Mulligan bent leg raise technique--a preliminary randomized trial of immediate effects after a single intervention

"Mulligan Bent Leg Raise" Technique in Avascular Necrosis

This case report examines the effectiveness of the "Mulligan bent leg raise" (MBLR) method for treating femoral head avascular necrosis (AVN). A professional physiotherapist directed a six-week rehabilitation program for a 37-year-old male patient with AVN that included this innovative physiotherapeutic method. According to radiographic results and standardized evaluations, the patient showed significant improvements in hip range of motion, functional ability, and pain levels. As a viable supplement to conventional rehabilitation techniques, the MBLR method has shown promise in improving joint function and reducing symptoms in individuals with acute compartment syndrome. The present study provides significant contributions to the discipline. It highlights the necessity for more investigation to examine the wider relevance and enduring effectiveness of this methodology in various population affected.

Sham treatment effects in manual therapy trials on back pain patients: a systematic review and pairwise meta-analysis

OBJECTIVE

To assess the effects and reliability of sham procedures in manual therapy (MT) trials in the treatment of back pain (BP) in order to provide methodological guidance for clinical trial development.

DESIGN

Systematic review and meta-analysis.

METHODS AND ANALYSIS

Different databases were screened up to 20 August 2020. Randomised controlled trials involving adults affected by BP (cervical and lumbar), acute or chronic, were included.Hand contact sham treatment (ST) was compared with different MT (physiotherapy, chiropractic, osteopathy, massage, kinesiology and reflexology) and to no treatment. Primary outcomes were BP improvement, success of blinding and adverse effect (AE). Secondary outcomes were number of drop-outs. Dichotomous outcomes were analysed using risk ratio (RR), continuous using mean difference (MD), 95% CIs. The minimal clinically important difference was 30 mm changes in pain score.

RESULTS

24 trials were included involving 2019 participants. Very low evidence quality suggests clinically insignificant pain improvement in favour of MT compared with ST (MD 3.86, 95% CI 3.29 to 4.43) and no differences between ST and no treatment (MD -5.84, 95% CI -20.46 to 8.78).ST reliability shows a high percentage of correct detection by participants (ranged from 46.7% to 83.5%), spinal manipulation being the most recognised technique.Low quality of evidence suggests that AE and drop-out rates were similar between ST and MT (RR AE=0.84, 95% CI 0.55 to 1.28, RR drop-outs=0.98, 95% CI 0.77 to 1.25). A similar drop-out rate was reported for no treatment (RR=0.82, 95% 0.43 to 1.55).

CONCLUSIONS

MT does not seem to have clinically relevant effect compared with ST. Similar effects were found with no treatment. The heterogeneousness of sham MT studies and the very low quality of evidence render uncertain these review findings.Future trials should develop reliable kinds of ST, similar to active treatment, to ensure participant blinding and to guarantee a proper sample size for the reliable detection of clinically meaningful treatment effects.

PROSPERO REGISTRATION NUMBER

CRD42020198301.

The Effect of Spinal Mobilization With Leg Movement in Patients With Lumbar Radiculopathy-A Double-Blind Randomized Controlled Trial

OBJECTIVES

To evaluate the effect of spinal mobilization with leg movement (SMWLM) on low back and leg pain intensity, disability, pain centralization, and patient satisfaction in participants with lumbar radiculopathy.

DESIGN

A double-blind randomized controlled trial.

SETTING

General hospital.

PARTICIPANTS

Adults (N=60; mean age 44y) with subacute lumbar radiculopathy.

INTERVENTIONS

Participants were randomly allocated to receive SMWLM, exercise and electrotherapy (n=30), or exercise and electrotherapy alone (n=30). All participants received 6 sessions over 2 weeks.

MAIN OUTCOME MEASURES

The primary outcomes were leg pain intensity and Oswestry Disability Index score. Secondary variables were low back pain intensity, global rating of change (GROC), straight leg raise (SLR), and lumbar range of motion (ROM). Variables were evaluated blind at baseline, post-intervention, and at 3 and 6 months of follow-up.

RESULTS

Significant and clinically meaningful improvement occurred in all outcome variables. At 2 weeks the SMWLM group had significantly greater improvement than the control group in leg pain (MD 2.0; 95% confidence interval [95% CI], 1.4-2.6) and disability (MD 3.9; 95% CI, 5.5-2.2). Similarly, at 6 months, the SMWLM group had significantly greater improvement than the control group in leg pain (MD 2.6; 95% CI, 1.9-3.2) and disability (MD 4.7; 95% CI, 6.3-3.1). The SMWLM group also reported greater improvement in the GROC and in SLR ROM.

CONCLUSION

In patients with lumbar radiculopathy, the addition of SMWLM provided significantly improved benefits in leg and back pain, disability, SLR ROM, and patient satisfaction in the short and long term.

Effects of orthopaedic manual therapy in knee osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

This systematic review to aimed to evaluate the effects of orthopaedic manual therapy (OMT) on pain, improving function, and physical performance in patients with knee osteoarthritis (OA).

DATA SOURCES

Four databases (PubMed, Web of Science, CENTRAL, and CINAHL) were searched.

STUDY SELECTION

Trials were required to compare OMT alone or OMT in combination with exercise therapy, with exercise therapy alone or control.

DATA EXTRACTION

Data extraction and risk assessment were done by two independent reviewers. Outcome measures were visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score, WOMAC function score, WOMAC global score, and stairs ascending-descending time.

RESULTS

Eleven randomized controlled trials were included (494 subjects), four of which had a PEDro score of 6 or higher, indicating adequate quality. The results of the meta-analysis indicated that reduction of VAS score in OMT compared with the control group was statistically insignificant (SDM: -0.59; 95% CI: -1.54 to -0.36; P=0.224). The reduction of VAS score in OMT compared with exercise therapy group was statistically significant (SDM: -0.78; 95% CI: -1.42 to -0.17; P=0.013). The reduction of WOMAC pain score in OMT compared with the exercise therapy group was statistically significant (SDM: -0.79; 95% CI: -1.14 to -0.43; P=0.001). Similarly, the reduction of WOMAC function score in OMT compared with the exercise therapy group was statistically significant (SDM: -0.85; 95% CI: -1.20 to -0.50; P=0.001). However, the reduction of WOMAC global score in OMT compared with the exercise therapy group was statistically insignificant (SDM: -0.23; 95% CI: -0.54 to -0.09; P=0.164). The reduction of stairs ascending-descending time in OMT compared with the exercise therapy group was statistically significant (SDM: -0.88; 95% CI: -1.48 to -0.29; P=0.004).

CONCLUSIONS

This review indicated OMT compared with exercise therapy alone provides short-term benefits in reducing pain, improving function, and physical performance in patients with knee OA.

REVIEW REGISTRATION

PROSPERO 2016:CRD42016032799.

Effectiveness of mobilization with movement (Mulligan concept techniques) on low back pain: a systematic review

Objective:

To evaluate evidence on the effectiveness of Mulligan techniques on low back pain.

Data sources:

PubMed/Medline, Scopus, Ovid, CINAHL, Embase, PEDro, Google Scholar, and Cochrane Library were searched from inception to 31 March 2018 for randomized clinical trials reporting outcomes of pain or disability in adult patients (⩾18 years) with low back pain.

Review methods:

Two authors screened the results and extracted data for use in this review. The risk of bias was evaluated using the Cochrane criteria. Basic information and treatment protocols were also extracted. In addition, the level of evidence of each study and strength of conclusion for pain and disability were determined.

Results:

A total of 20 studies with 693 patients were included. Nine trials focused on sustained natural apophyseal glide, three on spinal mobilization with limb movement and seven on bent leg raise. The results showed that Mulligan techniques can decrease pain and disability and increase range of motion in patients with low back pain; however, the strength of conclusion for pain and disability was moderate. Furthermore, inconclusive results were observed for the effectiveness of Mulligan techniques on movement speed. In this review, eight studies were categorized as low risk of bias, while 12 studies had high risk of bias. Level of evidence analysis revealed that 17 studies were classified as level of evidence B, while three studies were classified as level of evidence A2.

Conclusion:

Current evidence is insufficient in supporting the benefits of Mulligan techniques on pain, disability, and range of motion in low back pain patients.

The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis

Study Design Systematic review with meta-analysis. Objectives To determine the efficacy of neural mobilization (NM) for musculoskeletal conditions with a neuropathic component. Background Neural mobilization, or neurodynamics, is a movement-based intervention aimed at restoring the homeostasis in and around the nervous system. The current level of evidence for NM is largely unknown. Methods A database search for randomized trials investigating the effect of NM on neuromusculoskeletal conditions was conducted, using standard methods for article identification, selection, and quality appraisal. Where possible, studies were pooled for meta-analysis, with pain, disability, and function as the primary outcomes. Results Forty studies were included in this review, of which 17 had a low risk of bias. Meta-analyses could only be performed on self-reported outcomes. For chronic low back pain, disability (Oswestry Disability Questionnaire [0-50]: mean difference, -9.26; 95% confidence interval [CI]: -14.50, -4.01; P<.001) and pain (intensity [0-10]: mean difference, -1.78; 95% CI: -2.55, -1.01; P<.001) improved following NM. For chronic neck-arm pain, pain improved (intensity: mean difference, -1.89; 95% CI: -3.14, -0.64; P<.001) following NM. For most of the clinical outcomes in individuals with carpal tunnel syndrome, NM was not effective (P>.11) but showed some positive neurophysiological effects (eg, reduced intraneural edema). Due to a scarcity of studies or conflicting results, the effect of NM remains uncertain for various conditions, such as postoperative low back pain, cubital tunnel syndrome, and lateral epicondylalgia. Conclusion This review reveals benefits of NM for back and neck pain, but the effect of NM on other conditions remains unclear. Due to the limited evidence and varying methodological quality, conclusions may change over time. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2017;47(9):593-615. Epub 13 Jul 2017. doi:10.2519/jospt.2017.7117.

Effect of Butler's neural tissue mobilization and Mulligan's bent leg raise on pain and straight leg raise in patients of low back ache

Low back ache (LBA) is a common musculoskeletal disorder sometimes associated with a positive limited Straight leg raise (SLR) test. Mulligan's bent leg raise (BLR) and Butler's neural tissue mobilization (NTM) are commonly used techniques for the treatment of low back ache where SLR is limited. The aim of this study was to evaluate the effect of both the techniques on pain and limited SLR in patients with LBA. Thirty one patients with LBA with radiculopathy were randomly allocated into 2 groups; BLR [n = 16] NTM [n = 15]. The outcome measures i.e. visual analogue scale (VAS) for pain and universal goniometer for measuring SLR range of motion (SROM) were assessed at the baseline, post intervention and after 24 h (follow up). Within group analysis using paired t-test revealed a significant difference between pre-treatment and post-treatment VAS and SROM score(p < 0.05). However no difference was seen between pre-treatment and follow up (p > 0.05). The study showed that both techniques produce immediate improvement in pain and SLR range but this effect was not maintained during the follow up period.

One-week time course of the effects of Mulligan's Mobilisation with Movement and taping in painful shoulders

Previous research suggests that Mulligan's Mobilisation-with-Movement (MWM) technique for the shoulder produces an immediate improvement in movement and pain. The aims of this study were to investigate the time course of the effects of a single MWM technique and to ascertain the effects of adding tape following MWM in people with shoulder pain. Twenty-five participants (15 males, 10 females), who responded positively to an initial application of MWM, were randomly assigned to MWM or MWM-with-Tape. Range of movement (ROM), pressure pain threshold (PPT) and current pain severity (PVAS) were measured pre- and post-intervention, 30-min, 24-h and one week follow-up. Following a one-week washout period, participants were crossed over to receive a single session of the opposite intervention with follow-up measures repeated. ROM significantly improved with MWM-with-Tape and was sustained over one week follow-up (p < 0.001; 18.8°, 95% confidence intervals (CI) 7.3-30.4), and in PVAS up to 30-min follow-up (38.4 mm, 95% CI 20.6-56.1 mm). MWM demonstrated an improvement in ROM (11.8°, 95% CI 1.9-21.7) and PVAS (40.4 mm, 95% CI 27.8-53.0 mm), but only up to 30-min follow-up. There was no significant improvement in PPT for either intervention at any time point. MWM-with-Tape significantly improved ROM over the one-week follow-up compared to MWM alone (15.9°, 95% CI 7.4-24.4). Both MWM and MWM-with-Tape provide a short-lasting improvement in pain and ROM, and MWM-with-Tape also provides a sustained improvement in ROM to one-week follow-up, which is superior to MWM alone.

Imperfect placebos are common in low back pain trials: a systematic review of the literature

The placebo is an important tool to blind patients to treatment allocation and therefore minimise some sources of bias in clinical trials. However, placebos that are improperly designed or implemented may introduce bias into trials. The purpose of this systematic review was to evaluate the adequacy of placebo interventions used in low back pain trials. Electronic databases were searched systematically for randomised placebo-controlled trials of conservative interventions for low back pain. Trial selection and data extraction were performed by two reviewers independently. A total of 126 trials using over 25 different placebo interventions were included. The strategy most commonly used to enhance blinding was the provision of structurally equivalent placebos. Adequacy of blinding was assessed in only 13% of trials. In 20% of trials the placebo intervention was a potentially genuine treatment. Most trials that assessed patients' expectations showed that the placebo generated lower expectations than the experimental intervention. Taken together, these results demonstrate that imperfect placebos are common in low back pain trials; a result suggesting that many trials provide potentially biased estimates of treatment efficacy. This finding has implications for the interpretation of published trials and the design of future trials. Implementation of strategies to facilitate blinding and balance expectations in randomised groups need a higher priority in low back pain research.