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SUMMARY. This preliminary study indicates the proportion of patients with lateral epicondylalgia that
demonstrate a favourable initial response to a manual therapy technique the mobilization with movement
(MWM) for tennis elbow. Twenty-five subjects with lateral epicondylalgia participated. In a one-group pretest
post-test design, we measured (1) pain with active motion, (2) pain-free grip strength and, (3) maximum grip
strength before and after a single intervention of MWM. Results of the study indicate that MWM was effective in
allowing 92% of subjects to perform previously painful movements pain-free, and improving grip strength
immediately afterwards. Significant differences were found between the grip strength of the affected and unaffected
limbs prior to the intervention. Both pain-free grip strength and maximum grip strength of the affected limb
increased significantly following the intervention. Pain-free grip strength increased by a greater magnitude than
maximum grip strength. It can be concluded that MWM is a promising intervention modality for the treatment of
patients with Lateral Epicondylalgia. Pain-free grip strength is a more responsive measure of outcome than
maximum grip strength for patients with Lateral Epicondylalgia. Further research is warranted to investigate the
long-term effectiveness of MWM in the treatment of impairment and disability resulting from Lateral
Epicondylalgia. # 2001 Harcourt Publishers Ltd.
METHODS
Subjects
A convenience sample of subjects was solicited from
local orthopaedic surgeons and physical therapists,
and from the medical department of a major shipbuilding site. Inclusion criteria included any person
who, at the time of testing, experienced lateral elbow
pain with gripping activities, or resisted wrist or
finger extension. Exclusion criteria included persons
who had a) bilateral lateral epicondylalgia; b) surgery
for lateral epicondylitis within the last twelve months;
c) history of fracture of either radius or ulna that they
knew to limit ROM; or d) history of rheumatoid
disease, or neurologic impairment including stroke or
head injury.
Materials
A grip dynamometer (Jamar, Clifton, NJ, USA) was
used for grip strength measurements.
Frequency
9
10
3
1
Procedure
The research protocol is summarized as follows:
1. Subjects signed a consent form to participate in
the study, and filled out a brief questionnaire
2. Subjects were instructed to lie supine on a
treatment table. The primary investigator (PI)
established with the patient what active motion
reproduced the patients elbow pain; this was
considered to be the comparable sign. The
comparable sign was one of the following:
making a fist, gripping a rolled elastic bandage
of 5 cm diameter, wrist extension unresisted, wrist
extension resisted by rubber tubing (Theratube,
Theraband Corporation, USA), third finger
extension unresisted, or third finger extension
resisted. The first of the above motions to be
reported as painful was designated the comparable
sign, and no further motions were assessed
3. By random assignment, either the left or right arm
was designated to be tested first
4. Dynamometric measurement of pain-free grip
strength, and then maximum grip strength was
performed with the arm at approximately 308 of
abduction, with the elbow rested on the treatment
table and the wrist rested on rolled towel 8 cm in
diameter. The forearm was in neutral pronation/
supination. The PI was unable to see the face of
the dynamometer, which was read and recorded
# 2001 Harcourt Publishers Ltd
RESULTS
Grip Strength
Measured
(n=23)
Pain-free grip
(unaffected limb)
Pain-free grip
(affected limb)
90.0 (27.9)
87.3 (25.9)
72.7 (NS)
51.6 (27.2)
62.0 (25.0)
10.4{
. Difference
between
means of pairs
38.4{
25.3{
Maximum grip
(unaffected limb)
Maximum grip
(affected limb)
95.1 (27.8)
95.8 (29.0)
0.7 (NS)
81.8 (35.0)
85.9 (32.6)
4.1
13.2{
9.9}
DISCUSSION
The results of this study indicate that the Mulligan
MWM is a useful technique for eliminating the
pain of a previously painful active movement, in
patients with lateral epicondylalgia. Ninety-two
percent of subjects in this sample were able to
perform a previously painful motion pain-free,
during the application of the MWM. These
results indicate that MWM may be a useful
intervention modality in the rehabilitation of patients
with LE.
MWM resulted in a significant increase in both
pain-free grip strength and maximum grip strength
from pre-intervention to post-intervention for the
affected limb (Table 2). While pain-free grip increased
by almost 17%, which we consider to be clinically
significant, the magnitude of change for maximum
grip strength was less than five percent, which we do
not consider to be clinically significant. The observation that the average percent magnitude of change in
pain-free grip strength was more that three times that
of maximum grip strength are in contrast to the
results of Stratford et al. (1993). In their study
maximum grip strength was found to be more
responsive to change than pain-free grip strength,
based on a greater mean magnitude of change,
combined with a greater homogeneity of change
(represented by a lower standard deviation from the
mean). In our sample, pain-free grip strength
demonstrated the greater magnitude of change, and
the greatest homogeneity of change, on the affected
limb (Table 2). These results suggest that pain-free
grip strength is the more responsive measure.
# 2001 Harcourt Publishers Ltd
CONCLUSION
The Mulligan MWM technique for tennis elbow
(Mulligan 1995; 1999) was effective in allowing a
previously painful active movement to be performed
pain-free, while the mobilization was being applied,
in ninety-two percent of subjects with lateral epicondylalgia in this study. Measures of pain-free grip
strength and maximum grip strength improved
significantly immediately following the MWM intervention. These initial results indicate that randomized
controlled clinical trials should be undertaken to
investigate the long-term efficacy of a treatment
protocol utilizing the Mulligan MWM technique for
tennis elbow. We recommend that future studies
intending to differentiate patients who undergo
clinically important functional changes, from patients
who do not, should utilize pain-free grip strength as a
dependent variable in preference to maximum grip
strength.
Acknowledgements
The authors wish to thank Drs Albert Volk, James Grimes, Arnold
Graham-Smith, and Maria Mazorra, as well as John Bendt,
Matthew Jeffs, Jenna Geiger, and Leigh-Ann Tabor for their
assistance in obtaining volunteer subjects for this research. Thanks
also to Corlia van Rooyen for her valuable assistance with data
collection, and to the staff of the medical department of Bath Iron
Works, particularly Darren Beilstein, Paul Hempstead, Joanna
Streeter, and Wayne McFarland for their cheerful and extremely
valuable assistance. Thanks also to Drs Susan Mercer and Darren
Rivett for critical review of previous versions of this manuscript.
Mr Abbott wishes to express his sincere appreciation to his
research advisors; thank you Drs Catherine Patla, Richard Jensen
and Deborah Jackson. This paper is dedicated to the memory
of the primary advisor for this research, the late Dr. William
Manual Therapy (2001) 6(3), 163169
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# 2001 Harcourt Publishers Ltd