Manual Therapy (2001) 6(3), 163169

# 2001 Harcourt Publishers Ltd

doi:10.1054/math.2001.0408, available online at http://www.idealibrary.com on

Original article

The initial effects of an elbow mobilization with movement technique on grip

strength in subjects with lateral epicondylalgia
J. H. Abbott, C. E. Patla, R. H. Jensen
Institute of Physical Therapy, University of St. Augustine for Health Sciences, St. Augustine, Florida, USA

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.

(Noteboom et al. 1994; Vicenzino & Wright 1996).

The preferred nomenclature is lateral epicondylalgia,
as the suffix -algia denotes pain; the pathophysiology of the condition is less commonly inflammation
(-itis) or degeneration (-osis) than it is predominantly hyperalgesia and pain (-algia) (Vicenzino &
Wright 1996).
Mobilization with movement (MWM) is a system
of manual therapy interventions developed by Brian
Mulligan which combine a sustained manual gliding
force to a joint with concurrent physiologic (osteokinematic) motion of the joint, either actively
performed by the patient, or passively performed by
the operator (Mulligan 1992; 1993; 1995). The
manual force, or mobilization, is theoretically intended to cause repositioning of bony positional
faults (Mulligan, 1993). The intent of MWMs is to
restore pain-free motion at joints which have painful
limitation of range of movement (ROM) (Mulligan
1995). Therein lies one of the key aspects of the
mobilizations with movement system: a trial of
MWM at the time of the initial patient examination
will determine whether MWM is an appropriate
therapeutic intervention for that patients dysfunction. If a trial of MWM is able to eliminate the pain

BACKGROUND AND SIGNIFICANCE

Lateral epicondylalgia (LE) is a condition with
complex aetiological and pathophysiological factors.
LE is characterized by pain at the lateral aspect of the
elbow, commonly associated with resisted wrist or
finger extension and gripping activities (LaFreniere
1979; Kushner & Reid 1986; Wadsworth et al. 1989;
Yaxley & Jull 1993; Noteboom et al. 1994; Stephens
1995; Vicenzino & Wright 1996). LE is also known
as: lateral epicondylitis, lateral epicondylosis, tennis
elbow, or tendonitis of the affected forearm extensor
muscles (e.g. extensor carpi radialis brevis tendonitis)

Received: 10 October 2000

Revised: 25 April 2001
Accepted: 11 May 2001
J. Haxby Abbott, MScPT, DipPhty, MTC, MNZCP, Assistant
Lecturer, Department of Anatomy and Structural Biology,
University of Otago, PO Box 913, Dunedin, New Zealand,
Catherine E. Patla, PT, DHSc, OCS, Associate Professor,
University of St. Augustine for Health Sciences,
Richard H. Jensen, PhD, PT, Professor, University of St. Augustine
for Health Sciences.
Correspondence to: JHA. Tel.: +64 3 479 5145; fax: +64 3 479
7254; E-mail: haxby.abbott@anatomy.otago.ac.nz
163

164 Manual Therapy

associated with an active movement, then MWM is

an appropriate intervention; if not, then MWM is not
an appropriate intervention. In the event that a trial
of MWM is not able to eliminate the pain associated
with an active movement, the therapist should not
employ the MWM, and other therapeutic interventions should, therefore, be explored (Mulligan 1992,
1993, 1995; Vicenzino & Wright 1995; Exelby 1996;
Hetherington 1996; OBrien & Vicenzino 1998).
The specific MWM utilized in this study was the
MWM for tennis elbow described by Mulligan
(1992). The technique involves a laterally directed
gliding force to the ulna of the affected extremity,
with the humerus stabilized, while the patient
concurrently performs an active, pain-free, wrist
movement. The active movement utilized is determined by establishing a comparable sign. A comparable sign is a movement that reproduces the patients
lateral elbow pain. This is established at the initial
examination, prior to the application of the MWM.
For LE, this is typically either making a fist, gripping
an object, wrist extension with or without radial
deviation (resisted or unresisted), or extension of the
middle and/or index fingers (resisted or unresisted)
(LaFreniere 1979; Kushner & Reid 1986; Wadsworth
et al. 1989; Yaxley & Jull 1993; Noteboom et al.
1994; Mulligan 1995; Stephens 1995; Vicenzino &
Wright 1996).
Since the publication of this technique, only three
published reports are available which document the
use of this MWM in LE patients: a single-case study
(Vicenzino and Wright 1995) and two case reports
(Stephens 1995; Miller 2000).
Vicenzino and Wright (1995) utilized a single
subject ABC design to investigate the effect of
MWM on the pain and impairments of LE. In their
study pain and function were assessed by visual
analogue scale for pain, visual analogue scale for
function, pressure algometry, pain-free grip strength
on a dynamometer, and a pain-free function questionnaire. The authors found that four treatment
sessions of MWM, taping techniques to replicate
MWM, and instructing the subject in self-MWM,
improved all measures of pain and function. Pain-free
grip, in particular, improved dramatically from the
pre-treatment assessment phase (A) to the end of
the six-week post-treatment assessment phase (C)
(Vicenzino and Wright 1995).
Stephens (1995) retrospectively reported a patient
case in which MWM for LE was a part of the
treatment plan. Other interventions included MWM
at the wrist, taping techniques, utilization of thermal
modalities, ultrasonic therapy, transverse friction
massage, exercise, massage, and self-stretches. While
improvement was reported for this complex presentation, few objective measures were reported. Millers
(2000) case report describes the use of the MWM for
LE as the primary modality for the correction of
Manual Therapy (2001) 6(3), 163169

what Miller diagnoses as a positional fault of the

elbow joint complex mimicking a contractile element
pathology of the common extensor bundle (Miller
2000). Full function and absence of pain were
reported at a one month follow-up, following the
successful two week course of therapy (Miller 2000).
Treatment interventions for LE lack scientific
validation (Labelle 1992; Stratford et al. 1993; Wright
& Vicenzino 1997). No therapy reported to date has
strong evidential support, therefore novel therapies
are worthy of consideration. Lack of supporting
evidence for existing therapies may, however, be due
to methodological deficiencies in the research reported to date, including insufficient subject numbers
and inappropriate or invalid measures of change
(Stratford et al. 1993). Grip dynamometry is an
established outcome measure in research studies of
LE interventions (Burton 1984; Thurtle et al. 1984;
Stratford et al. 1987; Wadsworth et al. 1989; Vicenzino & Wright 1995; Pienemaki et al. 1996; Wuori
1998). Stratford et al. state that maximum grip
strength and visual analogue scale pain reports are
the measures most commonly utilized in the literature
(Stratford et al. 1987; Stratford et al. 1993). Stratford
et al. (1993) found that maximum grip strength
demonstrated the greatest responsiveness to change
following an intervention, but that it had poor
validity as a measurement of outcome-over-time for
the assessment of clinically important change, in a
clinical trial of LE interventions. Pain-free grip
strength was stated to be the most valid physical
measure of clinically meaningful change over time in
patients with LE, but it was found to be less
responsive to change than maximum grip strength
(Stratford et al. 1993). Dynamometric measurement
of grip strength is highly reliable (Bohannon 1999;
Nitschke et al. 1999), although Stratford et al. (1993)
report that the reliability coefficient for measurement
of pain-free grip strength by dynamometer (0.87) was
superior to that of maximum grip strength (0.60). In
this study, both pain-free grip and maximum grip
strength were utilized to assess the immediate effects
of MWM in a symptomatic population, to allow
comparison of the outcome measures.
Specific aims of this study were:

1. To establish what proportion of patients with LE

respond favourably to MWM, as indicated by the
patients ability to perform a previously painful
active motion pain-free, during the application of
the MWM.
2. To establish whether the pain-free grip strength or
maximum grip strength of the affected extremity
changed following the application of one session
of MWM.
3. To compare the responsiveness of pain-free grip
strength and maximum grip strength, and report
# 2001 Harcourt Publishers Ltd

Effects of elbow mobilization with movement technique on grip strength 165

the effect size of these measures, in subjects with

LE.

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.

Fig. 1Mobilization with movement (MWM) for tennis elbow.

white arrow=direction of force to medial proximal forearm,
X=stabilisation of humerus, curved arrow=example of movement
performed by subject (making a fist with concurrent wrist
extension).

Table 1 Effective direction of MWM* (group one, n=23)

Direction of MWM
Directly lateral
*58 posterior of lateral
*58 anterior of lateral
*58 caudal of lateral

Frequency
9
10
3
1

*MWM=Mobilization with Movement for tennis elbow, as

described by Mulligan (1995)

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

by a research assistant. Both limbs were tested in

the order dictated by random assignment;
5. The PI then performed the MWM, consisting
of a laterally-directed manual pressure to the
proximal medial forearm (Fig. 1) while the subject
performed the comparable sign motion (Mulligan
1995). Based on the suggestion of Mulligan (1995),
up to four attempts were allowed to find the
direction of the manual pressure that eliminated
the comparable sign on the affected side. The four
directional options were standardized and
recorded on the data form (see Table 1). At this
time, if pain with the comparable sign was
eliminated (positive response to MWM) the
subject was allocated to group one; if pain with
the comparable sign was not eliminated (negative
response to MWM) the subject was allocated to
group two. Differential grouping of subjects who
respond negatively to the MWM trial is consistent
with established principles of clinical decisionmaking in the application of all mobilizations
with movement (Mulligan 1993, Mulligan 1995,
Vicenzino & Wright 1995).
Based on the suggestion of Mulligan (1995), the
patient performed the previously painful motion
up to ten times while the MWM was being
applied. If the pain returned prior to achieving
ten movements, no further repetitions were
performed. The number of repetitions was
Manual Therapy (2001) 6(3), 163169

166 Manual Therapy

recorded on the data form by the research

assistant. When the unaffected limb was tested,
the procedure remained unchanged. Having no
symptoms on the unaffected side, the subject was
instructed to perform the same motion on the
unaffected side as had been established as being
the comparable sign on the affected side;
6. The limb tested first was re-measured for pain-free
grip strength, and then maximum grip strength;
7. The limb that remained untested, according to
random assignment, then received the MWM
intervention and was subsequently re-measured
for grip strength. The total time per subject was
approximately 15 minutes.
This research study was approved by the Institutional Review Board of the University of St.
Augustine for Health Sciences, as being in compliance with the Protection of Human Subjects Regulations, the guidelines of the 1975 Helsinki declaration,
and the American Physical Therapy Association
(APTA) code of ethics.
Data Analysis
The statistical package used for data analysis was
SPSS 9.0 (SPSS Inc., Chicago, Ill.). The a priori level
of significance was set at a = 0.05.
The grip dynamometry data are matched samples
(pre post, or affected unaffected). The one-tailed
t-test was used to compare group means, as clinical
observations indicated a unidirectional effect of the
intervention on the dependent variables.

dominant arm was affected in fifteen (60%) of the

subjects.
Response to MWM
Of the 25 eligible subjects, 23 (92%) responded
positively to MWM assessment (i.e. were able to
perform a previously painful active motion pain-free,
during the application of the MWM), and so were
placed in group one. The number of times that each
possible direction of force for MWM was used is
reported in Table 1. Twenty-two of the 23 subjects
were able to perform ten repetitions of the comparable sign movement pain-free, while the MWM was
applied. The one remaining subject experienced a
return of pain on the eighth repetition, at which point
intervention was ceased.
Normality of distribution of data
Appropriate use of the t-test requires that the data
fall within the typical normal distribution. Analysis
by the w2 test confirmed that the data from group
one (n = 23) were not significantly different to the
distribution defined by the normal curve. The t-test
was, therefore, used to obtain the following results
for group one. The data from group two (n = 2) will
be addressed separately.
Grip strength dynamometry
Pre-intervention and post-intervention dynamometric
grip strength data are provided in Table 2. Data from
group one only were included in the analysis.

RESULTS

Table 2 Maximum and Pain-free grip strength measurements*

Properties of the Sample

Grip Strength
Measured
(n=23)

Thirty-two subjects were referred for this study. Four

subjects were ineligible (two with bilateral epicondylalgia, one with medial epicondylalgia, one without a
comparable sign). Two subjects declined to participate in the study, and one potential subject was
unable to be contacted. Of the eligible subjects (25),
seventeen (68%) were males. The average age of
subjects was 46 years (range, 2960). Eighteen (72%)
were employed at industry or heavy industry, three
(12%) performed clerical or data input work, three
(12%) were involved in the teaching or delivery of
health-care, and one did not claim an occupation.
Two subjects had LE of less than one month
duration. The remaining (23) subjects had chronic
LE (average 16 months, range 2 months to 8 years).
Hand dominance was determined by which arm
the subjects reported they would use to throw a ball.
Eighteen subjects were right-hand dominant. Seven
were left-hand dominant. Twelve reported LE of the
right elbow, thirteen reported left-sided LE. The
Manual Therapy (2001) 6(3), 163169

Pre-intervention Post-intervention Difference

mean (SD)
mean (SD)
between
means of
pairs

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

. Difference between means of

pairs

13.2{

9.9}

*Measured by a grip dynamometer in pounds of force.

SD = standard deviation from the mean.
NS = Not significant.
{
Significant difference P0.001.
{
Significant difference P0.005.
}
Significant difference P0.025.

Significant difference P0.05.

# 2001 Harcourt Publishers Ltd

Effects of elbow mobilization with movement technique on grip strength 167

The affected limb was significantly weaker in both

pain-free grip and maximum grip strength, compared
to the unaffected limb (Table 2). This difference
persisted, to a lesser degree, post-intervention
(Table 2).
Both pain-free grip strength and maximum grip
strength increased significantly from the pre-intervention to post-intervention on the affected side
(Table 2).
No significant differences were seen between the
pre-intervention and post-intervention measures for
either pain-free grip strength or maximum grip
strength on the unaffected side.
Due to the small number of subjects in group two
(those who did not respond favourably to MWM),
statistical analyses were not possible. In these two
cases maximum grip strength of the affected limb
decreased post-intervention, by an average of 23%
(15 lb.). Pain-free grip strength for the subjects in
group two changed by 5 lb. or less (range 05 lb.) in
all instances, and was therefore not considered to be
clinically significant.

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

Additionally, Stratford et al. (1993) found that

pain-free grip strength was a more valid measure of
clinically important change over time than maximum
grip strength. These facts are important in the design
of further research into the efficacy of interventions
for patients with LE.
An important issue in research design is determining an adequate sample size. To do this, the
researcher performs a power analysis, which requires
an estimate of the magnitude of effect the proposed
intervention may have on the measured dependent
variable (called the effect size index). To assist future
researchers in performing a power analysis, we used
the data from our study to calculate the effect size
index (d) for the dependent variables of pain-free grip
strength and maximum grip strength. The results
(adjusted for paired data) show that pain-free grip
strength (d = 0.861) had a greater effect size than
maximum grip strength (d = 0.585), meaning that a
study using pain-free grip strength as a dependent
variable will not need as many subjects as a study that
uses maximum grip strength in order to demonstrate
that an actual change has occurred.
The one-group pretest post-test design is an
uncontrolled, quasi-experimental design, and therefore susceptible to threats to internal validity
(Portney & Watkins, 1993). Temporal effects, such
as maturation and history effect, are a particular
threat to an uncontrolled design such as this. In this
case, however, there was minimal time between
pretest and post-test (a few minutes), therefore we
feel it is unlikely that the changes in grip strength
found are the result of a temporal factor. Testing
effects are also a threat to an uncontrolled experiment. In the case of a painful condition, however, a
decrease in grip strength with repeated testing would
seem the more likely effect, and therefore we feel that
this effect is unlikely to explain the outcome of this
study. In situations where extraneous variables such
as temporal and testing effects are effectively controlled, the one-group pretest post-test design is
reasonable (Portney & Watkins, 1993). External
validity may have been affected by inadvertent bias
due to our use of the purposive method of sample
selection. Another limitation of our study is that only
the immediate effects of MWM were measured, with
no attempt made to determine whether the absence of
pain with the comparable sign movement, or the
changes in grip strength, were maintained over time.
Therefore these results are not generalizable to
outcomes of an episode of care, only to a single
treatment session. Mulligans clinical experience
(Mulligan 1995; 1999), case reports (Stephens 1995;
Miller 2000), and a single case study (Vicenzino and
Wright 1995) indicate the usefulness of this MWM
for the rehabilitation of patients with LE. Further
research to establish the efficacy of MWM over
complete episodes of care, and long-term follow-up,
Manual Therapy (2001) 6(3), 163169

168 Manual Therapy

for patients with LE should use pain-free grip

strength as an outcome measure in preference to
maximum grip strength. Our results indicate that a
sample size of twenty-five subjects was sufficient to
demonstrate statistical significance of all measures of
grip strength which met our criterion for clinical
significance, however we would expect that over a
longer trial, more subjects would drop out or fail to
respond to the intervention, necessitating a larger
sample. Other outcome measures utilized may possess
smaller effect sizes, and therefore would necessitate
larger sample sizes. Stratford et al. (1993), for example, recommend a pain-free function questionnaire
as a valid measure, (i.e. a measure that correlates
significantly with the patients global impression of
change over time). Based on their calculation of effect
size, Stratford et al. (1993) conclude that a sample
size of sixty-three subjects would be necessary to
statistically demonstrate change, where change
exists and within standard probabilities of error,
using their pain-free function questionnaire as an
outcome measure.

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

A. Saville, who passed away suddenly before completion of the

project.

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