Author Names
Kochar, M., Dogra, Ankit.
Reviewer Name
Haley Mills, SPT
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
The effect of a combination of Mulligan mobilisation (a manual therapy approach) and ultrasound therapy is compared with that of ultrasound therapy alone. In both cases, a progressive exercise programme followed ten sessions of therapy to improve strength and facilitate return to work. Sixty-six patients (male:female ratio 6:5, mean age 41 years) were recruited. Of these patients, 46 were randomised into two treatment groups by a random draw of chits. The remaining 20, who could not be randomised, comprised the control group.The first (MM) group was treated with a combination of ultrasound therapy and Mulligan mobilisation while the second group was treated with ultrasound therapy alone for ten sessions (completed within three weeks). Both groups then followed a progressive exercise regime for a further nine weeks. They were evaluated at weekly intervals from the time of selection until the third week and finally at the 12th week with four outcome measures: visual analogue scale (VAS), isometric grip strength, weight test and patient assessment test. In the follow-up visit after 12 weeks of therapy, there was improvement in VAS, weight test and grip strength in both the MM (p < 0.01, 0.01, 0.01) and ultrasound groups (p < 0.01, 0.05, 0.05). The MM group showed a greater improvement than both the ultrasound group and the control group on VAS (p < 0.05, 0.05); weight test (p < 0.01, 0.001) and grip strength (NS, p < 0.05). The ultrasound group was superior to the control group on VAS (p < 0.05); weight test (p < 0.01), but the difference from the control group in grip strength was not significant. The MM group showed improvement on most parameters from the first week onwards whereas the ultrasound group improved only from the second week. Also the patient assessment score improved for the MM group (p < 0.05) and for the ultrasound group improvement was significant at three weeks of therapy (p < 0.05), but the difference was not statistically significant at 12 weeks.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT?
- No
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Cannot Determine, Not Reported, or Not Applicable
- Were study participants and providers blinded to treatment group assignment?
- Cannot Determine, Not Reported, or Not Applicable
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- Cannot Determine, Not Reported, or Not Applicable
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Yes
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- Cannot Determine, Not Reported, or Not Applicable
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Cannot Determine, Not Reported, or Not Applicable
- Was there high adherence to the intervention protocols for each treatment group?
- Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Cannot Determine, Not Reported, or Not Applicable
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
- No
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- Yes
- Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
- Yes
Key Finding #1
The Mulligan mobilization group showed significantly better subjective and objective short- and medium-term outcomes than the ultrasound and control groups.
Key Finding #2
Using ultrasound and Mulligan mobilization greatly reduced pain, improved grip strength, and the amount of weight lifted.
Key Finding #3
The ultrasound group demonstrated greater improvement than the control group in most parameters.
Key Finding #4
The Mulligan mobilization group had lower pain levels than the ultrasound group at discharge, when they began their exercise regime, likely explaining why their recovery was more strikingly improved than the ultrasound group.
Please provide your summary of the paper
The researchers aimed to evaluate whether the addition of manual therapy to the typical treatment plan, including ultrasound and exercise, would change outcomes. To study this they took 66 patients with elbow lateral epicondyle pain and randomly divided them into a Mulligan mobilization (manual therapy) and ultrasound group, an ultrasound group, and a control group. The researchers describe Mulligan mobilization as “mobilization with movement”, where a patient lifts a weight that would usually produce their symptoms while the therapist provides a lateral glide. The control group was compiled of people who could not make it to the clinic. Both groups receiving interventions received a graduated exercise therapy program in addition to the treatments being assessed. The outcome measures used for the study were the VAS, a weight test, grip strength, and a self-reported pain question about pain in the last 24 hours. Outcomes were assessed before the interventions, once a week for 3 weeks, and then once after 4 months. After gathering the data and processing it, the researchers found that the Mulligan mobilization group showed the greatest out of the groups in all of the short- and medium-term outcomes. They also found that though the ultrasound group did not improve more than the Mulligan mobilization group, they did improve more than the control group. With this information, the researchers suggest that the addition of Mulligan mobilization to a regimen comprising ultrasound therapy and progressive exercises will enhance the recovery of patients with tennis elbow.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This paper, though slightly dated, provides some information that could be used to help develop a plan of care for patients with tennis elbow. The design of this study does, however, have a limitation that they do not address entirely and that I believe to be an important distinction to make. They seem to rationalize the use of ultrasound as the standard treatment regime by listing that the group had greater improvements than the control. What they fail to appropriately highlight, when discussing results, is that the control group did not receive the same graduated exercise regime that the other two treatment groups received. This oversight could contribute to drawing incorrect conclusions about the strength of ultrasound as a stand-alone treatment, when in fact it was used in conjunction with exercise in the context of this study. Having said that, it does highlight the impact that manual therapy had on the participant’s success with their at-home exercise regime which I believe translates well into clinical practice. This finding can allow clinicians to understand manual therapy as an adjunct to exercise which sets patients up to perform their exercises with little to no pain, rather than a passive modality that may or may not be as good as exercise therapy.
