Maitland Mobilization Techniques Health And Social Care Essay
Codman introduced the term frozen shoulder in 1934, In 1946 Neviasernamed the condition adhesive capsulitis based on the radiographic appearance with arthography ,which suggested that adhesion of the capsule of the glenohumeral joint limiting the overall joint space volume .( Brentbrotzman,Kevin E.wilk2003)Incidence in general population is 2%, in diabetes is 10-35%in bilateral case 12%,more common in females than in males, mean age is 40-60 yrs(john ebnezar,2010)
During abduction and overhead activities, of the shoulder, long head of biceps, and rotator cuff undergo repeated strain. This results inflammation, fibrosis and consequent thickening of the shoulder capsule which results in loss of movement (john ebnezar, 2010)
The causes for periarthritis shoulder are two types, primary and secondary. Primary is idiopathic. Secondary, according to Lumberg it is divided into shoulder causes and non shoulder causes. Shoulder causes are directly related to shoulder joint like, shoulder fractures & dislocation. Nonshoulder causes are not related to shoulder joint .e.g.Diabetes, cardiovasculardiseases (johnebnezar, 2010)
MAITLAND MOBILIZATION TECHNIQUES (Maitland 1991)
This is also called as graded oscillation techniques. It includes 5 grades. It performed slowly(one in 2 seconds) or quickly (3/second) with small and large amplitude and it applied in any part of the total ROM, these movements may be performed while the joint surfaces are compressed or distracted position.
Grade 1&2 are primarily used for treating joints limited by pain. The oscillation may have an inhibitory effect on the perception of the painful stimuli by repetitively stimulating mechanoreceptors that block nociceptive pathway at the spinal cord or brain stemlevels. These non stretch motions help move this synovial fluid to improve nutrition to the cartilage.
Grade 3&4 are primarily used as stretching maneuvers.
MOBILIZATION WITH MOVEMENT
Brain Mulligan of New Zealand is described these techniques. It is a concurrent application of sustained accessory mobilization applied by a therapist and an active physiological to end range applied by the patient.
OPERATIONAL DEFINITION
Periarthritisshoulder: painful restriction of both active and passive glenohumeral joint motion due to causes within the shoulder joint or remote
Pain: an unpleasant sensory and emotional experience associated with actual or potential tissue damage
Range of motion:it is “the measurement of the extent to which a joint can go through all of its normal spectrum of movement”. It is measured by goniometer.
Functionalactivities: activities are required to perform the activities of daily living.
Mobilization:it is a passive, skilled manual therapy technique applied to the joints and related soft tissues at varying speed and amplitudes using physiological or accessory motions for therapeutic purposes.
Mobilization with movement:MWM is the concurrent application of sustained accessory mobilization applied by the therapist and an active physiological movement to end range applied by the patient.
NEED FOR THE STUDY
Considering the serious economic and social influence of periarthritis shoulder, an appropriate management is essential. There is a growing concern about the effectiveness of treatments for periarthritis shoulder. Although both mulligan MWM technique and Maitland mobilization technique are promising, the evidence for its effectiveness is unclear. This study is sought to compare and to find out the effectiveness of mulligan MWM technique and Maitland mobilization technique .
SPECIFIC OBJECTIVE
To compare the effectiveness of Mulligan’s MWM versus Maitland mobilization technique in pain reduction and increase in range of motion and functionoutcome in patients with periarthritis shoulder.
HYPOTHESIS
1. There will a significant difference in pain, abduction ,external rotation ROM of shoulderand functional outcome with mulligan(MWM)technique in patients with periarthritis shoulder.
2. There will a significant difference in pain, abduction, external rotation ROM of shoulderand functional outcome with Maitland mobilization technique in patients with periarthritis shoulder.
3. There will a significant difference in pain, abduction, external rotation ROM of shoulder and functional outcome in between the groups of periarthritis shoulder patient who undergone Mulligan (MWM) technique and Maitland mobilization technique.
PROJECTED OUTCOME
Based on the literature review, it is expected that the participant with periarthritisshoulder whoundergo MWM will have reduction in pain, increased ROM andfunctional outcome thereby, improving overall functional activities of the affected shoulder.
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REVIEW OF LITERATURE
CHAPTER – II
REVIEW OF LITERATURE
Jing-lan Yang, Chein-weiChang,et al(, Journal of physical therapy 2007) this study was to compare the use of 3 mobilization techniques-end-range mobilization (ERM), mid-range mobilization (MRM), and mobilization with movement (MWM)-in the management of subjects with periarthritis shoulder .Twenty-eight subjects with FSS were recruited for the study.. A multiple-treatment trial on 2 groups (A-B-A-C and A-C-A-B, where A=MRM, B=ERM, and C=MWM) was carried out. The duration of each treatment was 3 weeks, for a total of 12 weeks. Outcome measures included the ROM,functional score and shoulder kinematics. The result shows that ERM and MWM were more effective than MRM in increasing mobility and functional ability.
Grenith J. Zimmerman, Andrea J. Johnson, et.al Journal of orthopedics and sports physical therapy 2007 )conducted a study To compare the effectiveness of anterior versus posterior glide mobilization techniques for improving shoulder external rotation range of motion (ROM) in patients with periarthritis shoulder,.. Twenty consecutive subjects with a primary diagnosis of periarthritis shoulder and were randomly assigned to 1 of 2 treatment groups. All subjects received 6 therapy sessions consisting of application of therapeutic ultrasound, joint mobilization, and upper-body ergometer exercise..The outcome measures were pain and external rotation ROM of shoulder. This study shows that posteriorly directed joint mobilization technique was more effective than an anteriorly directed mobilization technique for improving external rotation ROM and pain.
Pamela teys,Leannebisset,billvicenzino(Journal of manual therapy,2008 ) conducted a study to investigate the initial effects of mulligan’s MWM technique as shoulder ROM in plane of scapula and pressure pain threshold in participants with anterior shoulder pain. In this study 24 subjects are randomly allocated to 2 groups. The outcome measures used evaluated were ROM and PPT. the results indicated that specific manual therapy treatment has immediate positive effect on both ROM and pain in subject with painful limitation of shoulder movements.
Vermeulen HM, Obermann WR, Burger BJ, Kok GJ, et.al( Journal of physical therapy 2000) conducted a study to describe the use of end-range mobilization techniques in the management of patients with periarthritisshoulder. it is a multiple subject case report. In this study. Four men and 3 women with periarthritis shoulder were treated with end-range mobilization techniques, twice a week for 3 months. Outcome measures were shoulder ROM and pain .this study shows that the end-range mobilization technique is effective in the treatment ofperiarthritis shoulder.
James camarinos(journal of manual and manipulative therapy 2009) conducted a systemic review to identify the effectiveness of manual therapy to the glenohumeral joint across all the painful shoulder conditions. A search of Medline, cinahl ,web of science and Cochrane central register of randomized controlled trials of articles dated 1996 to 209 was performed. The outcome measures were ROM, pain, function /quality of life. Seventeen related articles are found. According to the study manual therapy appears to increase either active or passive mobility of the shoulder and also reduces the pain, but the effect of function and quality of life remaininconclusive.
Jose Orlando ruiz( Journal of manual and manipulative therapy 2009) this study describes the use of positional stretching technique of the coraco humeral ligament on a 51 yr old female diagnosed with periarhritis shoulder, it is a single patient case report. The outcome measures evaluated were ROM and disability. Theresults show that positional stretching of the corcohumeral ligament has improved the ROM and reduce the disability.
Chung yee Cecilia hoa ,joannemunnab et al,(Journal of manual therapy2009)conducted a study to determine the effectiveness of manual therapy technique for the management of the musculoskeletal disorders of shoulder. It is a systemic review of randomized controlled trials. Fourteen randomized controlled trials met the inclusion criteria and their methodological were assessed using the PEDro scale. The results show that massage and mobilization with movement is useful in shoulder dysfunction.
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MATERIALS AND METHODOLOGY
CHAPTER – III
MATERIALS AND METHODOLOGY
STUDY DESIGN
A Qausi-experimental study design, in which subjects are randomly assigned into two groups. GroupA for Maitland mobilization technique and Group B for mulligan mobilization with movement technique. All the subjects have same chance of being in either Maitland or Mulligan mobilization. In this study pre test values for both groups were compared with the post test values in the selected parameters over a period of time.
STUDY SETTING
Department of physical therapy, PSG hospitals, Coimbatore.
POPULATION AND SAMPLING
Subjects referred from the department of orthopedics with periarthritis shoulder were chosen as a population and total 30 subjects were selected by using convenience sampling method and randomly assigned into two groups.
CRITERIA FOR SAMPLE SELECTION
Inclusion criteria
Age 40 – 60 yrs
Shoulder pain > 3 months
Diagnosed as PAshoulder referred to physiotherapy
Exclusion criteria
Diabetic mellitus
History of surgery on particular shoulder joint
Rheumatoid arthritis
Fracture of shoulder complex
Rotator cuff rupture
Tendon calcification
Osteoporosis
STUDY DURATION
6 months
TREATMENT DURATION
3weeks, 3 session / week – 30 mints /session
INSTRUMENT AND TOOL FOR DATA COLLECTION
Visual analogue scale
It is a 10 cm scale, which is used to assess pain, which has score from 0 (no pain) to 10 (severe pain)
Goniometer
It is used to assess the range of motion of abduction and external rotation of shoulder.
SPADI
Shoulder pain and disability index, it includes 13 items into 2 subscales pain (5 items) and disability (8 items) and score for each component of the subscale ranging from 0 to 10 was used to assess the functional activities of the patient.
TECHNIQUE FOR DATA COLLECTION
Samples were selected for the study after meeting the inclusion criteria. The subjects were assigned into two groups. The first group subjects received Maitland mobilization and second group received mulligan mobilization with movement respectively.
Assessment of shoulder pain, active range of motion of abduction and external rotation and functional activities of shoulder were taken before the intervention. At the end of 3rd week, post intervention assessments were taken. Pre and post test values of the both groups were documented before and after intervention.
TECHNIQUE OF DATA ANALYSIS AND INTERPRETATION:
. Data collected from both group subjects were analyzed using paired ‘t’ test to measure the changes between the pre and post test values within the group and Independent ‘t’ test to measure the changes between the group
Paired ‘t’ test:
d = Difference b/w pretest & posttest values
= Calculated Mean Difference of pretest & posttest values
SD = Standard deviation.
n = Number of samples.
The independent’ t ‘ test calculated by the formula,
t = | X1−X2|
SD √1/n1+1/n2
SD= (n1-1) SD12 +(n2 -1) SD 22
√ n1 + n2 – 2
SD = standard deviation
n =number of samples
x1= Mean of group A
x2 = Mean of group B
SD1 = standard deviation of group A
SD2 =Standard deviation ofgroup B
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DATA ANALYSIS AND INTERPRETATION
CHAPTER 1V
DATA ANALYSIS AND INTERPRETATION
Data analysis is a method by which the validity of research study is evaluated. It is a systemic organization and synthesis of research data and testing the research hypothesis using these data. Interpretation is the process of making sense of results of a study and examining the implication (pilot and bect 2004)
The pre and post test values for both groups A&B were taken before and after Maitland and mulligan mobilization respectively. The mean , standard deviation, paired ‘t’ values were used to find out if there is a any significant difference between pre and post test values of the Maitland and mulligan mobilization technique and independent t test was used to find out the difference between the groups.
TABLE I
The pre test and post test values of Pain (VAS) in Group-A (Mulligan MWM technique) (n=15)
No.
PRE TEST
POST TEST
1
7
3
2
5
1
3
6
2
4
7
3
5
5
1
6
8
3
7
7
2
8
6
1
9
9
3
10
8
2
11
7
2
12
7
3
13
8
3
14
6
1
15
7
3
TABLE II
The pre test and post test values of Pain (VAS) in Group B (Maitland) (n=15)
NO
Pre test
Post test
1
8
6
2
5
3
3
7
5
4
9
7
5
6
4
6
5
3
7
6
2
8
7
5
9
8
6
10
5
5
11
7
5
12
6
4
13
7
6
14
7
5
15
8
7
TABLE III
Paired’t’ test the mean, mean difference, standard deviation of Pain in Group A and B.
GROUPS
MEAN
MEAN DIFFERENCE
SD
t VALUE
p VALUE
GROUP A
PRE TEST
POST TEST
6.86
2.13
4.73.
1.66
11.2
<0.001
GROUP B
PRE TEST
POST TEST
6.73
4.86
1.86
.83
8.85
<0.001
GRAPH I
Mean difference of Pain in Group A and B.
TABLE IV
Pre and post test values of abduction ROM in Group A(Muligan MWM ) (n=15)
Patient number
Pre test
Post test
1
60
100
2
45
95
3
40
90
4
50
120
5
70
110
6
45
85
7
50
100
8
90
150
9
50
80
10
80
120
11
60
100
12
50
110
13
70
90
14
45
100
15
60
110
TABLE -V
Pre and post test values of abduction ROM in Group B(Maitland mobilization technique) (n=15
NO
PRE TEST
POST TEST
1
80
100
2
60
100
3
90
140
4
70
110
5
65
105
6
50
90
7
45
100
8
60
90
9
90
130
10
40
80
11
45
100
12
50
95
13
60
110
14
40
50
15
70
110
TABLE -VI
Paired’t’ test the mean, mean difference, standard deviation of abduction ROM in Group A and B.
Groups
mean
Mean difference
SD
t value
p value
GROUP A
PRE TEST
POST TEST
57.3
104
46.7
12.60
14.3
<0.001
GROUP B
PRE TEST
POST TEST
61
100.6
39.6
11.56
13.2
<0.001
GRAPH II
Mean difference, of abduction ROM in Group A and B.
TABLE VII
Pre and post test values of external rotation ROM in Group A
(MuliiganMWM technique) (n=15)
NO
PRE TEST
POST TEST
1
10
40
2
5
20
3
25
60
4
15
30
5
25
6
10
35
7
5
20
8
10
40
9
5
25
10
10
40
11
15
12
10
40
13
30
40
14
10
50
15
5
20
TABLE VIII
Pre and post test values of external rotation ROM in Group B
(Maitland mobilization technique) (n=15)
NO
PRE TEST
POST TEST
1
20
25
2
15
30
3
10
30
4
20
25
5
30
60
6
15
35
7
25
50
8
40
60
9
45
55
10
35
45
11
10
30
12
30
60
13
20
30
14
15
25
15
40
60
Groups
Mean
Mean difference
SD
t value
p value
GROUP A
PRE TEST
POST TEST
9.33
34.1
24.97
8.86
10.9
<0.001
GROUP B
PRE TEST
POST TEST
22.69
38.6
16.06
7.36
8.42
<0.001
GRAPH III
Mean difference, ofexternal rotation ROM in Group A and B.
TABLE X
Pre and post test values of functional outcome in Group A(Mulligan MWM technique) (n=15)
NO
PRE TEST
POST TEST
1
60
40
2
70
30
3
60
20
4
70
40
5
60
30
6
80
40
7
70
20
8
60
40
9
70
60
10
50
30
11
70
30
12
60
20
13
70
30
14
50
20
15
70
40
TABLE XI
Pre and post test values of functional outcome in Group B
(Maitland mobilisation technique) (n=15)
NO
PRE TEST
POST TEST
1
70
50
2
50
40
3
60
50
4
70
50
5
40
30
6
80
50
7
80
80
8
60
40
9
40
30
10
60
30
11
50
40
12
60
50
13
70
30
14
80
70
15
50
30
TABLE XII
Paired’t’ test, mean, mean difference, standard deviation of functional outcome in group A&B
GROUPS
MEAN
MEAN DIFFERENCE
SD
t VALUE
p VALUE
GROUP A
PRE TEST
POST TEST
64.6
32.6
32
10.99
10.81
<0.001
GROUP B
PRE TEST
POST TEST
61.3
44.66
16.64
10.49
6.17
<0.001
GRAPH IV
Mean difference, of functional outcome in Group a and B.
TABLE XIII
Independent t value, standard deviation of pain , ROM,and functional outcome
GROUPS
DIFFERENCE IN MEAN
SD
‘t’value
‘p’ value
VAS
2.73
1.31
5.16
<0.001
ABDUCTION
3.4
12.09
2.54
<0.001
EXTERNAL ROTATION
4.5
8.14
3.07
<0.001
SPADI
12.06
10.74
4.82
<0.001
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RESULTS AND DISCUSSION
CHAPTER -V
RESULTS AND DISCUSSION
The purpose of these study was to compare the effectiveness of mulligan versus Maitland mobilization technique in pain reduction, improvement in abduction and external rotation ROM and functional outcome of subject with periarthritis shoulder the outcome measures used were VAS,goniometer,and shoulder pain and disability index (SPADI)
Correlating the study results with the literature stated byJing-lan Yang et al, it is clear that Mulligan mobilization with movement( MWM )method is more effective than maitland mobilization technique.
Among 30 patients 21 were female and 9 were males who age ranged from 40-60 .pre test value was taken prior to the intervention, treatment was given by 3weeks, 3 session / week – 30 mints . A repeat assessment was taken after the intervention. The paired data analyzed by paired t test & independent t test.All subject in groupAshowed a significant improvement in pain, ROM, functional outcome.
The independent t test was performed between group A &B to compare the pain, ROM and functional outcome. Based on VAS calculated t value was5.16, which is greater than the t table value p<0.001. Based on external rotation ROM calculated t value which was 3.07 greater than the t table value p<0.001. Based on abduction ROM calculated t value which was 2.54 greater than the t table valuep<0.001. Based on SPADI calculated t value which was 4.82 greater than the t table value p<0.001.
The results showed that there was a significant effect of mulligan than Maitland in periathritis shoulderas calculated t value for the VAS,goniometer and SPADI which was greater than t table value.
LIMITATION OF THE STUDY
The study was done only for a short period of time.
The sample size was small.
.
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SUMMARY AND CONCLUSION
CHAPTER -VI
SUMMARY AND CONCLUSION
With reference to the statistical analysis and interpretation done for the data collected by Visual Analogue Scale, goniometer, shoulder pain and disability index was noted that Mulligan MWM technique has significant effect in participants with periarthritis shoulder than Maitland mobilization technique. Therefore from the statistical analysis of the data obtained following the treatment, the study concluds that
Mulliganmobilisation with movement ( MWM) technique has significant effect in reducing pain ,improving range of motion and functional outcome for periarthritis shoulder.
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