in 14 patients with

Toni G et al 2001 conducted a randomized controlled trial with blinded assessors

experimental group received the anteroposterior mobilization, using a force that

Sterling M et al 2001 conducted a placebo-controlled, double blind, repeated

Sluka KA et al 2001 stated that application of a manual therapy technique will

produces a significant reversal of secondary mechanical hyperalgesia induced by

Skyba DA et al 2003 conducted a study to determine which spinal neurotransmitter

posterior direction. A bilateral decrease in mechanical withdrawal thresholds occurred

Moss P et al 2007 conducted a double blind controlled study in 38 subjects to find

Johnson AJ et al 2007 compared the effectiveness of anterior versus posterior glide

the mobilization technique performed. Shoulder external rotation ROM measured

Annina S et al 2008 conducted a systematic review to assess the consistency of

Pollard H et al 2008 conducted a study randomized controlled trial to determine

Importantly the MIMG Knee Protocol intervention group reported no adverse

Denham F et al 2008 conducted a randomized clinical trial in 60 patients. Patients

Kanlayanaphotporn R et al 2009 conducted a triple-blind, randomized controlled

Maher S et al 2010 explored the effects of tibio-femoral (TF) manual traction on

Nor Azlin MN et al 2011 conducted a controlled, single blinded experimental study

Sambandam CE et al 2011 conducted a study to find out the effectiveness of

Jansen MJ et al 2011 conducted a meta-analysis of randomised controlled trials in

Villafane JH et al 2012 investigated the effect of passive accessory mobilization in

Kadu SS 2013 determined the effectiveness between supervised clinical exercise

Arguello Prada EJ et al 2013 conducted a experiment in which a novel

Ghanbari A et al 2013 conducted a Quasi experimental study to investigate the

Villafane JH et al 2013 conducted a double blind randomized controlled trail to

Kenkampha K et al 2013 investigated the immediate effects of Sacroiliac joint

Shum GL et al 2013 conducted a experimental study to find the effect of

Martins DF et al 2013 in their experimental study, investigated the contribution of

Syed S at al 2014 conducted a study to compare the effectiveness of Maitland‟s

Joshi S et al 2014 conducted a experimental study to compare the effectiveness of

reductions in pain and other symptoms with an improvement in quality of life.(t of

Kappetijin O et al 2014 evaluated the efficacy of passive knee extension

Lee NY et al 2015 investigated the effect of the manual joint mobilization in

Rangey PS et al 2015 conducted a study in which they compared the immediate

Moon GD et al 2015 compared the Maitland mobilization and Kaltenborn

E. Kaya Mutlu et al 2015 conducted a randomized control trail study in 48

Young NL et al 2015 investigated the effects of the manual joint mobilization in 30

Taeseong Ju et al 2015 investigated the effects of hip mobilization on pain,

Frantz A et al 2015 conducted a study to determine the effect of joint mobilization in

Ahmad A et al 2016 conducted a comparative study in 50 osteoarthritis knee

Kulkarni AV et al 2017 conducted a study to determine the effectiveness of

Gonclaves Tavares FA et al 2017 evaluated the effects of joint mobilization on pain

Nawaz MS et al 2017 conducted a quasi experimental study to determine the outcome

Jiao Xu et al 2017 conducted a single blind, prospective, randomized study to find

Megha M et al 2017 conducted a study to find out the effects of Patellofemoral

Ujwal L Y et al 2017 conducted a randomized controlled trail to find the effect of

Farooq MN et al 2018 determined the effect of mobilization and routine

Migule EE 2018 conducted a randomized controlled trail to compare the effectiveness

Rao RV et al 2018 conducted a randomized cross over trail to determine whether

2.2 Proprioceptive Neuromuscular Facilitation (PNF)

Proprioceptive Neuromuscular Facilitation (PNF) stretching is an advanced technique

Osternig LR et al 1987 investigated the effect of three common PNF stretching

Robertson RN et al 1990 investigated the effects of sustained stretch and two

Worrell TW et al 1994 determined the most effective stretching method for

R.Ferber et al 2002 conducted a study to find the effects of proprioceptive