CRITICALLY APPRAISED TOPIC (CAT)

Journal of Sport Rehabilitation, 2009, 18, 448-457

© 2009 Human Kinetics, Inc.

Effect of Manual Mobilization With

Movement on Pain and Strength in Adults
With Chronic Lateral Epicondylitis
Stacey Pagorek

Clinical Scenario
Lateral epicondylitis, or tennis elbow, is a painful musculoskeletal condition that
often limits strength and function. Manual therapy, specifically mobilization with
movement (MWM), is a treatment intervention to help decrease pain and improve
strength of those with lateral epicondylitis. This clinical scenario places the thera-
pist in an outpatient, orthopedic clinic where a 35-year-old male tennis player
presents with lateral epicondylitis of 7 weeks’ duration. His lateral elbow pain has
become unbearable and significantly limits his participation in tennis and other
functional, gripping activities. He has been referred to physical therapy by his
primary-care physician and has an immediate goal of decreasing his lateral elbow
pain and increasing his strength. He hopes to play in a tennis tournament in 3
weeks.

Focused Clinical Question

For adults with chronic lateral epicondylitis, does MWM decrease pain and
increase strength?

Summary of Search, “Best Evidence” Appraised,

and Key Findings
• The literature search resulted in 9 relevant articles meeting the inclusion and
exclusion criteria: 3 systematic reviews, 2 randomized controlled trials, 1
cohort study, 2 case series, and 1 clinical commentary.
• One randomized controlled trial reported a 58% improvement in pain-free
grip strength during MWM, a 46% improvement in pain-free grip strength

The author is with the University of Kentucky, Rehabilitation Services Dept, Sports Physical Therapy,
Lexington, KY 40536.

448
 Manual Mobilization and Epicondylitis   449

immediately after MWM, and a 10% improvement in pressure-pain threshold

immediately after MWM.
• One study reported that 92% of subjects were able to perform a previously
painful movement pain free during the application of MWM.
• One randomized controlled trial reported that MWM produced hypoalgesia
(improvements in pain-free grip strength and pressure-pain threshold) and
physiological sympathoexcitation (change in heart rate, blood pressure, and
cutaneous sudomotor and vasomotor function).
• Improvements in pain-free grip strength and pressure-pain threshold occurred
only in the affected arm, not in the unaffected arm or in the placebo or control
condition.

Clinical Bottom Line

Manual MWM as a treatment intervention is strongly recommended to decrease
pain and increase strength with gripping activities for adults with chronic lateral
epicondylitis. However, the long-term effects of the treatment, as well as the ben-
efits for a particular subgroup of patients, remain unknown.
Strength of Recommendation: Level A evidence exists that manual MWM
treatments decrease pain and increase strength in adults with chronic lateral
epicondylitis.

Search Strategy
Terms Used to Guide Search Strategy:
• Patient/Client group: lateral epicondylitis or lateral epicondylalgia or tennis
elbow
• Intervention (or assessment): manual therapy or mobilization with
movement
• Comparison: nil
• Outcomes: decrease in pain or increase in strength

Sources of Evidence Searched

• The Cochrane Library
• PEDro Database
• Medline
• PubMed
• CINAHL
• SportDiscus
450   Pagorek

Inclusion and Exclusion Criteria

Inclusion
Studies that contained
• Chronic lateral epicondylitis ≥6 weeks in duration
• Strength or pain as an outcome
• MWM performed at symptomatic elbow
• Limited to English language
• Limited to adult humans
• Limited to studies published between 2001 and 2008

Exclusion
Studies that contained
• Acute lateral epicondylitis ≤6 weeks in duration
• Experimentally induced lateral epicondylalgia
• A manual mobilization technique performed to wrist, shoulder, or cervical
spine
• A combination of manual therapy with another modality (shockwave therapy,
ultrasound, corticosteroid injection)

Results of Search
Nine relevant studies were located and categorized as shown in Table 1 (based on
levels of evidence, Centre for Evidence Based Medicine, 1998)

Table 1  Summary of Study Designs of Articles Retrieved

Level of Study design or methodology Number
evidence of articles retrieved located Author
1a Systematic review of randomized 1 Bisset et al1
controlled trials
1b Randomized controlled trials 2 Vicenzino et al,2
Paungmali et al3
2a Systematic review of cohort studies 1 Trudel et al4
2b Cohort studies 2 Abbott et al,5
Paungmali et al6
3a Systematic review of case-control 1 Vicenzino et al7
studies and higher
4 Case series, poor-quality cohort 1 McLean et al8
study
5 Expert opinion, clinical commentary 1 Vicenzino et al9
 Manual Mobilization and Epicondylitis   451

Best Evidence
The studies in Table 2 were identified as the “best” evidence and selected for
inclusion in the CAT. Reasons for selecting these studies were that they were
graded with a high level of evidence and most closely addressed the clinical
question.

Implications for Practice, Education,

and Future Research
The studies included in this CAT all address the effect of a manual MWM treat-
ment technique on pain and strength for adults with chronic lateral epicondylitis.
There is a high level of evidence supporting the use of MWM as a treatment tech-
nique with this patient population. All 3 critically appraised studies reported an
improvement in pain and grip strength. One study2 reported a 58% improvement
in pain-free grip strength during the MWM treatment, a 46% improvement in
pain-free grip strength immediately after the treatment, and a 10% improvement
in pressure-pain threshold immediately after treatment. Another study5 found that
during the MWM, 92% of subjects were able to perform a previously painful
movement pain free. Finally, the other study3 reported that MWM produced
hypoalgesia (improvements in pain-free grip strength and pressure-pain thresh-
old) and physiological sympathoexcitation (chance in heart rate, blood pressure,
and cutaneous sudomotor and vasomotor function). In the 2 controlled studies,2,3
improvements in pain-free grip strength and pressure-pain thresholds occurred
only in the MWM treatment condition and not in the placebo or control condi-
tions. In all studies,2,3,5 improvements were seen in the affected arm, not in the
unaffected arm.
The benefits of using this intervention in clinical practice are that it is rela-
tively quick, does not require additional equipment, and results in immediate
pain reduction and improvement in function. The limitation of this treatment
technique is that it does not always work for all patients, and current research
has not explored why it is not always effective. Further research should focus on
a particular subgroup of patients that benefits most with this treatment tech-
nique. In addition, further studies need to explore the effect of the MWM treat-
ment on acute lateral epicondylitis as opposed to chronic lateral epicondylalgia.
Finally, future research should examine the long-term benefits of the MWM
treatment, such as how long the hypoalgesia lasts and how many treatments are
required to permanently relieve symptoms of pain and reports of impaired grip
strength.
 Table 2  Characteristics of Included Studies, Summary of Best Evidence
452
Vicenzino et al2
Study design Randomized controlled trial
Participants 24 participants (10 female,14 male) with
unilateral lateral epicondylalgia of >6 wk
duration. Condition diagnosed based on
pain with digital palpation over the lateral
epicondyle and on gripping a handheld
dynamometer.
Included only if pain experienced in at
least 1 of the following tests: resisted
static contraction of the wrist extensors or
extensor carpi radialis brevis or stretching
of the extensor muscles of the forearm.
Excluded if concomitant problems in
neck or upper limbs, neurological impair-
ment, previous experience of manipula-
tive therapy to the elbow, aversion to
manual contact, health conditions that
preclude manipulative therapy, or concur-
rent use of certain medications such as
analgesic or anti-inflammatory drugs.
Convenience sample recruited with
public media releases and from estab-
lished network of physiotherapy clinics.
Key demographic information: age range
34–66 y (mean = 46) and duration of con-
dition range 2–36 months (mean = 8).
No dropouts.
Paungmali et al3
Randomized controlled trial
24 participants (7 female, 17 male) with
chronic lateral epicondylalgia.
Included if pain over lateral side of elbow
provoked with palpation of lateral epicon-
dyle region and gripping tasks. In addition,
pain over lateral epicondyle with at least 1
of following: resisted static contraction of
wrist extensors or extensor carpi radialis
brevis or stretching of the forearm extensor
muscles.
Excluded if cervical spine or other upper
limb problems, neuromuscular disease,
cardiovascular disease, health conditions
that limit treatment, recent steroid injec-
tion, prescription medication such as anti-
inflammatory or analgesic drugs, aversion to
manual contact, or previous therapy to the
elbow joint.
Key demographic information: mean age
48.5 y, mean duration of lateral epicondylal-
gia 8.9 months.
Convenience sample recruited by media
releases and referral from health care practi-
tioners in Brisbane, Australia.
Sample size determined a priori on basis of
pilot study.
All 24 participants completed the study.
Abbott et al5
Cohort study
25 subjects (8 female, 17 male) with
lateral
epicondylalgia.
Included if lateral elbow pain with
gripping activities or with resisted
wrist or finger extension.
Excluded if bilateral lateral
epicondylalgia, surgery for lateral
epicondylitis in past year, fracture of
radius or ulna that limits range of
motion,
history of rheumatoid disease or
neurologic impairment.
Convenience sample from orthopedic
surgeons and physical therapists.
Key demographic information: age
range 29–60 y (mean = 46); 23 of the
25 subjects had chronic lateral
epicondylitis, duration of condition
range 2 months to 8 y (mean =
16 months). 72% of subjects employed
in industry or heavy industry; 12%
performed clerical or data input; 12%
involved in teaching or health care; 4%
claimed no occupation.
All eligible participants completed the
study.
(continued)
 Table 2 (continued)
Vicenzino et al2
Intervention 3 treatment conditions, all applied
investigated by same, experienced manipulative phys-
iotherapist.
MWM: 1 hand glides the proximal fore-
arm
laterally and the other fixes the
distal end of the humerus.
Sustained glide while subject
performed pain-free gripping
action. 6 repetitions performed
with 15-s rest interval.
Placebo: Application of firm manual con-
tact directly over both sides of elbow.
Control: No manual contact. Subject
remained in same position as during
MWM and placebo treatment
conditions.3 experimental sessions
per subject, 48 h apart, 1 treatment
condition per session in random
order, determined by drawing lots.
Separate investigator, who was blinded
to treatment condition, measured
outcomes (pain-free grip strength and
pressure-pain threshold).
Subjects blinded to treatment
received and physiotherapist blinded to
test results.
453
Paungmali et al3
3 treatment conditions, all applied by same
physiotherapist with 8 y clinical experience
and qualification in manipulative physical
therapy.
MWM: 1 hand stabilizes the distal
end of the humerus while the other applies
a lateral glide of the proximal ulna and
radius. Glide sustained for approximately 6
s while
participant performed a pain-free gripping
action. 10 repetitions of MWM performed,
approximately 15-s rest intervals between
repetitions.
Placebo: Application of firm manual contact
with both hands over elbow, with care not to
cause loading across the elbow joint like that
applied in MWM, while subject performed
pain-free gripping action.
Control: No manual contact while subject
performed the pain-free gripping action.
Participants attended 3 laboratory sessions
at the same time of day (± 2 h) with at least
48 h between sessions.
Treatment randomized by drawing lots.
Investigator collecting data blinded to
treatment condition; participants unaware of
outcome measures.
Abbott et al5
MWM consisting of laterally directed
manual pressure to the proximal
medial forearm while the subject per-
formed a comparable sign motion.
Comparable sign = active
motion that previously reproduced
elbow pain: making a fist, gripping a
5-cm-diameter rolled elastic bandage,
wrist extension unresisted, wrist
extension resisted by rubber tubing,
third finger extension unresisted, third
finger extension resisted.
Up to 4 different directions were
attempted to find the direction of
manual pressure that eliminated the
comparable sign: directly lateral, ~5°
posterior
of lateral, ~5° anterior of lateral, ~5°
caudal of lateral.MWM with
comparable sign performed up to 10
times; if pain returned before
10 repetitions, stopped MWM.
Random assignment of right
or left arm tested first.
Therapist blinded to grip-strength
results; measurements read and
recorded by research assistant.
(continued)
 Table 2 (continued)
454
Vicenzino et al2
Outcome Primary Outcomes
measures Pain-free grip strength: Measured by
electronic digital dynamometer with
upper limb at the subject’s side in elbow
extension and internal rotation. Subject
informed to stop squeezing when pain
first provoked. 3 measures of pain-free
grip strength recorded, 30-s rest between
intervals. Scores averaged. High intra-
tester reliability (ICC .98, SEM 1.03 N).
Pressure-pain threshold: Measured with
an electronic algometer over the tender-
est area of the lateral epicondyle. Test
terminated when subject first perceived
the onset of pain. Pressure-pain thresh-
old measured 3 times, 30-s rest period
between measurements. Scores averaged.
Intratester reliability for pressure-pain
threshold was high (ICC .95, SEM 7.08
kPa).
Outcomes assessed on the unaffected
and affected side for each experimental
condition.
Pain-free grip strength measured before,
during, and after treatment intervention.
Pressure-pain threshold measured before
and after treatment intervention.
Paungmali et al3
Primary Outcomes
2 categories: pain threshold and sympathetic
nervous system function.
Pain threshold: Pain-free grip force, pres-
sure-pain threshold, thermal pain threshold.
Pain-free grip force: grip force required to
produce onset of pain; measured over 3 rep-
etitions with 30-s rest intervals.
Pressure-pain threshold: measured with
electronic algometer as the amount of pres-
sure required to cause pain; measured 3
times with 30-s rest intervals.
Thermal pain threshold: measured using
Thermotest System as when the heat sensa-
tion first became painful; measured 3 times
with 30-s rest intervals.
Sympathetic nervous system function: Cuta-
neous blood flow, skin conductance, skin
temperature, blood pressure, and heart rate
measured throughout treatment session.
Abbott et al5
Primary Outcomes
Pain with active motion, pain-
free grip strength, maximum
grip strength.
Dynamometric measurement
of pain-free grip strength and
maximum grip strength with
arm at 30° abduction, elbow
rested on treatment table,
forearm in neutral pronation/
supination, with wrist resting
on towel roll 8 cm in diameter.
Grip-strength measurements
taken before and after
MWM treatment.
(continued)
 Table 2 (continued)
Vicenzino et al2
Main Significant 3-way interaction effect
findings between treatment condition (MWM treat-
ment, placebo, and control), side (affected
and unaffected), and time (before, during,
and after application) for pain-free grip
strength (P < .0001).
On affected side, MWM produced sub-
stantial increase in pain-free grip strength
from a mean of 107.53 N at baseline to
156.02 N during application period and
151.77 N after application. No change
in pain-free grip strength during or after
intervention in the placebo and control
conditions.
During treatment application, pain-free
grip strength increased from preapplica-
tion values by 57.58% with the MWM, by
10.32% with the placebo condition, and
by 5.58% with the control condition.
Significant difference between effects of
MWM treatment and placebo (P = .001)
and effects of MWM and control (P <
.0001).
After treatment application, there was a
45.67% increase in pain-free grip strength
for the MWM technique, a 9.74% increase
for the placebo technique, and a 2.69%
reduction for the control condition. The a
priori contrasts between MWM treatment
455
Paungmali et al3
Pain-free grip force increased from 127.1 to
166.2 N (37%) during the MWM treatment
and to 174.1 N (47.5%) immediately after
the MWM treatment.
Pressure-pain threshold increased from 281.4
to 300.8 kPa after MWM.
Thermal pain threshold did not change after
the MWM.
No significant change in placebo and control
conditions for pain-free grip and pressure-
pain threshold.
MWM caused a mean increase in heart rate
(4.1%) and blood pressure (3.5% systolic
and 3.1% diastolic).
No change in placebo and control conditions
for heart rate and blood pressure.
On the affected side, cutaneous blood flow,
skin temperature, and skin conductance all
activated (sympathoexcitation) during MWM
but not in placebo or control.
Abbott et al5
23 of 25 subjects (92%) responded
positively to MWM and were
able to perform a previously painful
movement pain free. Data from
these subjects were analyzed.
Significant difference between pain-
free grip strength and maximum
grip strength of affected and
unaffected limbs before intervention.
In the affected limb, pain-free
grip strength increased
significantly (P £ .005) after
MWM from a mean of 51.6 to
62.0 lb of force.
In the affected limb, maximum grip
strength increased significantly
(P £ .05) after MWM from 81.8
to 85.9 lb of force.
Pain-free grip strength increased
by a greater magnitude than
maximum grip strength.
No significant differences between
pre and post measurements of pain-
free grip strength and maximum
grip strength on unaffected side.
(continued)
 Table 2 (continued)

456
Vicenzino et al2 Paungmali et al3 Abbott et al5

and placebo (P = .002) and between

MWM treatment and control (P < .0001)
were statistically significant.
Pressure-pain threshold increased 10.26%
after application of the MWM treatment.
This was significantly greater than the
3.88% reduction in pressure-pain thresh-
old produced by the placebo treatment (P
= .01) and significantly greater than the
0.31% change after the control condition
(P = .049).
Level of 1b 1b 2b
evidence
Validity PEDro 5/10 PEDro 8/10 NA
score (if
applicable)
Conclusion Rapid hypoalgesic effect during and MWM produced a hypoalgesic effect dem- MWM effective for treating lateral
after MWM. Effect only occurred with onstrated by improvements in pain-free grip epicondylalgia.
the MWM technique, not with placebo strength and pressure-pain threshold. During MWM, 92% of subjects
or control condition. Hypoalgesic effect MWM produced a physiological effect, able to perform previously
occurred only to affected arm, not unaf- sympathoexcitatiown, such as changes in painful movement pain free.
fected arm. heart rate, blood pressure, and cutaneous Pain-free grip strength more
MWM treatment technique produced sudomotor and vasomotor function, similar responsive than maximum
a 58% improvement in pain-free grip to that reported for spinal manipulations. grip strength.
strength during the treatment, a 46%
improvement in pain-free grip strength
immediately after treatment, and a 10%
improvement in pressure-pain threshold
immediately after treatment.
Abbreviations: MWM, mobilization with movement.
 Manual Mobilization and Epicondylitis   457

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