Comparison of the effectiveness of a combined

treatment of Mobilization with Movement (MWM) and

Post isometric Relaxation(PIR) with MWM alone and PIR alone for
Painful Stiff Shoulder

Presented By:
Devdeep Ahuja
Sumanjeet Arora

Guided By:
Dr.Dheeraj KV

Aim of the study

To study and compare the effects of
Mobilization with Movement (MWM) and
Post isometric relaxation (PIR) in patients
with painful stiff shoulders.

Hypothesis
Combined treatment of MWM and PIR
gives better results in cases of painful stiff
shoulder than either MWM alone or PIR
alone.

Design
Study is experimental in nature.
Combined effects of MWM and PIR
compared with MWM alone and PIR alone.
The control group received conventional
exercise and stretching regime.

Variables
Independent Variables
MWM & PIR
MWM
PIR

Dependent variables
Visual Analog Scale (VAS)
Shoulder Pain & Disability Index (SPADI)
Percentage change in ROM

Control variables
Active exercises
Cold packs
Stretching

Sampling
Sample size total 60 (15 in each group)
Stratification done using RALLOC software
by a statistician.
Allocation to four groups

Group A MWM + PIR

Group B MWM
Group C PIR
Group D- Controlled

Inclusion Criteria
Pain & stiffness in the shoulder
Age 40-70yrs
No previous shoulder surgery
Symptoms for at least 3 months duration

Exclusion criteria
Any significant systemic history affecting shoulder

Myocardial infarction
Osteoporosis
Rheumatoid arthritis
Stroke

Either shoulder documented

Grade III rotator cuff tear
Fractures around the shoulder

Thoracic outlet syndrome

Severe skin allergies, sensitivity or other dermatological
problems in the area.
Trauma or any other predisposing event.

Interventions
MWM
Identification of restricted movement
Appropriate glide applied
3 sets of ten repetition

PIR
Identification of restricted movement
5 sec isometric hold , 2-3 sec relaxation with
exhalation
6-10 repetitions

MWM + PIR
Both the protocols followed
Half of the patients given MWM first, rest given PIR first to
minimize the order bias

CONTROL GROUP

Cold packs
Active exercises
Codmans pendular exercises
Stretching exercises
Strengthening exercises

Data Analysis
Two Way ANOVA was used at 5% level of
Significance

Results
On all the parameters (percentage change in flexion, abduction, Internal
Rotation, External rotation, SPADI & VAS) the experimental groups that are
MWM, PIR, & the combination had significant difference in effectiveness as
compared to the control.
In flexion and External rotation, the combination group gave better results
than MWM alone.
In Abduction, no difference was found among the three.
In internal rotation MWM was more effective than PIR alone.
On SPADI score no significant difference was found between the three
experimental groups.
On VAS, the combination was more effective when compared to MWM
alone.

Percentage Change In Flexion ROM

Treatment Mean

50
40
30
Series1
20
10
0
MWM

PIR

MWM+PIR

CONTROL

Treatment Group

Percentage Change In Abduction ROM

Treatment Mean

60
50
40
Series1

30
20
10
0
MWM

PIR

MWM+PIR

Treatment Group

CONTROL

Treatment Mean

Percentage Change In Internal rotation ROM

45
40
35
30
25
20
15
10
5
0

Series1

MWM

PIR

MWM+PIR

CONTROL

Treatment Group

Percentage Change In External Rotation ROM

Treatment Mean

60
50
40
30

Series1

20
10
0
MWM

PIR

MWM+PIR

Treatment Group

CONTROL

SPADI

50
40
30

Series1

20
10
0
MWM

PIR

MWM+PIR

CONTROL

Treatment Group

VAS

Treatment Mean

Treatment Mean

60

8
7
6
5
4
3
2
1
0

Series1

MWM

PIR

MWM+PIR

Treatment Group

CONTROL

Discussion
Individually used both MWM & PIR have been successful in the
management of musculoskeletal pain & joint restriction but there are no published studies
to see the effect of their combination.
MWM is based on the Mulligans principle that a minor positional fault of the joint may occur
following an injury or strain
Abbott 2001 postulated that MWM may act neurophysiologically to decrease the level of contractile
activity of shoulder rotator muscles.

Wright 1995 had postulated that mechanism responsible for manual therapy treatment
effects may feasibly involve changes in the joint, muscle, pain & motor control systems
Liebenson stated that PIR can relax an overactive muscle or its associated fascia, when
connective tissue or viscoelastic changes have occurred

Our study used both MWM and PIR with the aim of addressing both the joint
and soft tissue problems simultaneously and this could explain the result why
combination treatment proved better than either MWM or PIR alone or the
control group.
We wish to continue our study for follow up of the results at 3, 6, 9, 12 months
to assess the long term effects of the results we have obtained and how far
these can be retained

Limitations
Sample size was very small(N=60)
No follow up was done
Doubt about the applicability and generazibility of this study to all
age groups and both sexes.

Scope For Future Study

1. The study can be done with a larger sample size.

2. The study can be followed up to see the long term effect of the results
obtained.
3. The study can be carried out on males and females individually to see its
effects on different sexes.
4. The study can be carried out with EMG study during PIR to understand the
basic mechanisms involved.
5. The study can be carried on other joints to see its overall effects

Conclusion
With our study we come to a conclusion that combination of MWM
and PIR is much better than MWM alone and PIR alone for the
reasons as stated in the discussion. We could thereby conclude that
practicing MWM and PIR together in patients with painful stiff
shoulder would enhance the recovery of the patients and thereby
reduce the number of sittings required as well.

THANK
YOU