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ORIGINAL ARTICLE
Year : 2019  |  Volume : 1  |  Issue : 1  |  Page : 17-23

Effect of mulligans mobilization versus manipulation, along with mulligans taping in anterior innominate dysfunction – A randomized clinical trial


Department of Orthopaedic Manual Therapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Submission13-Nov-2018
Date of Acceptance05-Apr-2019
Date of Web Publication3-Jul-2019

Correspondence Address:
Ms. Saviola Ribeiro
Department of Orthopaedic Manual Therapy, KAHER Institute of Physiotherapy, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijptr.ijptr_20_19

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  Abstract 


Background and Objective: Low back pain is one of the major causes for disability and absenteeism at workplace. The anterior innominate dysfunction is a common type of dysfunction leading to low back pain in which the joint adapts to an abnormal position locking it in an anterior pelvic tilt thus leading to low back or buttock pain that may radiate to lower extremity pain. Mulligan mobilization particularly helps restoration of joint movement in a pain free manner and has reported to be effective in increasing range of motion and reducing pain. Manipulation, on the other hand has also proved to be effective in inhibiting pain receptors causing relaxation of muscle and increasing range of motion. Since there is a dearth of literature stating the comparative effects of both techniques, the current study has aimed at finding out the effectiveness of both techniques on anterior innominate dysfunction.
Materials and Methods: A clinical trial conducted on 30 subjects with a mean age of 37.57±10.32 years were randomly assigned into two groups, Group A (n = 15) received Postero-medial SI Mulligan mobilization and Mulligan taping technique + Conventional Therapy and Group B (n = 15) received SI Manipulation and Mulligan taping technique + Conventional Therapy. Patients were assessed at baseline and on 6th day of therapy using Visual Analogue Scale (VAS), Modified Oswestery Disability Questionnaire (MODQ), Modified Schober's lumbar range of motion and Pelvic Inclinometer scale
Results: Pre and post mean difference in group A were 6.56±1.01 cm for VAS, 27.33±7.76 for MODQ, 1.90±0.68° for lumbar flexion range, 2.19±0.45° for lumbar extension range and 2.00±1.46 mm for pelvic tilt. While the pre and post mean difference in group B were 6.56±1.01 cm for VAS, 27.33±7.76 for MODQ, 1.90±0.68° for lumbar flexion range, 2.19±0.45° for lumbar extension range and 2.00±1.46 mm for pelvic tilt. The intra-group comparison was statistically significant with P = 0.0001 (VAS, MODQ, Lumbar flexion and extension ROM) and P < 0.05 (Pelvic tilt), the inter-group comparison was also statistically significant with P = 0.0001 (VAS and lumbar extension ROM), P = 0.0005 (Lumbar flexion ROM).
Conclusion: The present study concluded that Mulligan mobilization with Mulligan taping technique showed superior effects than Manipulation with Mulligan taping technique.

Keywords: Manipulation, Mulligan mobilization, Mulligan taping, Randomized clinical trial, Sacroiliac joint


How to cite this article:
Ribeiro S, Heggannavar A, Metgud S. Effect of mulligans mobilization versus manipulation, along with mulligans taping in anterior innominate dysfunction – A randomized clinical trial. Indian J Phys Ther Res 2019;1:17-23

How to cite this URL:
Ribeiro S, Heggannavar A, Metgud S. Effect of mulligans mobilization versus manipulation, along with mulligans taping in anterior innominate dysfunction – A randomized clinical trial. Indian J Phys Ther Res [serial online] 2019 [cited 2019 Jul 20];1:17-23. Available from: http://www.ijptr.org/text.asp?2019/1/1/17/261995




  Introduction Top


The lumbopelvic complex forms a mechanical unit comprising the lower lumbar vertebra, both hip joint, sacrum, and pubic symphysis. Therefore, any loss or decrease in motion, alignment in any joint may alter forces, and hamper the lumbopelvic complex.[1] The sacroiliac joint (SIJ) is found to be very potential cause of pain in 30% of individuals with mechanical back pain and 13%–30% of nonspecific chronic low back pain sufferers.[2],[3] The condition arises due to altered biomechanics within the joint leading to reduced mobility and pain.[4] There are several special tests which enable us for the diagnosis of SIJ dysfunction (SIJD) such as standing forward flexion, sitting forward flexion, Gillet test, Passive straight leg raise (SLR), Gaenslen, supine to sit, Patrick test, side lying approximation, and prone knee bending supine gapping.[5] Few authors have recommended four tests (three of which must have positive findings) to diagnose whether an individual has SIJD.[6] The treatment of SIJD is an overall approach of osteopathic medicine, manual physical therapy, chiropractic, and medical management.[7] Physical therapy approaches mainly focus on manual modification of SIJ asymmetry, lumbopelvic stabilization, and correction of muscle imbalance.[8]

The concept of Mulligan mobilization has proved to regain functional movement with application of pain-free accessory glides either through active or passive physiological movements. Therapist carries out the treatment in a dynamic way which is more functional.[9] According to Alkady et al., Mulligan mobilization is an effective manual approach in improving joint range and reducing pain.[10] Furthermore, there has been literature stating that Mulligan taping technique easily fits into the clinical reasoning concept giving long-lasting results which provides pain-free movement.[11]

On the other hand, manipulation is a passive technique which allows the joint or group of joints to be thrusted with high velocity and low amplitude beyond their physiologic range.[12] It produces an inhibitory reflex response that involves a decrease in motor neuron activity and in turn reduces hypertonicity.[13] According to Schneider et al., spinal manipulation methods are effective in treating low back pain.[14]

In spite of many studies done on Mulligan mobilization and manipulation in SI dysfunction, there is a dearth of literature stating the comparative effects of both techniques. Thus, the present study intended to compare the effect of Mulligan taping technique as an adjunct to Mulligan mobilization and manipulation alone on SIJD.


  Materials and Methods Top


The experimental study was conducted in a tertiary health care centre, Belagavi, Karnataka, on 30 participants diagnosed with anterior innominate dysfunction. Participants between the age group of 25–55 years, with acute/subacute pain within 4–12 weeks of onset and at least three of four clinical tests positive (supine to long-sitting test, prone knee-flexion test, standing flexion test, and passive straight leg raise test) for anterior innominate dysfunction were included in the study. The exclusion criteria were as follows: participants with clinical conditions contraindicated for ultrasound therapy, red flags to high-velocity low amplitude thrust, red flags to SI mobilization, pregnant females, hypersensitive skin over the pelvic area, recent trauma in the past 6 months or history of any orthopedic surgery, and conditions such as ankylosing spondylitis, gout, psoriasis, and rheumatoid arthritis were excluded from the study.

Outcome measures

Visual analog scale

Pain intensity was measured using the visual analog scale (VAS). A 10 cm line was drawn where 0 symbolized no pain and 10 as maximum pain. The patient was made to mark his/her pain according to the severity.[15]

Modified Oswestry Disability Questionnaire

A functional index intended to find out the limitations that patient experiences while performing daily activities. This scale consists of 10 items in the form of activities of daily living with each item scoring from 0 to 5 where 0 is no difficulty in performing that activity and 5 inability to do that activity.[16]

Modified Schober's lumbar range of motion

The range of motion (ROM) in the lumbar spine was measured using this method. The posterior superior iliac spine was located and a midpoint was marked. From midpoint, a point was marked 10 cm superior. Another point was marked 5 cm inferior to the midpoint. The patient was asked to bend forward, and the distance between both points was recorded. The patient was then asked to bend backward and the distance was recorded.[17]

Pelvic inclinometer scale

The pelvic innominate tilt was measured in millimeters using the pelvic inclinometer scale. The patient was asked to stand in an erect posture with feet, shoulder width apart, and the participant was asked to place the arms across the chest. Calipers of the scale were placed on the highest level of iliac crest and with the help of the bubble readings were recorded.[18]

Procedure

The study was approved by the Institutional Ethical Committee. Participants were taken in the study based on the inclusion and exclusion criteria before their enrolment. A written informed consent was obtained from all the study participants. The privacy rights of all participants were reserved. A total of 40 participants were initially assessed, and 10 were excluded from the study. The remaining 30 eligible participants were recruited in the study and randomly allotted to two groups using the envelop method giving equal chances to each individual to be allotted into either groups [Figure 1]. The outcome measures were obtained from the participant at baseline and on the 6th day after the treatment. Both the groups received six sessions of treatment for 6 days.
Figure 1: CONSORT chart

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Group A (n = 15)

[Figure 2] and [Figure 3] show posteromedial SI mobilization plus Mulligan taping technique and conventional treatment. Participants were asked which movement caused maximum pain. Then, according to the offending movement, treatment was given.[18] Therapist stood toward the opposite side of the affected area. The therapist then fixed sacrum with one hand and placed fingers of other hand over the anterior superior iliac spine (ASIS) of the affected side. The therapist pulled the ilium over sacrum in a posteromedial direction and asked the participant to perform offending movement while glide was maintained. Movements were performed for three sets for 10 repetitions.[19]
Figure 2: Postero-medial sacroiliac mobilization (starting position)

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Figure 3: Postero-medial sacroiliac mobilization

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Taping

Participant was asked to stand in an erect posture with his/her upper limbs crossed over shoulders. The same position of the glide was maintained, and a leukotape was wrapped in front of ASIS and terminated obliquely over lumbar spine. The underwrap was put below the rigid tape without any stretch. The tape was left for 48 h provided there was no skin irritation.

Group B (n = 15)

[Figure 4] shows SIJ Manipulation plus Mulligan taping technique and conventional treatment. Participants were in supine lying, both hands clasped behind the neck, and upper and lower body was passively side flexed away from the therapist, and then only the upper body was passively rotated toward the therapist. Therapist stood toward the opposite side to be manipulated. Manipulating hand was placed over affected ASIS and other hand was passed through participants flexed arm. A quick posterior and inferior thrust through ASIS was delivered by the therapist.[20]
Figure 4: Sacroiliac manipulation

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Taping

Similar taping technique is mentioned as above.

The conventional treatment included pulsed mode therapeutic ultrasound (0.8 W/cm 2) for 5 min.

Statistical analysis

Data were analyzed using SPSS Windows version 21 (IBM Corp,. IBM Version 21, Armonk, NY, USA). Nominal data from participant's demographic data distribution were analyzed using t-test. Kolmogorov–Smirnov test was utilized to measure the difference between the two groups in terms of pain relief, level of disability, ROM, and pelvic tilt. An alpha level of P < 0.05 was considered appropriate for the level of statistical significance.


  Results Top


There was no statistically significant difference in the baseline characteristics among both groups (P > 0.05) [Table 1]. Between-group and within-group difference with respect to VAS, lumbar flexion, and lumbar extension were statistically significant [Table 2], [Table 3], [Table 4]. There was no statistical difference in the scores observed for the Modified Oswestry Disability Questionnaire (MODQ) and pelvic tilt between the group [Table 5] and [Table 6].
Table 1: Comparison of Group A and Group B with mean age and body mass index using t-test

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Table 2: Comparison of pre- and post-scores of visual analog scale in both groups

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Table 3: Comparison of pre- and post-scores of lumbar flexion in both groups

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Table 4: Comparison of pre- and post-scores of lumbar extension in both groups

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Table 5: Comparison of pre- and post-scores of Modified Oswestry Disability Questionnaire in both groups

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Table 6: Comparison of pre- and post- scores of pelvic tilt in both groups

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  Discussion Top


The study revealed a statistically significant intragroup difference in VAS, MODQ, lumbar flexion and extension ROM, and pelvic tilt with a percentage change being slightly superior in Group A when compared to that of Group B. Furthermore, a statistical improvement in intergroup comparison was seen in VAS, lumbar extension ROM, and lumbar flexion ROM.

In the present study, a statistically significant difference was noted in pain intensity between both groups. The results are in accordance with a randomized clinical trial done to relate the effect of Mulligan mobilization and Mulligan taping technique in SI dysfunction. The authors investigated the use of posteromedial movement with mobilization (MWM) for SIJ and Mulligan taping technique that showed a significant decrease in pain and improvement in disability in Mulligan mobilization and Mulligan taping technique group.[19] According to the biomechanical concept, MWM corrects mechanical malfunction through realignment of a particular structure. Whereas the neurophysiological concept states that MWM causes hindrance of descending pain pathways causing modification in the central pain mechanism.[9] Therefore, in the present study, it is feasible to say the reduction of pain was due to the correction of positional faults, thus alleviating pain during functional movement. It was also found that the correction was maintained using the tape which helped in pain reduction throughout activity as well. The evidence behind the therapeutic effect of SI manipulation is thought to be that the audible sound is heard after manipulation which is due to fall in the internal pressure of the joint leading to release of dissolved nitrogen gas within the synovial fluid. The volume inside the capsule increases because of the elastic recoil in surrounding structures. According to the neurophysiological concept, the firings of afferent mechanoreceptors of muscle and joint cause reflex inhibition of pain receptors leading to reflex relaxation as well.[20] Another study done to determine the effect of kinesio taping aided as an adjunct treatment to SIJ manipulation of chronic SIJ syndrome hold positive with the findings of the present study, and the reason for the reduction in pain intensity was due to the neurophysiological mechanism.[21]

The level of functional disability improved in both groups resulting in somewhat similar effects using both techniques. The present study findings were in accordance to a study done to find out the immediate effect of Mulligan mobilizations in nonspecific low back pain patients which showed a statistically significant difference in pain reduction, improvement in function, and kinematic algorithms.[22] The reason for the decrease in functional disability may be due to decrease in subjective pain perception. As pain decreases, mobility increases, thus reducing disability. The taping technique stabilizes the joint structure by maintaining the alignment of the joint and also acts as an external feedback to the individual.[22] Another study done to find out the effects of SI manipulation and kinesio taping showed similar improvements in all three groups and did not show any statistical significance between the groups [21] which coincide with the findings of the present study. The theory supporting this may be due to the pain control mechanism thus leading to inhibition of nociceptors and improvement in functional disability.

The pelvic innominate tilt in both groups reduced but did not show statistically significant results when compared between groups. Statistical analysis showed slightly greater percentage of change in Group A as compared to that of Group B. This may be because Mulligan mobilization is more effective in correcting positional faults. Statistical significance was not seen in either of the groups this may be because biomechanical adaptive changes cannot take place within 6 days. A study was done to find out the effects of SIJ mobilization on obliquity of the pelvis. The study reported that MWM with functional training for 8 weeks was effective in reducing pelvic alignment, pain levels, and improved balance ability.[23] The findings of the present study were consistent with the findings of one study done to detect the changes in innominate tilt after SIJ manipulation in participants with low back pain, it was reported that there were changes in the innominate orientation, but no statistically significant difference was seen.[24] The reduction in pelvic tilt could be because manipulative technique causes mechanical correction and improved joint mechanics.[21]

In the present study, a statistically significant difference was noted in lumbar flexion and extension ROM in both the groups and this matched the findings of another group which reported that mobilization was beneficial in improving lumbar sacral flexion ROM, reducing pain intensity, and disability in pregnant women with SIJD.[25] The reason for increase in ROM was due to decrease in pain levels. A study was done to compare lumbar manipulation and SI manipulation in participants with low back pain. The study revealed that there is no significant difference between the study groups.[21] Since the technique applied rotational forces to the spine, this may have caused an increase in lumbar mobility, another reason could be that since there was a reduction in pain levels, the mobility must have increased. Long-term effects were not assessed, gender distribution was unequal, and it was a single-center trial.


  Conclusion Top


Both Mulligan mobilization and Manipulation technique in conjunction with taping showed improvement in anterior innominate dysfunction, but the Mulligan mobilization group demonstrated a superior effect as compared to that of the Manipulation group.

Acknowledgment

We are grateful to all the participants for providing time for the study. Sincere gratitude to the Management of Institute of Physiotherapy, Belagavi, Karnataka, for providing infrastructure and facilities to carry out the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zelle BA, Gruen GS, Brown S, George S. Sacroiliac joint dysfunction: Evaluation and management. Clin J Pain 2005;21:446-55.  Back to cited text no. 1
    
2.
Shearar KA, Colloca CJ, White HL. A randomized clinical trial of manual versus mechanical force manipulation in the treatment of sacroiliac joint syndrome. J Manipulative Physiol Ther 2005;28:493-501.  Back to cited text no. 2
    
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O'Sullivan PB, Beales DJ, Beetham JA, Cripps J, Graf F, Lin IB, et al. Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine (Phila Pa 1976) 2002;27:E1-8.  Back to cited text no. 3
    
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Alkady SM, Kamel RM, AbuTaleb E, Lasheen Y, Alshaarawy FA. Efficacy of mulligan mobilization versus muscle energy technique in chronic sacroiliac joint dysfunction. Int J Physiother 2017;4:311-8.  Back to cited text no. 10
    
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Vicenzino B, Paungmali A, Teys P. Mulligan's mobilization-with-movement, positional faults and pain relief: Current concepts from a critical review of literature. Man Ther 2007;12:98-108.  Back to cited text no. 11
    
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Greenman P. Principles of Manual Medicine. 4th ed. Philadelphia: Lippincott; 2003. p. 344-61.  Back to cited text no. 12
    
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Schneider M, Haas M, Glick R, Stevans J, Landsittel D. Comparison of spinal manipulation methods and usual medical care for acute and subacute low back pain: A randomized clinical trial. Spine (Phila Pa 1976) 2015;40:209-17.  Back to cited text no. 14
    
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Akodu AK, Akinbo SR, Omootunde AS. Comparative effects of muscle energy technique and core stability exercise in the management of patients with non-specific chronic low back pain. Med Sportiva J Rom Sports Med Soc 2017;13:2860.  Back to cited text no. 17
    
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D'Silva P, Kage V. Posterior Pelvic Tilt Kinesio Taping Versus Mulligan Taping in Subjects with Sacroiliac Joint Dysfunction – A Randomized Clinical Trial. [Dissertation] Belagavi, Karnataka: KLE University; 2016.  Back to cited text no. 18
    
19.
Fernandes S. Comparative effectiveness of mulligan mobilisation and mulligan taping technique. In: Sacroiliac Joint Dysfunction-Randomized Clinical Trial [Dissertation]. Belagavi, Karnataka: Rajiv Gandhi University of Health Sciences; 2010. p. 1-11.  Back to cited text no. 19
    
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Kamali F, Shokri E. The effect of two manipulative therapy techniques and their outcome in patients with sacroiliac joint syndrome. J Bodyw Mov Ther 2012;16:29-35.  Back to cited text no. 20
    
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De Beer QH. The Relative Effectiveness of Kinesio® Taping Methods as an Adjunct to a Single Sacroiliac Joint [Dissertation]. Durban University of Technology; 2013. p. 8-39.  Back to cited text no. 21
    
22.
Hidalgo B, Pitance L, Hall T, Detrembleur C, Nielens H. Short-term effects of mulligan mobilization with movement on pain, disability, and kinematic spinal movements in patients with nonspecific low back pain: A randomized placebo-controlled trial. J Manipulative Physiol Ther 2015;38:365-74.  Back to cited text no. 22
    
23.
Son JH, Park GD, Park HS. The effect of sacroiliac joint mobilization on pelvic deformation and the static balance ability of female university students with Si joint dysfunction. J Phys Ther Sci 2014;26:845-8.  Back to cited text no. 23
    
24.
DeVocht JW, Pickar JG, Wilder DG. Spinal manipulation alters electromyographic activity of paraspinal muscles: A descriptive study. J Manipulative Physiol Ther 2005;28:465-71.  Back to cited text no. 24
    
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Sabour AH, Awad MA, Mansy AA, Tolba MI. Effect of mulligan technique on sacroiliac dysfunction during pregnancy. Med J Cairo Univ 2016;84:35-41.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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