INTRODUCTION

Supracondylar fracture of Humerus is most common Pediatric injury, 1it

represents about 3% of all fractures.2 it is second most common fracture and is

most frequent fracture in children under 8 years of age1,3 and the most

common Elbow fracture.3-5 Two-third of children hospitalized because of an

Elbow injury having Supracondylar Fracture Of Humerus. Upper extremity

fractures are more common than lower extremity fractures in children. Boys

have higher incidence of this type of fracture, but the difference in comparison

with girls seems to be equalizing, and higher rates in girls have actually been

reported in some series.4

Severely displaced Supracondylar Fracture Of Humerus are

challenging injuries to treat 6and technically difficult procedures for orthopedic

surgeons.3There remains a controversy in the literature with regards to the

definitive management of this type of fractures. Various methods of treatment

have been used for these fractures, including traction, manipulation under

anesthesia, operative fixation using percutaneous wires and open reduction

and internal fixation. All of these methods have their advantages and

disadvantages, the differences among authors relate mainly to the choice

3,7,8
between treatment by closed reduction and percutaneous k-wire fixation or

open reduction and wiring under direct vision.7

The literature supports closed reduction and percutaneous pinning as

the treatment of choice for this fractures.5, 6, 9

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 1
Epidemiology

Supracondylar fracture comprise 65-75% of all Elbow fractures in

children.10These injuries are the most challenging and have the highest

complication rate.11Supracondylar fractures mostly occur between the ages of

5 and 1012 years with the peak incidence occurring between 5-8 years of age

(after this, dislocations become more frequent).10This injury occurs during this

time period due to greater likelihood of falls, general ligamentous laxity and

weak bone structure at the Supracondylar region11 and a Joint position of

hyperextension.13Supracondylar fractures are more common in males and on

the non-dominant side.10

Mechanism of Injury

Hyperextension occurs during a fall on outstretched hands with the

Elbow in extension, which indirectly puts force on the distal Humerus and

displaces it posteriorly; this can occur with or without a valgus or varus force.

This ‘extension’ type of injury accounts for 95% of the cases.10

 If the hand is in a supinated position, then a posterolateral

displacement occurs.10

 If the hand is pronated, then a posteromedial displacement occurs

(more common).10

 Direct trauma or a fall onto a flexed Elbow resulting in a ‘flexion’ type

injury (5%) with anterior displacement.1

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 2
 Figure no.1: Hyperextension injury

Figure No.2: X-Ray Showing Extension type of Supracondylar fracture of

humerus

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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Classification of Extension Fracture

Gartland in 195914

Classified extension fractures into three types:

 Type I Fractures are non-displaced.

 Type II Fractures are angulated but not translated.

 Type III Fractures are posteriorly displaced with;

 Type III a Posteromedial displacement.

 Type III b Posterolateral displacement.

ANATOMY OF ELBOW JOINT

The Elbow is a relatively simple hinge Joint which only allows flexion

and extension. This makes it quite a stable Joint too.

Bones forming the Elbow Joint-

Elbow Joint occurs at the junction of three bones, the Humerus, Ulna

and Radius. The Humerus forms the upper part of the Joint and widens near

the end to form the medial and lateral epicondyles which are the two bony

processes you can feel either side of the Elbow Joint. The Ulna is situated on

the inside of the Joint and forms a cup shape which allows articulation with

the Humerus. The Radius is the smaller of the two forearm bones and sits on

the outside of the Joint. The radial head is round and again cup-shaped to

allow it to move around the wide base (capitulum) of the Humerus

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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Elbow complex has 3 Joints,

The first being the hinge Joint formed between the Humerus and the

Ulna (humeroulnar Joint), which allows us to bend and straighten our Elbows.

The second is the humeroradial Joint between the Radius and Humerus

which again allows flexion and extension but is also involved in the more

complex motion of turning the hand over so the palm faces up/down

(Supination/Pronation).The third is a pivot Joint formed by the Radius and

Ulna (proximal radioulna Joint).15

Ligaments of the Elbow Joint

There are three main ligaments supporting the Elbow Joints:

 Medial collateral ligament.

 Lateral Collateral ligament.

 Annular ligament.

Primary muscles of the Elbow Joint

There are a large number of muscles which cross the Elbow Joint to

cause flexion/extension and Supination/Pronation.

 Biceps brachii.

 Triceps brachii.

 Brachialis.

 Brachioradialis.

 Pronator teres.

 Supinator teres.

 Anconeus.15

Normal Range of Motion of Elbow Joint

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar
Fracture of Humerus” -Varsha M. Wadekar.
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  Elbow flexion: 0o - 1450

 Elbow extension: 1450 – 00

 Total Pronation and Supination : 1500 15

FRACTURE HEALING

The healing of a fracture is an extremely interesting process in the

human body. In optimal conditions, injured bone can be reconstituted without

a scar almost identically to its original shape. Bone healing has been under

extensive investigation for many years. The process of fracture healing can

occur in two ways, Direct or primary bone healing which occurs without callus

formation and Indirect or secondary bone healing occurs with a callus

precursor stage. The healing of fracture in many ways is similar to the healing

of soft tissue wounds except that the end result is mineralized mesenchymal

tissue that is bone. Fracture begins to heal as soon as the bone is broken,

and through a continuous series of stages described below.21

Stages of Fracture Healing of Cortical Bone (frost, 1989).

 Stage of Hematoma:-

Less than 7 days.

Fracture end necrosis occurs with Sensitization of precursor cells.

 Stage of Granulation:

2 to 3 weeks.

Proliferation and differentiation of daughter cells into vessels,

fibroblasts, osteoblast etc but still Fracture is mobile.

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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  Stage of Callus:-

4 to 12 weeks.

Fracture clinically united, no more mobile due to Mineralization of

granulation tissue. Callus radio logically visible at this stage.

 Stage of Remodelling:-

1 to 2 years.

Outline of callus become dense and sharply defined due to lamellar

bone formation by multicellular unit based remodeling of callus.

 Stage of Modelling:-

Modeling of endosteal and periosteal surfaces causes the fracture

site becomes indistinguishable from the parent bone.This stage

lasts for many years.

Because of rich blood supply and thick periosteum, fracture of

children unites faster than adults. Callus is often visible on X rays as early as

2 weeks after fracture. On an average bones in children unite in half the time

compared to adult.21In case of Supracondylar fracture callus is visible at 3

weeks and remodeling occurs at 6 weeks.22

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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Stages of Wound Healing

Healing tissue progresses through three stages:

 Inflammatory Stage- At this stage wound prepares to heal within first

week.20

 Fibro plastic Stage- At this stage tissue structure is rebuilt; scar is not

strong and cannot tolerate excessive stress that’s why any force applied

must be slow, gentle and sustained within 1 week to 3weeks.19

 Maturation Stage- At this stage collagen deposition is accompanied by

collagen degradation creating equilibrium. Wounds that were well into the

maturation stage exhibit a hard endfeel.18 in ideal circumstances the

healing wound progresses through these stages in orderly and timely

manner last for 3 weeks to 6 weeks. 19

STIFFNESS

The term stiff is commonly used when describing the hand

lacking full mobility. Stiffness is the constraint created by cross linking the

previously elastic configuration of the collagen fibres. 17Stiffness is caused by

the fixation of the tissue layers so that the useful elastic relational motion is

restricted by cross links binding the collagen together. It describes the

physical properties of matter whose close molecular structure make it rigid,

resisting deformation when external force is applied.16Elbow Stiffness is a

common problem encountered in orthopedics practice. It is a morbid. The

reasons for stiff Elbow are injury, massage, and fractures around Elbow,

infection, burns and Rheumatoid arthritis.

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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 Mismanagement in the form of native treatment with oil massage, tight

bandages jeopardizing the circulation to the arm and splinting by unqualified

person is a common practice.

Figure no.4: Intermolecular cross links of collagen

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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CONVENTIONAL THERAPY

In a Physical therapy setting, agents are rarely used in isolation;

rather, they are used to enhance the effectiveness of other therapeutic

interventions directed at functional restoration.22

 Physical agents may influence pain by resolving inflammation.

 Facilitating tissue repair.

 Activating temporary analgesia.

 Altering nerve conduction.

 Providing a counterirritant.

 Modifying muscle tone or collagen extensibility.

A. HOT PACKS (Moist Heat)

It is a superficial heating modality24

Uses

 Pain control.

 Increased Range of Motion.

 Accelerates healing.24

Physiological Effects of Heat

 Relief of pain.

 Increase in flexibility of collagenous tissues.

 Reduction of muscle spasm.

 Increase in blood flow.22-24

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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 Moist heat causes Analgesia, increased flexibility of collagenous

tissues, and reduction of muscle Spasm through selective decrease in

excitation of nociceptive nerve endings. Increased muscle temperature also

decreases spindle sensitivity and reduces “muscle spasm". Heat increases

blood flow to the warmed area, which also may accelerate healing. Because

heat increases extensibility of collagen tissues, it may be helpful before

stretching exercises of shortened muscles.4, 6

Dosage

20 minutes.22

B.STRETCHING

Passive static stretching is therapeutic Technique to increase

lengthening, mobility, extensibility of soft tissue and subsequently improve

Range of Motion by elongating structures that have adaptively shortened and

become hypo-mobile over time.22, 25-28 There have been a number of studies

which proved that stretching causes lengthening and extensibility of soft

tissue and increase Joint range of motion.22, 25-28Connective tissue structures

such as ligaments, tendons, and capsules respond to mechanical stress in a

time-dependant or viscoelastic manner. Viscoelasticity is a mechanical

property of materials that describes the tendency of a substance to deform at

a constant rate. The rate of deformation does not depend on the speed of

external force applied. In ligaments and the Joint capsule, the collagen fibers

vary between the two extremes and they resist multidirectional forces

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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because collagen is the structural element that absorbs most of the tensile

stress.22

This occurs when tissue is taken to the end of its Range of motion and a

gentle stretch is applied. When a stretch is applied to connective tissues

within elastic limits, over time the tissues may demonstrate creep, the bonds

between fibers and between the surrounding matrix are strained, some micro

failure between the collagen bonds begins, and some water may be displaced

from the ground substance.

There is complete recovery from this deformation and the tissue

returns to its original size and shape when the load is released if the stress is

not maintained for any length of time and if the amount of deformation does

not exceed the elastic range. If the loading is continued into the plastic range,

passing the yield point, failure of the tissue will occur. Failure is thought to be

a function of breaking intermolecular cross-links rather than rupture of the

collagen tissue. If permanent increase in ROM is a goal of treatment then

Manual therapy should be aimed at producing plastic deformation. 1This is the

underlying physiology behind stretching. If the stretching is sustained and

maintained for 15 to 30 seconds, 12 the deformation remains within the tissues

and in turn improves the flexibility of the soft tissues and Joint mobility of the

restricted structures around the shoulder.25

Low load prolonged stress will cause plastic deformation of tissue. It

will favorably modify cross links and the collagen micro fills slip over each

other.22, 25-28

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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B. RANGE OF MOTION EXERCISES

Range of Motion (ROM) exercises increase and preserve Joint range

of motion. They can be done passively by a physical therapist or family

member or can be active-assistive, when the patient performs the Range of

Motion while assisted by another person who increases the ROM with gentle

stretch. Active Range of Motion is movement of a segment within the

unrestricted ROM that is produced by active contraction of the muscles

crossing the Joints. ROM exercises increases elasticity of soft tissue,

especially when accompanied by gentle stretch. In case of elbow stiffness

ROM exercises should be done for proximal and distal joints, this involves

shoulder, Elbow and wrist Joint movement.

Indication:

Whenever the patient is able to contract the muscle actively and move

a segment with or without assistance active Range of Motion is used. When a

segment of the body is immobilized for a period of time AROM is used on the

regions above and below the immobilized segment to maintain the Joints in as

normal as possible and to prepare for new activities.

Goals

 Provide sensory feedback from the contracting muscles.

 Provide a stimulus for bone and Joint tissue integrity.

 Increase circulation and prevent thrombus formation.

 Develop co-ordination and motor skills for functional activities.25, 29, 30

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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D.MULLIGAN MOBILIZATION TECHNIQUE

Mulligan is nothing but Mobilization with Movement. Mulligan is a

Mobilization Technique which is effective, gentle, safe and satisfying. The use

of Mobilization with movement (MWM) for peripheral Joints has been

developed by Brain Mulligan. This Technique is unique because,

It consist of the application of a sustained accessory glide to a joint

while the patient performs previously painful movement of that Joint. The

most important feature of Mobilization with Movement is that when indicated

the treatment technique produces a total and immediate relief of pain during

the treatment application. This improvement is often

enhanced and maintained following several repetitions. Human Joint surfaces

are not fully congruent and physiological movements occur as a combination

of a rotation and a glide. Mulligan concepts place particular emphasis on

restoration of the glide component of Joint movement to facilitate full pain-free

range of movement.

Mulligan proposed that a minor positional fault of the Joint may occur

following an injury or strain, resulting in movement restrictions or pain.

Reduced Joint mobility can often be a result of a ‘mechanical block’ from inert

structures within a Joint. Joint afferent discharge and optimal muscle

recruitment are closely linked. A Mobilization is applied parallel or at right

angles to the restricted Joint movement. If the applied Mobilization achieves

immediate improvement in the functional movement and abolishes the pain

the treatment involves sustaining the Mobilization while the patient performs

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 14
the active movement repetitively. Once the glide has been chosen it must be

sustained throughout the physiological movement until the Joint returns to its

original starting position.

Principles of the Treatment

In the application of manual therapy Techniques, Physiotherapists

acknowledge that contraindications to treatment exist and should be

respected at all times. Although always guided by the basic rule of never

causing pain, therapist choosing to make MWMs in the extremities must still

know and abide by the basic rules of application of manual therapy

Techniques.

Figure no.4: A graphic representation of Mulligan concept

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 15
Specific to the application of MWMs in clinical practice the following basic

principles have been developed:

1. During assessment the therapist will identify one or more comparable

signs as described by Maitland these signs may be; a loss of Joint

movement, pain associated with movement or pain associated with

specific functional activities.

2. A passive accessory Joint Mobilization is applied. This accessory glide

must be pain free.

3. The therapist must continuously monitor the patient’s reaction to

ensure no pain is recreated. Utilizing his/her knowledge of; Joint

arthrology, a well developed sense of tissue tension and clinical

reasoning, the therapist investigates various combinations of parallel

or perpendicular glides to find the correct treatment plane and grade of

accessory movement.

4. While sustaining the accessory glide, the patient is requested to

perform the comparable sign. The comparable sign should now be

significantly improved (that is increased range of active motion, muscle

contraction and free of the original pain).

5. Failure to improve the comparable sign would indicate that the

therapist has not found the correct treatment plane, grade of

Mobilization or that the Technique is not indicated.

6. The previously restricted and/or painful motion or activity is repeated

by the patient while the therapist continues to maintain the appropriate

accessory glide.

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 16
 Further gains are expected with repetition during a treatment session

particularly when pain-free overpressure is applied. Self-treatment is often

possible using this principles with sports type adhesive tape and/or the patient

providing the glide component of the Mobilization and the patient’s own efforts

to produce the active physiological movement.

Pain is always the guide. Sustained improvements are necessary to

justify ongoing intervention. As the Joint moves the therapist must sustain the

pressure, being constantly aware of minor alterations in the treatment plane.

The Mobilizations performed are always into resistance but without pain. If

this is not achieved the therapist may try a different glide or a rotation. On re-

assessment of the Joint function, the movement should remain improved

without the Mobilization. Theories as to why these Techniques provide rapid

improvement in pain-free range were proposed and the general principles of

examination and treatment are outlined. Once the aggravating movement has

been identified, an appropriate glide is chosen. The decision to use a weight-

bearing or non-weight-bearing restricted movement will depend on the

severity; irritability and nature of the condition Specific clinical examples

demonstrate how MWM can be used in isolation or integrated with other

manual approaches to improve the quality of Joint intraarticular gliding and

neurodynamics and the facilitation of correct muscle recruitment.31-33

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 17
Outcome Measures

Many scoring systems have been used for Elbow disorders however,

only few of these have been validated, and many assess only few aspects of

Elbow function. The Mayo Elbow Performance Index (MEPI) is one of the

most commonly used physician-based Elbow rating systems.35, 36

MAYO ELBOW PERFORMANCE INDEX

The Mayo Elbow Performance Index is one of the most commonly

used physician-based Elbow rating systems.35, 36This index consists of four

parts:

 Pain.

 Ulnohumeral motion.

 Stability.

 Ability to perform five functional tasks.

Pain (with a maximum score of 45 points), ulnohumeral motion (20

points), stability (10 points) and the ability to perform five functional tasks (25

points). Pain is rated as none (45points); mild (30 points) if there is no

limitation of activity and occasional use of analgesics; moderate (15 points) if

there is limitation of activity and regular use of analgesics; severe (0 points) if

there is constant pain and regular use of analgesics.

The Joint’s stability is graded as stable, mildly unstable or unstable.

The functional score is determined on the basis of the patient’s ability to

perform normal activities of daily living.

The total score ranges from 5 to 100 points, with higher scores indicating

better function.
“Effect of Mulligan Mobilization technique in post operative management of Supracondylar
Fracture of Humerus” -Varsha M. Wadekar.
Page 18
  90 to100- Excellent.

 75 to 89- Good.

 60 to 74- Fair

 Less than 60- Poor.35-40

UNIVERSAL GONIOMETER

Universal goniometer is the instrument most commonly used to measure Joint

position and motion of all Joints of body. Moore designated this type of

goniometer as “universal “because of its versatility. Universal goniometer may

be constructed of plastic or metal and were produced in various shapes and

sizes, but adhere to the same basic design. Typically the design includes a

body and two-thin extensions called arms – a stationary arm and a moving

arm. The length of arm varies from 1 – 14 inches.

Traditionally, the arms of a universal goniometer were designated as

moving or stationary according to how they were attached to the body of a

goniometer. The stationary arm is a structural part of the body of the

goniometer and cannot be moved independently from the body. The moving

arm is attached to the center of the body of goniometer by a rivet that permits

the arm to move freely on the body. In some metal goniometer, a screw-like

device is used to attach the moving arm. The body of a universal goniometer

resembles a protractor and may vary from a half circle to a full circle.

The index on a half circle goniometer read from 0 to 180 degrees and from

180 to 0 degrees. The index on a full circle goniometer may read from 0 to

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 19
360 degrees and from 360 to 0 degrees. The universal goniometer is highly

reliable and valid.49.

Figure no.5: Cycle represents Stiffness

Because of immobilization after any fracture a cycle is established in

which edema followed by inactivity leads to Stiffness and adherence, which

again leads to inactivity. In most of the surgical patients, changing one of the

three factors readily breaks this cycle, as the therapist and patient work

together on each of the three factors. This needs proper treatment with good

reduction, fixation and early Mobilization.18Alternative methods and delayed

treatment leads to severe Stiffness of the Elbow with excessive new bone

formation (heterotrophic ossification) and a dysfunctional useless upper limb.

Therefore this study was undertaken with the help of Mayo Elbow

Performance Index as an outcome measure to find out the effect of

conventional therapy with or without Mulligan Mobilization in post operative

management of Supracondylar fracture of humerus in children

NEED FOR STUDY

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 20
 The Supracondylar fracture of Humerus is the most common fracture in

children in which extension type of fracture is common. Supracondylar

fracture is one of the serious fractures in childhood as it is often associated

with complication. Undisplaced fracture is treated by conservatively, and

displaced operatively and then they immobilized the Elbow Joint in an above

Elbow plaster cast in 90 degree Elbow flexion for a period 3 to 6 week due to

which Stiffness occurs.

Elbow Stiffness is a common problem encountered in orthopedic practice.

It is a morbid mismanagement in the form of native treatment with oil

massage, tight bandages jeopardizing the circulation to the arm and splinting

is a common practice in our society. This needs proper treatment with good

reduction, fixation and early Mobilization. Alternative methods and delayed

treatment leads on to severe Stiffness of the Elbow with excessive new bone

formation (heterotrophic ossification) and a dysfunctional useless upper limb.

Because of Elbow immobilization not only Elbow but also hand

functions are affected. Hands play major role in defining the level of skill in

our activities and in our level of social expression and integration.

Intervention with conventional therapy have proved to be beneficial in

Elbow Stiffness following Supracondylar fracture, But there is no study has

been done to find the effect of Mulligan therapy in post operative

Supracondylar humeral fractures in children.

Therefore more comprehensive study needed by involving several

clients over the duration of 3 month. With this study I want to know whether

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 21
only conventional therapy or with Mulligan Mobilization is effective in

treatment of post operative Supracondylar humeral fracture. It would be

valuable to do a more comprehensive study.

AIM AND OBJECTIVES

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar
Fracture of Humerus” -Varsha M. Wadekar.
Page 22
AIM

To find out the effect of Mulligan Mobilization Technique in post

operative management of Supracondylar fracture of Humerus.

OBJECTIVES

1. To find out the effect of conventional therapy in post operative

management of Supracondylar fracture of Humerus.

2. To find out the effect of Mulligan Mobilization Technique along with

conventional therapy in post operative management of Supracondylar

fracture of Humerus.

REVIEW OF LITERATURE

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 23
Kovacs C,Heyl R,Paterno M,Nolte B, cherny C,Tissot J.et.al. 22(2007)these

guidelines were intended for the use in patients with Loss of Elbow motion

following surgery or trauma. They have included children with the age Group

of 4 to 18 years who has following Elbow fractures; fracture of distal Humerus,

Supracondylar humeral fracture ,condyle and epicondyles fracture, Elbow

dislocations,olecranon fracture. This guideline state that physical therapy and

occupational therapy management typically includes all or part of four

parameters, including exercise, manual therapy, modalities and splinting.

Objectives of this guideline are to:

Optimize Elbow function through long term maintenance of increased

active Elbow range of motion, increased Elbow strength in children who have

been immobilized after Elbow surgery or trauma minimized time spent in

therapy ,increase coordination and consistency of care provided by

therapists ,maintain and improve family satisfaction. They concluded that all

these parameters are useful to achieve these objectives.MWM provide a

passive pain-free end-range corrective Joint glide with an active movement

and at the end passive overpressure. The combination of Joint Mobilization

with active movement may be responsible for the rapid return of pain-free

movement.22

Exelby L.32 they have conducted a research on Mulligan’s Mobilization with

movement: a review of the tenets and prescription of MWMs proposes

possible reasons for the rapid increase in pain-free movement, outlines the

principles of treatment and illustrates via clinical examples how MWMs can be

successfully utilized in the peripheral Joints. In this study they have mentioned

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 24
parameters for Mulligan Mobilization it includes parameters for amount of

force, repetition /sets frequency, rest period.

Naik V, Khatri S, Chitra J 41(2007) they conducted research on “Effectiveness of

Maitland versus Mulligan Mobilization Technique following post surgical

management of colles fracture” In this study they have included 30 subjects of

post operative colles fracture and divided equally into two Gs, first G received

Maitland and second G received Mulligan for the period of 2 weeks. Outcome

measures used goniometer for range of motion, thumb motion scale to rate

the functions of thumb and hand respectively. Before Mobilization Moist heat

given for 15 minutes and then Maitland glide for Group A and Mulligan glide

for Group B. They have concluded that Mulligan Mobilization Technique could

be used effectively when the pain predominates. While Maitland Mobilization

Technique could be effectively used to restore mobility when pain is not the

major concerned to patients with colle’s fracture.

42
Vicenzino B, Paungmali A,Teys P (2006)they conducted research on

Mulligan’s Mobilization-with-movement, Positional faults and Pain relief. This

article provides an overview of the literature concerning the clinical efficacy,

effects and mechanisms of action of the MWM approach in the treatment of

musculoskeletal conditions the predominant explanation provided for this

rapid pain relieving effect is mechanical in nature and based on the proposed

existence of bony positional faults and the ability of MWM to correct these

faults. In this study they have included total 45 studies in that Kochar and

Dogra (2002) conducted a quasi-randomized-clinical trial of MWM with

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 25
ultrasound (US), US alone and a no treatment control On 66 subjects with

lateral epicondylalgia.

Forty-six of the 66 cases were randomized into the two treatment Gs

(23 each Group). The remaining 20 cases, who were unable to visit the

hospital for therapy sessions, were included in the study as a non-randomized

control G. Ten therapy sessions of the assigned treatment condition (i.e.

MWM+US or US) were delivered within the first 3 weeks and then followed up

by a progressive exercise regime for a further 9weeks. Four outcome

measures (10 cm pain visual analogue scale (PVAS), grip strength, a weight

lifting test, and patient self-assessment) were evaluated at baseline and then

after weeks 1, 2, 3 and 12. The results showed that the MWM+US Group was

superior than other Group .The evidence from the pain science studies that

have attempted to characterize the hypoalgesic effect has indicated that it

may be non-opioid in nature As well as exhibiting features that are complex

and widely distributed to other systems, such as the motor and sympathetic

nervous system.

Sukru A,Dilek Behice O.43(1994) in book of rehabilitation and in chapter of

rehabilitation after collies fracture they studied on 55 patients of colles fracture

and physical treatment was applied for all patients for 7-8 weeks. The

treatment procedure consisted of physical exercise and paraffin application.

They compared pretreatment and post-treatment degrees of flexion,

extension, radial and ulnar deviation, Supination and Pronation of the wrist.

Increased significantly compared to pretreatment degrees

(P<0.001).Extension of the wrist after physical treatment increased

significantly compared to pretreatment degrees (P<0.001),Radial deviation of

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 26
the wrist after physical therapy increased significantly compared to

pretreatment degrees (P<0.001),Ulnar deviation of the wrist after physical

treatment increased significantly compared to pretreatment degrees

(P<0.001).Supination of the wrist after physical treatment increased

significantly compared to pretreatment degrees (P<0.001),Pronation of the

wrist after physical treatment increased significantly compared to pretreatment

degrees (P<0.001).

They achieved satisfactory results following physical therapy of the

wrist. Rehabilitation program is of almost importance in Colles' fracture so it

should be applied soon after the orthopedic manipulation. They achieved

satisfactory results after physical therapy.

44
Darryl L. Millis in book of physical rehabilitation a practice they provided

much attention to the preoperative and operative management of veterinary

patients. Physical therapy in human patients is common and well accepted.

People receiving physical therapy have allowed us to adapt some of

the Techniques and procedures to small animals. And they have used

thermotherapy; range of to motion exercises and stretching post operatively.

They found very satisfactory results.

45
Landrum L, Kelln BM, William P.Christopher D the purpose of this study

was to determine if a single bout of grade iii anterior-to-posterior talocrural

Joint Mobilizations immediately affected measures of dorsiflexion ROM,

posterior ankle Joint Stiffness, and posterior talar translation in ankles of

patients who had been immobilize at least 14 days after a single application of

grade iii anterior-to-posterior talocrural Joint Mobilization, dorsiflexion ROM

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 27
and posterior ankle Joint Stiffness were significantly increased. There was

also a trend toward less posterior talar translation immediately after

Mobilization. The e trend toward decreased posterior talar translation and

increased posterior ankle Joint Stiffness supports the positional fault theory.

Correction of an anterior talar positional fault offers a possible explanation for

these results.
46
Morrey Bf, An KN they studied on functional evaluation of the Elbow and

its disorder and they proved that mayo Elbow performance index is a valid

scale for pain, Range of Motion and functional outcome assessment .and can

be used effectively after Elbow surgeries.

Vihari B, Somanchi, Funk L47 they studied on evaluation of functional

outcome and patient satisfaction after arthroscopic Elbow arthrolysis for

evaluation of Elbow. To understand the functional outcome and patient

satisfaction, 26 patients were reviewed at a mean follow-up of 25 months. Pre

and post-operative evaluation included the Elbow functional assessment

score and mayo Elbow performance index, patient satisfaction and return to

work and sports. Function improved significantly in 87%.

48
Longo U.P, Franceschi,F,Loppini,M, Maffulli.N, Vincenzo D they studied

rating systems for evaluation of the Elbow .in this study they have included 18

scoring Systems. These scoring systems are currently available for the

evaluation of Elbow disorders. Each of them evaluates

The Elbow performance using specific variables, including both

objective and subjective criteria. All these scoring systems are presented. And

they have used mayo Elbow performance index for evaluation of Elbow in

children with post operative Supracondylar fracture. And they have concluded

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 28
that this is a valid scale and can be used in post operative Supracondylar

fracture in children.

Sridhar V. Vasudevan, MD51 in book of Pain clinical update, they have

mentioned that countries with limited resources, including the United States

under managed care, physical agents merit consideration as first-line

treatment. Physical rehabilitation emphasizes the use of modalities such as

heat, cold, and electricity, and hands-on Techniques such as manipulation,

Mobilization, massage, and traction. It also involves planning so as to balance

rest for the injured part, prevention of re injury through use of orthotic devices

(braces, corsets, and splints), and strengthening by specific exercise

programs physical methods of pain control can aid in Aggressive Mobilization

and nonsurgical rehabilitative treatment of patients with acute as well as

chronic pain.

Colditz JC52 in book of “Stiffness of the Hand” he mentioned that definition of

Stiffness and Stages of wound healing. he has written about early

management of stiff hand it includes 5Techniques of edema control: 1)

compression 2) Elevation 3) active movements 4) Gentle External Massage 5)

Splinting .he has explained about benefits of early motion that is it establishes

tissue homeostasis, increases venous and lymphatic flow, increases tensile

strength of wound, and directs the alignment and orientation of collagen

fibers.

He has included manual Techniques for tightness which includes Mobilization

and stretching.

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 29
 HYPOTHESIS

Null Hypothesis: (H0)

1. There is no significant effect of Mulligan Mobilization Technique along

with conventional therapy in post operative management of

Supracondylar fracture of Humerus.

Alternate Hypothesis: (H1)

1. There is significant effect of Mulligan Mobilization Technique along with

conventional therapy in post operative management of Supracondylar

fracture of Humerus.

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 30
 MATERIALS AND METHODOLOGY

Study type: Experimental study

Study design: Pre-test Post-test.

Sample size: 30 subjects.

Study duration: 1 Year

Study place: OPD of Krishna College of Physiotherapy, Karad and

Wanless Hospital, Miraj.

Sampling method: Simple random sampling(lottery Method).*

Inclusion criteria

1. Age - 6 to 12years.

2. Gender- both males and females.

3. Patient with right and left supracondylar fracture of humerus were

included.*

4. Extension type fracture.

5. Post operative cases of closed reduction with k wire fixation.

6. Patients with cast removal after 6 weeks of immobilization.

Exclusion criteria

1. Patient with supracondylar humerus fracture secondary to any other

pathology or any other surgery around elbow .*

2. Fracture Associated with neurovascular deficit, rheumatologic

condition or tumors of Elbow.

3. Myositis ossificance.
“Effect of Mulligan Mobilization technique in post operative management of Supracondylar
Fracture of Humerus” -Varsha M. Wadekar.
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Materials

1. Plinth.

2. Towel.

3. Consent form.

4. Data collection sheet.

5. Goniometer.

6. Hot packs.

7. Mulligan belt.

Figure no.6: Hot pack Figure no.7: Mulligan belt

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 32
OUTCOME MEASURE

Mayo Elbow Performance Index

This index consists of four parts:

 Pain (with a maximum score of 45 points).

 Ulnohumeral motion (20 points).

 Stability (10 points).

 And the ability to perform five functional tasks (25 points).

PROCEDURE OF STUDY

30 subjects were recruited in this study diagnosed as Supracondylar

fracture of Humerus on the basis of their radiological investigations. They

were recruited from physiotherapy outpatient department of Krishna hospital

Karad,and Wanless Hospital, Miraj. Informed consent was taken from parents

of each individual participating in this study. 30 subjects were alloted into 2

Groups randomly by Lottery method that is Group A and Group B. first patient

was given 2 chits naming Group A and Group B and was ask to draw a chits

and according to chit they were recruited to that group and second patient

was recruited to remaining group and then subsequent patient was recruited

by same sequence of Group. Group A received conventional therapy and

Group B received Mulligan Mobilization along with conventional therapy.

The entire procedure was carried out for:

Number of weeks – for 3 weeks.

Number of sessions – 3 times / week.

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 33
 The patients were assessed before including them so that they fit into

the inclusion criteria. Complete history of the patient was taken and informed

consent was taken from each of the subjects prior to participation.

Instructions were given to the subjects about Techniques performed. Any

abnormal bony or soft tissue changes were observed, tenderness or pain

was palpated, for examination purpose both active and passive movement

was examined. Their functional activities were also assessed. Mainly the

patients were assessed for Range of Motion for Elbow.

In both the Groups the subject were scored on Mayo Elbow

Performance Index for 2 times at pre-interventionally and reassessment was

taken after completion of treatment duration that is post 3 weeks of

intervention in that, Range of Motion was assessed with the help of

goniometer as follows: Flexion and extension.

 Testing position –

The patient was placed in supine position with the shoulder was

placed in 00 of abduction, adduction and rotation. The Elbow was

placed in extension how much is present so that the forearm was

positioned in Supination so that the palm of the hand faced upward.

 Goniometer alignment –

The fulcrum of the goniometer was placed over the lateral

epicondyles of humerus. The stationary arm was aligned parallel to the

Humerus and the movable l arm with the lateral aspect of forearm.

 Testing motion –

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 34
 The patient was asked to flex the Elbow by lifting the hand off

the examining table, bringing the hand up as touch to shoulder. The

extremity was maintained in neutral abduction and adduction during the

motion. Shoulder is stabilized to avoid other movements.

GROUP- A

This group was treated with hot pack, passive stretching and Range of

Motion exercises.

Hot pack

Hot pack stored in hot water at about 70 0C to 750C, was placed over

the patient’s Elbow area to heat the tissue area to 40 0C to 450C, with the

towels placed as an interface between the hot packs and tissue surface.

Figure no.8: Application of Hot pack

Sensitivity of the skin was checked before application. Hot pack was applied

for 20 minutes before the Stretching to increase soft tissue extensibility and

increase ROM. the position of patient was supine lying and hot pack was

wrapped in a towel and placed in and around elbow region. Patient was asked

for any discomfort during and after treatment.

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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Stretching

The patient was explained about the Techniques which were going to be

performed.

Figure no.9: Application of Stretching

 Type of stretching (mode) –passive static stretching with low load.

 Starting position –at the point of tissue resistance.

 Grasp- grasp the area proximal and distal to the Elbow Joint.

 Stabilization – firmly stabilize proximal segment and move the distal

segment.

 Mode – low load (low intensity).34

 Stretch duration – 30 seconds.22

 Gradually release the stretch force maintains the range limiting tissue in

a comfortably elongated position.

 Repetitions – repeat the sequence 4 to 5 times.25-28

 Frequency-single session per day.

 Rest period-48 hours between each session.

 Treatment duration - 3weeks.32

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar
Fracture of Humerus” -Varsha M. Wadekar.
Page 36
 Range of Motion exercises-

These exercises were performed at the end of the session

Figure no.10: Active ROM exercises

 Type- Active Range of Motion exercises

 Repetitions -10 times.

 Frequency-single session per day

All movements of shoulder Elbow and wrist Joints are included.

All range of motion exercises were given in supine lying. The patient was

asked to perform all the exercises actively;

Active Range of motion exercises include;

 Shoulder –Flexion, Extension, Abduction, Adduction, Medial

and Lateral Rotation.

 Elbow-Flexion, Extension, Pronation, Supination.

 Wrist-all wrist movements and sponge ball exercises.

GROUP -B
“Effect of Mulligan Mobilization technique in post operative management of Supracondylar
Fracture of Humerus” -Varsha M. Wadekar.
Page 37
 Group-B Was treated with conventional therapy and Mulligan

Mobilization technique. Same protocol was followed for conventional therapy

MULLIGAN MOBILIZATION TECHNIQUE

Figure no.11: Application of Mulligan Mobilization (MWM)

The patient was explained about the Techniques.

Type of glide –Lateral glide with movement

Starting position –Supine with his arm on plinth and forearm supinated

Belt position- Wrap the belt around therapist hip and forearm lies within the

belt.

Stabilization- stabilize Lower end of Humerus with one hand and support the

forearm with other hand.

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 38
Amount of force - 1/3 rd of maximal force.

Rest period between glides-15 seconds.

Frequency - 3 sessions / week.

Rest period between sessions -48 hours.

Duration -3 weeks.32, 33

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 39
 DATA PRESENTATION

Data analysis and interpretation was done by using Instat Software.

For the significant difference P value is calculated.

GENDER DISTRIBUTION

Table no.7.1 Gender Distribution

Gender Number of patients

Male 18
Female 12
Total 30

A total of 30 participants with Supracondylar fracture of Humerus were taken

in the study. Out of the 30 participants, 18 were males, 12 were females.

Group A included 7 males, 8 females Group B included 11 males, 4 females.

Graph no.7.1 Gender Distribution

NUMBER OF PATIENTS

Fe-
male
40%

Male
60%

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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AGE DISTRIBUTION

Table no.7.2 Age Distribution

Groups Mean age

Group A 8.6

Group B 9.266

Total 8.533

Age Group of all participants was between 6 to 12 yrs. The mean age of the

participants in Group A was 8.6 and in Group B was 9.26667yrs. There was

no significant difference between the mean ages of the participants in both the

Groups. This was done by using unpaired’ test. (t=0.9635, P=0.3435).

Graph no7.2 Age Distribution

Mean age

9.4
9.2
9
9.266
8.8
8.6 8.6
8.4
8.2
Group A Group B

Mean age

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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SIDE DISTRIBUTION

Table no7.3 Side Distribution

Side No. Of patients

Left 18

Right 12

Total 30 children included in this study in that 18 were left sided and 12 were

right sided. In Group A 6 were right sided and 9 were left sided, in Group B 7

were right sided and 8 were left sided.

Graph no7.3 Side Distribution

No.of patients

right
40%

left
60%

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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 DATA ANALYSIS, RESULTS AND INTERPRETATION

Table no.7.4 Comparison of pre and post Mayo Elbow Performance

Index within the Groups.

Group Pre-treatment Post-treatment ‘t’ Df ‘P’

s
Mean±SD SEM Mean±SD SEM

2.32 86.33±6.1 1.57 27.03 1 <0.000

A 23.33±8.99
3 1 9 9 4 1

23.66±10.9 2.82 1.17 29.66 1 <0.000

B 97±4.55
3 3 5 5 4 1

The pre-interventional values of Mayo Elbow Performance Index Were

23.33±8.99 in Group A and 23.66±10.93 in Group B respectively, whereas

post-interventional values of Mayo Elbow Performance Index were

86.33±6.11in Group A and 97±4.55 in Group B respectively. Intra Group

results showed statistically extremely significant difference in post-intervention

values for both the Groups. This was done by using paired’ test.

Table no.7.5 Comparison of pre-pre and post-post MEPI values in

between groups

Pre-treatment Post-treatment
Groups
Mean±SD SEM Mean±SD SEM

A 23.33±8.99 2.323 86.33±6.11 1.579

B 23.66±10.93 2.823 97±4.55 1.175

‘t’ 0.09118 5.420

Df 28 28

‘P’ 0.9280 <0.0001

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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The pre-interventional values of Mayo Elbow Performance Index Were

23.33±8.99 in Group A and 23.66±10.93 in Group B respectively, whereas

post-interventional values of Mayo Elbow Performance Index were

86.33±6.11in Group A and 97±4.55 in Group B respectively Inter Group

analysis between Group A versus Group B for MEPI values showed

statistically extremely significant difference. This was done by using unpaired

t- test.

7.4 Mean values of Mayo Elbow Performance Index

100
90
80
70
60
GA
50
GB
40
30
20
10
0
Pre Post

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 44
 DISCUSSION

A Supracondylar Humerus fracture comprises 65-75% of all Elbow

fractures in children. These injuries are the most challenging and have the

highest complication rate. Two-thirds of children hospitalized because of an

Elbow injury having Supracondylar fracture of Humerus. Severely displaced

fracture are challenging injuries to treat and technically difficult procedures for

orthopaedic surgeons and for displaced fractures 4 to 6 weeks of

immobilization is enough. After cast removal Elbow Stiffness is a common

problem encountered in orthopaedics practice. Elbow immobilization may not

only affect Elbow, but also hand functions are affected. Hands play major role

in defining the level of skill in our activities and in our level of social

expression and integration.1

This research was conducted with the aim to study and compare the

effect of the Conventional therapy and Mulligan Mobilization Technique along

with Conventional therapy in post operative management of Supracondylar

Fracture of Humerus.30 participants with the age Group of 6 to 12 years

approaching to OPD of Krishna College of Physiotherapy and Wanless

Hospital, Miraj were included in this study. They were divided into two Groups

by simple random sampling method each Group had 15 patients. A thorough

musculoskeletal assessment was done before application of treatment

strategies. The average mean age of the participants in Group A was 8.6

years and in Group B was 9.266 years. There were no significant difference

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 45
between the mean ages of the participants in Group A and Group B (t=

0.9635, P = 0.3435).

 The Group A (control Group) was treated with Conventional therapy, 8

males and 7 females participated in this Group.

 The Group B (experimental Group) was treated with Mulligan

Mobilization along with conventional therapy, 11 males and 4 females

were included in this Group.

Pre treatment outcome measures for pain, ROM and functional

disability was done with Mayo Elbow Performance Index. The specific

protocol was given to the patients according to the Groups they were divided

and at the end of 3 weeks, post treatment outcome measures were performed

for pain, ROM, and functional disability. Statistical analysis was done using

paired t test within Group and unpaired t test between the two Groups. In the

study pre-interventionally MEPI was 23.33±8.99 in Group A and 23.66±10.93

in Group B respectively whereas post-interventionally MEPI was 86.333±6.11

in Group A and 97±4.55 in Group B respectively. Post-interventionally

Intragroup changes in the MEPI revealed statistically extremely significant

difference in both the Groups. Group A (t=27.039 P<0.0001), Group

B(t=29.67, P<0.0001).Inter Group analysis for Mayo Elbow Performance

Index showed statistically extremely significant difference between Group A

versus Group B. (t=5.42, P<0.0001).

The conventional approach showed significant results in pain

reduction, ROM improvement and improvement in functional status because:

Using modalities and other physical agents Increases muscle temperature,

decreases spindle sensitivity and reduces “muscle spasm." Heat increases

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 46
 23
blood flow to the area, which also may accelerate healing. Because heat

increases extensibility of collagen tissues, it may be helpful before stretching

exercises. Stretching Techniques were also incorporated at the end range

which helps in breaking the collagen bonds and realignment of the fibers for

permanent elongation. Joint mobility helps to relieve pain due to its

neurophysiologic effect on the Joint and also helps to maintain extensibility of

the articular and periarticular structures due to its biomechanical effect which

is focused directly on the tension of periarticular tissue. It prevents

complications resulting from immobilization and help to minimize loss of tissue

flexibility and contracture formation.25, 27, 34

Group B received Mulligan Mobilization along with Conventional

therapy also showed extremely significant results in pain reduction and ROM

improvement and improvement in functional status because This Group

received conventional treatment benefitted with the same physiological effects

as the other Group as well as Mulligan Mobilization treatment. MWM is based

on the concept related to a 'positional fault' that occur secondary to injury ,

resulting in symptoms such as pain, Stiffness or weakness The cause of

positional faults has been suggested to be due to changes in the shape

of articular surfaces, thickness of cartilage, orientation of fibers of ligaments

and capsules, or the direction and pull of muscles and tendons. MWM's

correct this by repositioning the Joint causing it to act normally.42

Group B received both the approaches compared to Group A. hence

Group B improved better than Group A.

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 47
 SUMMARY

This study was conducted to study and compare the effect of

Conventional therapy and Mulligan Mobilization Technique along with

Conventional therapy approach. This study was conducted in Krishna

hospital, karad and Wanless Hospital, Miraj, with a sample size of 30 and the

subjects were assessed on the basis of their chief complaints, history,

thorough observation, palpation, examination and radiographic investigations

for a confirmatory diagnosis. The patients were then divided into two Groups –

Group A and Group B by simple random sampling method Group A received

only Conventional Therapy it includes moist heat, stretching, and Range of

Motion exercises and Group B received Conventional as well as Mulligan

Mobilization (MWM) therapy it includes lateral Mobilization with movement

glide used to improve flexion and extension of Elbow The outcome measure

used was – Mayo Elbow Performance Index. This is a single scale which

includes 4 components 1.pain, 2.range of motion, 3.stability, and 4.functional

outcome. and total score is 100.in the study intragroup comparison results

showed that pain relief, improved Range of Motion and improved functional

status was statistically extremely significant in both the Groups (P<0.0001)

Whereas intergroup comparison results showed statistically significant

difference in Group B versus Group A (P<0.0001) thus, from all the above

results it was concluded that Mulligan Mobilization along with Conventional

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 48
therapy has a significant effect than conventional therapy alone in post

operative management of Supracondylar fracture of Humerus.

CONCLUSION

Based on the statistical results and interpretations it is concluded that

Conventional Therapy along with Mulligan Mobilization Technique is effective

in reducing pain, improving ROM and improving functional status in post

operative management of Supracondylar fracture of Humerus as compared to

conventional therapy alone. So the alternate hypothesis was accepted.

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 49
LIMITATIONS

1. The sample size was small.

2. Limited literature review on effect of Mulligan with Mobilization in

children with post operative Supracondylar fracture. *

SUGGESTION

 The study should be conducted with large number of sample.

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 50
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ANNEXURE I

CONSENT FORM

TITLE: “EFFECT OF MULLIGAN MOBILIZATION TECHNIQUE IN POST

OPERATIVE MANAGEMENT OF SUPRACONDYLAR FRACTURE OF

HUMERUS”.

INVESTIGATOR: Varsha M. Wadekar.

PURPOSE OF RESEARCH

I……………………………….have been informed that this research will

check the effect of Hot packs, Stretching Mulligan Mobilization Technique

and Exercises in reducing pain and increasing functional outcome in post

operative management of supracondylar fracture of humerus.

PROCEDURE

I understand that I will be given ………………… …………………………

for three weeks under Group. I also understand that this will be done under

physiotherapist supervision and only demonstrating on himself. I have to

follow therapist instruction as has been told to me.

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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RISK AND DISCOMFORT

I understand that there is a very minimal risk of getting electrical burn

or soft tissue injury after applying treatment. This may give me a very minimal

discomfort. All these treatment and examination will be completed in one

week.

BENEFITS

The recorded value will help to know the importance of Hot Packs,

Mulligan Mobilization and Exercises in reducing pain and increasing functional

outcome in Elbow Stiffness. So a better treatment can be established.

FINANCIAL INCENTIVE FOR PARTICIPATION

You will not receive any payment for participating in this study.

CONFIDENTIALITY

I understand that medical information procedure by this study will be

confidential. If the data are use for publication in medical literature or for

teaching purpose no name will be used and other literature such as

photographs, audio, or video tapes, will be used with my permission.

REQUEST FOR MORE INFORMATION

I understand that I may ask any question about the study at any time to

Varsha M. Wadekar and she is available to answer my questions. Copy of this

consent form will be given to me to keep for my careful reading.

REFUSAL OR WITHDRAWAL OF PARTICIPATION:

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 57
 I understand that my participation is voluntary and I may withdraw

consent and discontinue the participation at any time. I also understand that

she may terminate my participation from the study at any time after she has

explained the reason for doing so.

INJURY STATEMENT

I understand that in the unlikely event of injury resulting directly from

my participation in this study, medical treatment would be available but no

further compensation will be provided. I understand that my agreement to

participate in this study and I am not waiving any of my legal rights.

I have explained to……………………………………..the purpose of

research, the procedure required and the possible risk and benefits, to the

best of my ability.

I confirrmed that Varsha M. Wadekar has explained me the purpose of

this research, the study procedure and the possible risk and benefits, that I

may experienced. I have read and understood this consent form to participate

as a subject in this research project and I am giving consent willfully.

SIGNATURE OR LEFT THUMB SIGNATURE OR LEFT THUMB

IMPRESSION OF SUBJECT IMPRESSION OF WITNESS

PLACE: INVESTIGATOR

SIGNATURE

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
Page 58
DATE

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar.
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 ANNEXURE II

DATA COLLECTION SHEET

Date:

Name of the participant: ______________________________________

Age: __________ Years

Sex: __________

Occupation: ________________________

Address and contact no. (If any): ________________________________

Study Group: Group A  Group B 

Involved side: Left  Right 

Duration after cast removal (days) _________________________________

Past

History:- _________________________________________________

_________________________________________________

_________________________________________________

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar. Page 60
ON EXAMINATION:

Pain intensity

0 10 Pre--Intervention

0 10 Post – Intervention

Pre treatment – Pain Post treatment – Pain

Right Left Right Left

Elbow Range of Motion assessment: (Universal Goniometer)

Type of movement Pre treatment ROM Post Treatment

ROM

Side affected Side affected

Elbow Flexion ROM

Elbow extension ROM

Signature of Examiner__________

“Effect of Mulligan Mobilization technique in post operative management of Supracondylar

Fracture of Humerus” -Varsha M. Wadekar. Page 61