Accepted Manuscript

Immediate effects of Maitland mobilization versus Mulligan Mobilization with

Movement in Osteoarthritis knee- A Randomized Crossover trial

Ramya V. Rao, Ganesh Balthillaya, Anupama Prabhu, Asha Kamath

PII: S1360-8592(17)30241-3
DOI: 10.1016/j.jbmt.2017.09.017
Reference: YJBMT 1604

To appear in: Journal of Bodywork & Movement Therapies

Received Date: 6 February 2017

Revised Date: 30 July 2017
Accepted Date: 6 September 2017

Please cite this article as: Rao, R.V., Balthillaya, G., Prabhu, A., Kamath, A., Immediate effects of
Maitland mobilization versus Mulligan Mobilization with Movement in Osteoarthritis knee- A Randomized
Crossover trial, Journal of Bodywork & Movement Therapies (2017), doi: 10.1016/j.jbmt.2017.09.017.

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 ACCEPTED MANUSCRIPT

TITLE PAGE

Title- Immediate Effects of Maitland Mobilization versus Mulligan Mobilization with

Movement in Osteoarthritis Knee- A Randomized Crossover Trial.

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Authors-

1. Ms. Ramya V. Rao, MPT Post Graduate, Department of Physiotherapy, School of

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Allied Health Sciences, Manipal University, Manipal- 576104, Udupi district,

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Karnataka, India, rami2bliss@gmail.com

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2. Mr. Ganesh Balthillaya, MPT Assistant Professor Sr. Scale, Department of
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Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal-

576104, Udupi district, Karnataka, India, ganesh.bm@manipal.edu

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3. Ms. Anupama Prabhu, MPT Assistant Professor, Department of Physiotherapy,

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School of Allied Health Sciences, Manipal University, Manipal- 576104, Udupi

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district, Karnataka, India, anupama.prabhu@manipal.edu

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4. Dr. Asha Kamath, PhD Associate Professor, Department of Community Medicine,

Kasturba Medical College, Manipal University, Manipal- 576104, Udupi district,

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Karnataka, India, asha.kamath@manipal.edu

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Corresponding Author: Mr. Ganesh Balthillaya, Assistant Professor Sr. Scale,

Department of Physiotherapy, School of Allied Health Sciences, Manipal University,

Manipal- 576104, Udupi district, Karnataka, India.

E-mail:- ganesh.bm@manipal.edu; Phone no: +919448263631, +91820-2922533

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ABSTRACT

Background: Maitland Mobilization or Mulligan Mobilization with Movement (MWM)

approaches have been widely used clinically for pain relief and improving mobility in

Osteoarthritis knee. However the experimental evidence supporting the usage of these

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mobilization techniques as sole interventions in management of Osteoarthritis knee is

insufficient.

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Objective: To determine from Maitland Mobilization and Mulligan MWM, which

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mobilization technique will be more effective in reducing pain and improving mobility and

function in OA knee immediately after the intervention.

Study Design: Randomized Crossover trial.

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Materials and Methods: 30 subjects with osteoarthritis knee were recruited and 15 each

were randomly allocated to two intervention sequences- one sequence was where Maitland
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was given first followed by Mulligan and the other was where Mulligan was given first
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followed by Maitland with a washout period of 48 hours in between the two interventions.
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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.
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Results: Using Repeated Measures ANOVA for analysis of outcomes between and within

interventions, no significant differences were seen between Maitland Mobilization and

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Mulligan MWM, for NPRS, TUG and Pain free Squat Angle (p=0.18, p=0.27,p=0.17)
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respectively whereas within the interventions both Maitland and Mulligan all outcome

measures showed significant changes (p<0.001).

Conclusion: Thus it can be seen 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.

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INTRODUCTION

Osteoarthritis (OA) also known as degenerative joint disease, is associated with

degradation of articular cartilage, subsequently affecting the underlying bone causing
osteophyte formation at the joint margins (Altmann et al., 1991; Larmer et al., 2014). OA
knee has an increasing prevalence noted in the middle ages and women are more predisposed

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than men (NICE, 2008). Prevalence of OA knee in India is 30% and maximum of OA knee
affected population were individuals aged between 40-60 years and 19-30% of the total

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affected population were sedentary or unemployed (Pal et al., 2016). The management of OA
knee is witnessing a rise in economic burden in terms of long term medications like NSAIDs

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or opioid analgesics, intra articular injections of steroids or more recently used cartilage
analogue injections and surgeries like chondroplasties and widely performed knee

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arthroplasties. Physical therapy has known to play a vital role in pain relief and restoration of
mobility and function in OA knee which includes- range of motion exercises for knee,
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strengthening (isometric or dynamic resistance training) of muscles around hip and knee
(Quadriceps, Hamstrings, Gluteus Maximus, Gluteus Medius and Minimus); flexibility
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exercises (Iliotibial Band, Hamstrings, Gastro-soleus and Rectus femoris); aerobic

conditioning, aquatic exercises; patellar taping; electrotherapy modalities like thermotherapy,
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electrophysical modalities (Transcutaneous Electrical Nerve Stimulation, Interferential

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Therapy or Faradic Stimulation to the surrounding muscles, Ultrasound therapy) and more
recently manual therapy techniques (Page et al., 2011).
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Manual therapy includes hands-on soft tissue or joint mobilization techniques which
modulate pain and also improve extensibility of contractile tissues and movement of joints
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(French et al., 2011). Its neurophysiological effects are – mechanoreceptor mediated pain
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gate analgesia blocking nociception at spinal cord dorsal horn; periaqueductal grey matter
and rostroventral medulla mediated descending pain inhibition mostly through activity of
noradrenaline and to some extent opioids and serotonin causing reduction in maladaptive
cognitive-affective mechanisms observed in pain neuromatrix (Vincezino et al., 2001; Skyba
et al., 2003; Zusman et al., 2002 and Moseley et al., 2003). An RCT, where subjects with OA
knee were allocated into four groups to receive- usual care provided by a general practitioner,
manual physiotherapy, multi-modal exercise physiotherapy and combined exercise plus
manual physiotherapy (Abbot et al., 2013) showed that Western Ontario & McMaster

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Universities Arthritis Index (WOMAC) scores improved similarly for manual therapy group
as well as exercise therapy group as compared to usual care group; however there were no
additional improvements seen on combining exercise therapy and manual therapy rather an
antagonistic interaction was seen between exercise therapy and manual therapy. Manual
therapy is frequently used in combination with other interventions such as conventional
exercise or electrotherapy in OA knee, hence its individual effect in OA knee is not clear

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(NICE, 2008 and RACGP, 2011). A systematic review done on manual therapy in OA hip
and knee concluded that there is inconclusive scientific evidence substantiating effectiveness

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of manual therapy in reducing pain or improving function in OA hip and knee (French et al.,
2011).

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Mulligan Mobilization with Movement (MWM) is based on the concept that minor
position faults occur in articulating surfaces of joints following injury or strains resulting in
movement restriction and pain exacerbated by active contraction of muscles within the faulty

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positions of the joint (Mulligan, 2011). Thus, MWM involves passive accessory glide as a
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corrective technique, applied by the therapist perpendicular to the joint plane to correct the
positional fault combined with the offending movement being performed actively by the
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subject and sustained for several repetitions, the pain should always be reduced and/or
eliminated during the application and pain-free function should be restored (Mulligan, 2011).
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Maitland mobilization includes continuous analytical assessment of the nature of the

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disorder which mainly involves identifying the pain mechanisms driving the dysfunctional
movement patterns and utilizing clinical reasoning to integrate theoretical concepts with the
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clinical presentation of the disorder, in order to formulate a dynamic working diagnostic

hypothesis, with the appropriate intervention addressing all components of the disorder,
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according to the priority of presentation. In Maitland mobilization, passive physiological and

accessory oscillatory movements are applied to the joint to gain range of motion, lost due to
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pain or stiffness, and to restore optimal kinematics between the joint surfaces, where the
grade, frequency and dosage of mobilization is determined by Severity, Irritability and Nature
(SIN) of the disorder (Hengeveld and Banks, 2014).

Most of the studies of manual therapy in OA knee have utilized Maitland mobilization
techniques effectively. In an RCT done, Maitland joint mobilization including antero-
posterior (AP) glide of tibia on femur, and patella glides in all directions was given in
addition to control treatment of stretching, isometric quadriceps, closed-kinetic chain exercise

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and static bicycling; which resulted in better reduction in pain in the experimental group
(Azlin and Lynn, 2011). When OA knee participants were given 6 minutes of knee joint
mobilization, and after a gap of 1 week they received only cutaneous input intervention, it
was seen that there was a global increase in pressure pain threshold, significantly lowered
baseline pain, significantly enhanced Continuous Passive Motion (CPM) ranges and
increased vibration perception threshold acuity following in subjects receiving joint

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mobilization but not after cutaneous input intervention (Courtney et al., 2016). Mulligan
MWM though clinically claimed to be effective in pain relief and improving joint mobility in

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OA knee; there is lack of published literature on effectiveness of MWM in the management
of OA knee. In an RCT, experimental group where Mulligan MWM was applied in addition

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to trunk stabilization exercises and electrotherapy modalities (thermotherapy, ultrasound and
interferential therapy) in subjects with OA knee had better WOMAC scores and more
significant pain reduction than in the control group which received only trunk stabilization
and electrotherapy (Nam et al., 2013).
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The literature available, to date, shows that there are very few high quality studies
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comparing Maitland Mobilization and Mulligan MWM applied independently without any
conventional interventions in OA knee and hence it is difficult to determine their
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effectiveness individually. Most of the studies done so far have focused on the long-term
effects of repeated joint mobilization sessions along with exercise or electrotherapeutic
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interventions. Thus, less emphasis has been given to immediate or short-term effects of a
single mobilization session. Short term or immediate effects of mobilization if turn out
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positive and significant seem more appropriate to determine; considering long standing
morbidity and economic burden involved in OA knee due to which repeated sessions of
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intervention might be difficult to undergo for the OA knee subjects. Thus, the objective of
this study was to determine between Maitland Mobilization and Mulligan MWM, which
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mobilization technique will be more effective in reducing pain and improving mobility and
function in OA knee immediately after the intervention.

MATERIALS AND METHODS

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STUDY DESIGN
The current study was a Randomized Crossover trial conducted at the Physiotherapy
Department of a tertiary care hospital in the Karnataka State, India between June 2015 and
December 2015. The Institutional Research Committee and Institutional Ethics Committee
approved the study (IEC 120/2015) and the trial was registered at ClinicalTrials.gov (India)

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registry with the trial identifier CTRI/2016/08/007146.

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PARTICIPANTS
Subjects with OA knee referred to the Department of Physiotherapy, tertiary care

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hospital in the Karnataka State were recruited from a sample of convenience for study
participation. To be included in the study, the subjects needed to fulfill one or more of the
following Inclusion criteria- Diagnosis of Tibio-femoral OA knee confirmed by an

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Orthopaedician, Radiological evidence of OA Knee- Grades 0, 1 and 2 as per Kellgren
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Lawrence grading system (Peterson et al., 1997); in the absence of X-rays patient had to
fulfill the American College of Rheumatology (ACR) Clinical Criteria for OA Knee
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diagnosis which included- Pain along with satisfaction of any 3 of the clinical signs- Age >
50 years, Bony tenderness, Bony enlargement, Crepitus, No palpable warmth and No
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morning stiffness greater than 30 minutes (Altman et al., 1991). The subjects were excluded
if they had a history of surgical interventions at the knee joint, signs of active inflammation
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or infection at the knee joint, systemic infections or inflammatory diseases and relevant
neuromuscular impairments grossly affecting the outcome measures. All participants were
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explained about the purpose of the study and written informed consent was obtained from
them before enrollment.
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PROCEDURE
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As per the crossover design, each subject got exposed to both interventions- Maitland
Mobilization and Mulligan MWM. Subjects were randomly assigned to one of the two
intervention sequences using block randomization method; where the subjects were
sequentially allotted to blocks of 4 that contained 2 of each sequence- 1st sequence was
Mulligan MWM followed by Maitland mobilization and 2nd sequence was Maitland
mobilization followed by Mulligan MWM. The sequences were set up only for
randomization purpose. The subjects were aware that they would receive two sessions of
mobilizations however they were blinded to the order in which they would be applied. A

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washout period of 48 hours was provided in between two treatments of each sequence.

INTERVENTION
Intervention 1: Maitland mobilization- The Severity, Irritability, and Nature (SIN)
of OA knee along with range and nature of physiological and accessory movement limitation
was evaluated to determine the grade, frequency, repetitions, and duration of mobilization

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session (Hengeveld and Banks, 2014). Severity is the intensity of symptoms (pain or
movement limitation); Irritability is a temporal relationship between the intensity of

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provocation of symptoms, how long they persist and how long do they take to return to the
baseline; Nature of the condition is how it has affected the subject’s activity. Both

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physiological movements (flexion, extension, rotations) and accessory movements (Antero-
posterior, Postero-anterior, Medial, Lateral, Compression, and Distraction glides; Rotations)
were assessed for pain and restriction. Frequency of glides applied ranged from 1 oscillation

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per 2 seconds (gentle oscillations) to 3 oscillations per second (staccato rhythm) and if it was
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sustained then it would be each glide to be sustained for 5 seconds. In pain predominant
scenario, low amplitude grades 1 and 2 of mobilization at initial range to mid ranges were
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applied for pain relief through circulation of synovial fluid within the joint cavity and
mechanoreceptor mediated activation of pain gate. In presence of restriction with or without
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pain, high amplitude grade 3 through the range or grade 4 at the end of the range mobilization
was applied (see Fig. 1). Duration for which glides were applied could be from minimum of
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3seconds (for high SIN for pain relief) to ≥5 minutes (for low SIN to reduce joint stiffness).
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Intervention 2: Mulligan MWM- The range and direction of offending knee

movement (flexion or extension) performed by the subject were identified. The offending
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movement was repeated in weight bearing position with the application of appropriate glide
at the affected knee (medial glide, lateral glide, medial rotation, and lateral rotation of the
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tibia on femur) which should result in the offending movement becoming pain free. If the
movement combined with the glide showed no change in pain or increased the pain beyond 3
repetitions, the glide had to be changed and whichever glide applied with the offending
movement made the movement pain free beyond 3 repetitions, the repetitions were continued
further as per the response of the reduction in pain towards the mobilization (see Fig. 2)
(Mulligan, 2011). PLACE FIGURES 1 AND 2 AFTER THIS PARAGRAPH

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Figure 1- Maitland Mobilization Assessment

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Figure 2- Mulligan MWM Assessment

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Based on the subjects’ presentation intervention parameters were selected
pragmatically. On the day of recruitment, after the specific assessment, 1st intervention
(Maitland/ Mulligan) was given followed by 48 hours gap which was considered sufficient
for the washout of any possible residual effects of mobilization after the first intervention.
During the washout period, the subjects continued their routine activity. Next contact point
was the third day after recruitment where the subjects were re-evaluated and the 2nd

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intervention (Maitland/ Mulligan) was provided as per the sequence. The assessment was
done and intervention was provided by the primary investigator of the study.

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Outcome measures

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Outcome measures were recorded before and immediately after each intervention. All
measurements were performed by an assessor who was blinded to the sequence and
interventions given. Outcomes assessed were pain [Numeric Pain Rating Scale (NPRS)],

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function [Timed Up and Go (TUG)] and movement [Pain Free - Squat Angle]. Pain was
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taken as the primary outcome and was measured using the NPRS (ICC= 0.84) (Valente et al.,
2004). Patients were asked to rate the intensity of their worst pain on a scale of 0 to 10 (0 =
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no pain and 10 = maximum tolerable pain) while performing the most painful activity.
Secondary outcomes were TUG and Pain - free Squat angle. TUG (ICC=0.99) (Algadhir et
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al., 2015) was carried out by asking the subject to rise from a standard arm chair, walk 3m on
level ground, turn and walk back to return to sit on the chair. Time was recorded in seconds
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using a stopwatch. Pain free Squat Angle (ICC=0.94) (Cliborne et al., 2014) was measured
by asking the patient to stand against the wall and go for a functional squat until the first
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onset of pain. The knee flexion range at the angle of pain onset was measured using a bubble
inclinometer placed parallel to the tibial tuberosity of the affected knee.
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RESULTS
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Data analysis
The sample size needed to detect the minimum clinically important difference of 1.5
on NPRS (Bandholm et al., 2014) with a power of 90 was determined as 30. Statistical
analysis was performed using SPSS version 16. Shapiro-Wilk test verified the normality of
distribution of the collected data. Repeated Measures ANOVA was used for comparison of
the outcomes for the two interventions. Wilcoxon Signed Rank test was used to analyze and

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compare the effectiveness of the two interventions; since the difference of the outcome scores
were not normally distributed. Results are expressed as mean ± standard deviation (SD) along
with the p values (significance) for comparison of intervention outcome measure scores; and
for effectiveness of the interventions they are expressed as comparison of medians with inter
quartile range (IQR). Baseline demographic variables were analyzed by using descriptive
statistics, mean ±SD. The level of significance was set at p ≤ 0.05.

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A total of 110 subjects referred by the Orthopaedician to the Physiotherapy out-

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Patient Department of the tertiary hospital of Karnataka, India were screened for inclusion in
this study. Subjects were excluded (n=77) as they did not meet the inclusion criteria- among

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which most of the subjects (n=42) could not be recruited as they came from distant places
and were not available for consecutive sessions of interventions. Subjects who met the
inclusion criteria (n=33) were randomized to one of the two sequences. Three subjects

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dropped out i.e. received only one intervention and were not available for the second part of
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the sequence. Thus, thirty subjects were analyzed at the end of the study. Subject recruitment
procedure along with reasons for exclusion and drop-outs has been shown in Figure 3 (see
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Fig.3)
The demographic variables of the recruited subjects analyzed were- age, gender,
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duration of OA knee, dominant and affected leg, irritability and grade of OA knee are
summarized in Table-1 (see Table-1).
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PLACE FIRST FIGURE 3 AND THEN TABLE 1 AFTER THIS PARAGRAPH.

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Figure 3- Participant Flow through the trial

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Table 1- Demographic Characteristics of the Participants
Characteristics Values

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Age(mean ± SD), years 51.2 ± 9.2

Males/Females 6/24

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Duration of OA knee (mean ± SD), months 14.8 ± 6.5

Dominant Leg, Right / Left 24/6

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Affected Leg, Right / Left 12/18

Irritability* (Low- 0, Moderate- 1, High- 2) (%) 0 = 10 (33%); 1 = 18 (60%); 2 = 2 (7%)

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Grade of OA Knee** (n=0, 1, 2) (%) 0 = 8 (27%); 1 = 12 (40%); 2 = 10 (33%)
*According to Maitland Assessment (Hengeveld and Banks, 2006)

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**According to Kellgren Lawrence Radiological Grading (Grade 1= Minute osteophyte, doubtful
significance, Grade 2= Definite osteophyte, unimpaired joint space, minimal involvement, Grade 3=
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Moderate dimunition of joint space, moderate involvement) (Peterson et al., 1997)

Comparison of Interventions
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The results showed that there were no significant differences between the
interventions Maitland mobilization and Mulligan in terms of changes in any of the outcome
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measures NPRS, Timed Up and Go test and Pain free Range of Squat Angle [(p= 0.179), (p=
0.270), (p= 0.173)] respectively as seen in Table 3 (see Table-3). However, individually
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within both of the mobilization intervention group there was a statistically significant change
in all three outcomes- NPRS, TUG test and Pain free Range of Squat Angle at (p< 0.001) as
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seen in Table 2 (see Table-2). Also, it was seen that as per figures 4, 5 and 6 showing the
comparison of reduction of NPRS and TUG scores and increment in Pain free range of squat
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angle scores both Maitland Mobilization and Mulligan MWM were similarly effective (see
Figures- 4,5 and 6). PLACE TABLE 2 FOLLOWED BY TABLE 3 AND FIGURES 4,5
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AND 6 IN THE ORDER MENTIONED AFTER THIS PARAGRAPH

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Outcome Interventions Difference within interventions

Mulligan Maitland Mulligan Maitland

Pre Post Pre Post Post P Post P

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minus minus
Pre Pre

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NPRS 6.2 4.3 5.7 (2) 3.9 (1.9) -1.9 <0.001* -2.2 <0.001

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(1.8) (1.9) (0.25) (0.16) *

7.8 7.2 7.8

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TUG (s)
(1.7) (1.5) (1.7) (0.11) (0.14) *
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Pain free Squat

34 41 (12) 37 (11) 45 (12) 6.9 (0.81) <0.001* 8.7 <0.001
Angle (deg)
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(12) (1.38) *
*Denotes significant difference (P < 0.005)
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Table 2- Comparison of changes in outcome measures within (before and after)

Maitland and Mulligan mobilization techniques (n=30) [mean ± SD] at 95 %
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Confidence Interval
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Outcome Between Intervention Difference P

NPRS -0.30 (-0.27 to -0.33) 0.18*

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TUG (s) -0.19 (-0.28 to -0.32) 0.27*

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Pain free Squat Angle (deg) 1.80 (0.15 to 0.45) 0.17*
*Denotes no significant difference (P > 0.005)

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Table 3- Comparison of differences in outcome measures between Maitland and
Mulligan mobilization techniques (n=30) [median ± IQR] at 95 % Confidence Interval

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Figure 4- Changes in pre and post NPRS values for Mulligan MWM and Maitland
Mobilization

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Figure 5- Changes in pre and post TUG values for Mulligan MWM and Maitland
Mobilization
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Figure 6- Changes in pre and post Pain free Squat angle values for Mulligan MWM and
Maitland Mobilization

Comparison of Effectiveness of Interventions with respect to change in Outcome

measure scores-
Wilcoxin Signed Rank test showed similar reductions in NPRS scores (2; 2) and in

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TUG scores (0.37; 0.46) and similar increment in Pain free Squat Angle scores (5; 5)
comparing medians for change in outcome scores between both interventions- Maitland

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Mobilization and Mulligan MWM respectively. Also all the median values obtained were
similar or higher than the standard MCID values for the outcome measures that is- 1 or 1.5

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(MCID) for NPRS (Salaffi et al., 2004; Bandholm et al., 2014), 0.15s (MCID) for TUG
(Algadhir et al., 2015) and 5deg (MCID) for Pain free Squat Angle (Cliborne et al., 2014)
which implies both interventions were equally as well as individually effective.

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DISCUSSION
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The results obtained in this study state that, there is no significant difference between
immediate effects of Maitland mobilization and Mulligan MWM in OA Knee and also that
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both are equally effective in reducing pain and improving functional mobility and pain free
range of squat angle. This may be justified by the rationale that both interventions are based
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on similar mechanisms of pain relief like mechanical effect based pain inhibition by silencing
the slow conducting articular nociceptor afferents due to activation of the fast conducting
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mechanoceptor afferents (Courtney et al., 2010) and stimulation of descending pain inhibition
by activation of opioid receptors at spinal dorsal horn with release of enkephalins and
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enhanced noradrenaline activity regulated by PAG- RVM (Skyba et al., 2003). Besides both
interventions were applied according to the subjects’ presentation and had overlapping
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treatment techniques like tibiofemoral physiological rotations in Maitland mobilization and

passive tibiofemoral corrective medial or lateral rotation along with active flexion or
extension in Mulligan MWM. Similar results were found in an RCT comparing Maitland
Passive Joint Mobilization (PJM) and Mulligan MWM applied along with flexibility, strength
and active range of motion exercises to 48 subjects with OA knee; which found that there
were similar and significant improvements in terms of pain, function (WOMAC) and range of
motion for both PJM and MWM without any significant differences between the two groups

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(Mutlu et al., 2015). However, our study is different in terms of being a crossover trial
without a control group as well as the focus is solely on Maitland and Mulligan interventions
without any additional treatments. Along with pain relief, the co-existing improvements in
Pain free Squat Angle and TUG scores maybe explained due to reduction in the painful
inhibition of muscles, improved joint proprioception and reduction in joint stiffness with
facilitation of optimal arthrokinematic movements at the joint surfaces. This hypothesis is

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supported by a study which reported improved quadriceps strength in arthritic knee in both
groups- one receiving manual therapy and the other with resisted exercises; whereas joint

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proprioception measured in terms of joint positioning error improved significantly only in the
manual therapy group as compared to the resisted exercise group (Taesung et al., 2009).

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Improvement in outcome measure scores maybe explained in terms of temporary
correction of minor articular malposition defects in affected knee as in Mulligan MWM

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(Mulligan, 2011) and improved circulation or pain gate mediated analgesia immediately
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following mobilization of the biomechanically impaired arthritic knee (Sluka and Wright,
2001). Immediate effects of interventions were considered for the present study since
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appropriate dosage of manual therapy intervention applied according to an accurately

prioritized hypothesis targeting the primary and secondary source of symptoms sequentially
is believed to reduce the symptoms at least by 25% or more immediately post 1st session in
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accordance to clinical reasoning model (Jones et al., 2000). This ideology is supported by an
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RCT on effect of Maitland mobilization on hyperalgesia in OA knee (Moss et al., 2007)

which found immediate local and distant hypoalgesia seen at the knee and ankle respectively
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measured by increased Pain Pressure Threshold (PPT) following 9-minute A-P mobilization
of arthritic knee in an RCT done comparing tibio-femoral joint mobilization against manual
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contact and non-contact control procedures. Also, another case series on the effects of
Mulligan MWM in OA knee (Takasaki et al., 2012) found maximum reduction in pain during
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the most limited activity as well as rest pain after the 1st session of Mulligan mobilization
with movement and subsequent reduction in pain was seen gradually over total session of 5
weeks.

To the best of our knowledge, this was the first crossover trial focusing on manual
therapy techniques of Maitland Mobilization and Mulligan Mobilization with Movement
independently. Crossover design was considered appropriate for the present study as each
subject serves as his/her own matched control since every subject receives both interventions

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and OA knee being a chronic condition; there would be remote chances of the symptoms
returning to baseline post 1st intervention and hence the symptom change could be compared
over both sessions of the two interventions given consecutively with a washout period in
between them. This study followed the recommendations of the last published systematic
review on manual therapy for hip and knee OA like concealed allocation, blinded outcome
assessment and a pragmatic approach of manual therapy techniques (French et al., 2011). A

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pragmatic approach to determine the dosage and technique of both mobilization interventions
was followed in this study which might have led to significant improvement in the outcomes.

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This feature of the study is unique from most of the other manual therapy trials done so far
where they have used a set dosage of pre defined technique, grade and repetitions of the

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interventions. This can be seen in an RCT (Azlin and Lynn, 2011) where they used A-P glide
at Tibiofemoral joint and patellar glides in all directions for all the recruited subjects though
the intervention appears non-specific for the different subjects who may have varied

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presentations; whereas another study (Kappetjin et al., 2014) applied anterior translation of
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tibia grade 3 sustained for 20s with knee maintained in end range of extension stabilized with
a belt at the thigh uniformly in all the subjects with OA knee with extension limitation though
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the extent of pain and limitation in each of the subjects may have been obviously different.
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Limitations in this study were lack of control over the subjects’ activities prior to the
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initial intervention or during washout period and ongoing medications in few of the subjects
might have affected their presentation and outcomes, washout period of 48 hours may have
been inadequate for the symptoms to return to baseline after the 1st intervention wherein the
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carryover effect might have to be considered and lastly, since co-existing asymptomatic
patellofemoral OA subjects were not excluded, it might have affected squat angle and TUG
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performances. In the future studies, effect of confounding factors like activity and
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medications should be regulated, more objective tools can be used to quantify pain, other
factors affecting squat and timed up and go test like muscle strength, flexibility, joint
proprioception and motor control can be measured and compared and also any lasting effect
of the immediately improved outcomes post a single mobilization session can be measured
with subsequent measurement of the outcomes over further time periods.

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CONCLUSION

Thus this study proposes that, Maitland mobilization or Mulligan MWM are equally
effective and can be applied individually in osteoarthritis knee for immediate effects of pain
relief and improved mobility and function. It also gives a further scope for research to
investigate if Maitland mobilization or Mulligan MWM can be applied independently for a
longer duration with more lasting effects without any adjunct conventional modes of

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treatment.

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Acknowledgements- Mr. Y. V. Raghava Neelapala, Assistant Professor, Department of
Physiotherapy, Manipal University, Karnataka for his contribution towards inception of the

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study design and formulating the techniques and protocol.
Dr. C. Vaman Rao, HOD, Department of Biotechnology, NMAM Institute of Technology,

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Karnataka for his contribution towards editing of the manuscript and interpretation of the
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results.

Ethical Approval Statement- Kasturba Hospital, Manipal, Karnataka, India approved this
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study (REF NO- IEC 120/2015). All participants gave written informed consent and were
informed about the study procedure before the data collection began.
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Funding- This research did not receive any specific grant from funding agencies in the
public, commercial, or not-for-profit sectors.
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Conflict of Interest- There is no conflict of interests involved for any person or organization
to the best of knowledge of the authors of the paper.
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Figure 1- Maitland Mobilization Assessment (Hengeveld and Banks, 2014)

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Figure 2- Mulligan MWM Assessment (Mulligan, 2011)

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Figure 3- Participant Flow through the trial

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Table 1- Demographic Characteristics of the Participants

Characteristics Values

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N 30

Age(mean ± SD), years 51.2 ± 9.2

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Males/Females 6/24

Duration of OA knee (mean ± SD), months 14.8 ± 6.5

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Dominant Leg, Right / Left 24/6

Affected Leg, Right / Left 12/18

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Irritability* (Low- 0, Moderate- 1, High- 2) (%) 0 = 10 (33%); 1 = 18 (60%); 2 = 2 (7%)
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Grade of OA Knee** (n=0, 1, 2) (%) 0 = 8 (27%); 1 = 12 (40%); 2 = 10 (33%)
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*According to Maitland Assessment (Hengeveld and Banks, 2014)

**According to Kellgren Lawrence Radiological Grading (Grade 1= Minute osteophyte, doubtful

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significance, Grade 2= Definite osteophyte, unimpaired joint space, minimal involvement, Grade 3=
Moderate dimunition of joint space, moderate involvement) (Peterson et al., 1997)
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Table 2- Comparison of changes in outcome measures within (before and after) Maitland
and Mulligan mobilization techniques (n=30) [mean ± SD] at 95 % Confidence Interval

Outcome Interventions Difference within interventions

Mulligan Maitland Mulligan Maitland

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Pre Post Pre Post Post P Post P
minus minus

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Pre Pre

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NPRS 6.2 4.3 5.7 (2) 3.9 (1.9) -1.9 <0.001* -2.2 <0.001*
(1.8) (1.9) (0.25) (0.16)

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7.8 7.2 7.8 7.5 (1.6) 0.56 (0.11) <0.001* 0.37 <0.001*
TUG (s)
(1.7) (1.5) (1.7) (0.14)
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Pain free Squat

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34 (12) 41 (12) 37 (11) 45 (12) 6.9 (0.81) <0.001* 8.7 <0.001*

Angle (deg)
(1.38)
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*Denotes significant difference (P < 0.005)

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Table 3- Comparison of differences in outcome measures between Maitland and Mulligan

mobilization techniques (n=30) [median ± IQR] at 95 % Confidence Interval

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Outcome Between Intervention Difference P

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NPRS -0.30 (-0.27 to -0.33) 0.18*

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TUG (s) -0.19 (-0.28 to -0.32) 0.27*

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Pain free Squat Angle (deg) 1.80 (0.15 to 0.45) 0.17*
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*Denotes no significant difference (P > 0.005)
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Figure 4- Changes in pre and post NPRS values for Mulligan MWM and Maitland
Mobilization
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Figure 5- Changes in pre and post TUG values for Mulligan MWM and Maitland
Mobilization
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Figure 6- Changes in pre and post Pain free Squat angle values for Mulligan MWM and
Maitland Mobilization