How to cite:

Retnaningsih, W et al. (2024). The Effects of Mulligan Technique and Ul-

trasound on Pain and Functional Ability in Shoulder Impingement Con-

dition at EMC Sentul Hospital. Journal Eduvest. 4 (1): 202-210

E-ISSN:

2775-3727

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Eduvest – Journal of Universal Studies

Volume 4 Number 01, January, 2024

p- ISSN 2775-3735- e-ISSN 2775-3727

THE EFFECTS OF MULLIGAN TECHNIQUE AND

ULTRASOUND ON PAIN AND

FUNCTIONAL ABILITY IN SHOULDER IMPINGEMENT

CONDITION AT EMC SENTUL HOSPITAL

Widiani Retnaningsih

, Yuli Peristiowati

, Nurwijayanti

1,2,3

Program Studi Magister Kesehatan Masyarakat, IIK Strada Indonesia

Email: aningwied[email protected]m

ABSTRACT

The shoulder joint is a highly mobile joint that is prone to injuries. Shoulder impingement is

a painful shoulder condition caused by injuries to the structures in the subacromial space.

Symptoms include pain, disruptions in daily activities, and a decrease in the range of motion

of the joint. The research aims to analyze the effects of the Mulligan Technique and Ultra-

sound on pain and functional ability in shoulder impingement conditions at EMC Sentul Hos-

pital. The research method used is a quasi-experimental design with pre and post-test con-

trol groups. Thirty participants were divided into two groups: an intervention group receiv-

ing the Mulligan Technique and Ultrasound (15 participants) and a control group receiving

TENS and conventional exercise therapy (15 participants). Each participant underwent six

sessions per week, twice a week. Before and after the treatment, each participant's pain

level was measured using the Numeric Rating Scale (NRS), and functional ability was as-

sessed using the Shoulder Pain and Disability Index (SPADI). The analysis of the data showed

that both treatments in the two groups reduced pain and improved functional ability in

shoulder impingement conditions. However, there was a significant difference in the group

receiving the Mulligan Technique and Ultrasound, with an average pain reduction from 6.6

NRS to 1.3 NRS and an increase in functional ability from 62.6% to 11.85%. In contrast, the

group receiving TENS and conventional exercise therapy showed an average pain reduction

from 3.6 NRS to 6.13 NRS and an increase in functional ability from 61.3% to 40.2%. In con-

clusion, the study suggests that the application of the Mulligan Technique and Ultrasound

is more effective in reducing pain and improving functional ability compared to TENS and

conventional exercise therapy in shoulder impingement conditions.

KEYWORDS

Shoulder impingement, Technical Mulligan, Mobilization with Movement,

Ultrasound

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INTRODUCTION

Shoulder Impingement is a complaint in the shoulder joint that occurs due to

injury to the structures in the subacromial space, including rotator cuff tendinosis,

bursitis, and partial tear of the rotator cuff tendon. Symptoms include pain, func-

tional impairment, and decreased range of motion (ROM) of the shoulder joint, re-

sulting in the inability to perform daily and other functional activities (Steuri et al.,

2017). Physiotherapy intervention is widely recommended as an alternative option

for managing shoulder pain complaints. Physiotherapy interventions such as ma-

nipulation and manual therapy are effective in improving shoulder joint range of

motion and reducing pain. Recommended manual therapy and manipulation tech-

niques include high-velocity, low-amplitude manipulation, end-range mobilization,

mid-range mobilization, and mobilization with movement (Doner et al., 2013). Mo-

bilization with movement is one of the Mulligan techniques based on the analysis

and correction of minor positional faults in the joint caused by soft tissue lesions,

resulting in limited physiological movement (ROM) (Lirio Romero et al., 2015).

Manual therapy combined with electrotherapeutic modalities such as Ultrasound is

recommended to assist in tissue healing and regeneration, reduce pain, and increase

ROM (Analan et al., 2015). Shoulder pain conditions, including musculoskeletal

disorders, are frequently encountered in the Physiotherapy outpatient clinic of EMC

Sentul Hospital. However, the success of therapy in this condition is still considered

insufficient due to the variety of intervention choices. Most patients present with

complaints of pain when raising their arms, difficulty in dressing and toileting ac-

tivities, and even disruption of sleep patterns due to pain. The aim of this study is

to analyze the influence of Mulligan Technique and Ultrasound on pain and func-

tional ability in shoulder impingement conditions.

RESEARCH METHOD

The research design is quasi-experimental with a pre-test and post-test control

group design. Respondents are divided into 2 groups: the intervention group and

the control group. The population in this study consists of patients who come to the

physiotherapy clinic at EMC Sentul Hospital with complaints of shoulder pain.

Sample selection is done randomly with simple random sampling that meets the

inclusion and exclusion criteria. The sample size is 30 respondents determined

based on the Federer formula. The sample is divided into 2 groups: the intervention

group with 15 respondents receiving the Mulligan Technique and Ultrasound, and

the control group with 15 respondents receiving TENS and conventional exercise

therapy.

The research is conducted at the physiotherapy clinic of EMC Sentul Hospital

from August 14, 2023, to September 30, 2023. In the initial stage, each respondent

undergoes a pre-test, which includes measuring the degree of pain with NRS and

measuring functional ability with SPADI (Shoulder Pain and Disability Index) in

both the intervention and control groups. Treatment in each group is provided for 6

sessions with a frequency of twice a week. Then, at the end of the study, a post-test

Widiani Retnaningsih, Yuli Peristiowati, Nurwijayanti

The Effects of Mulligan Technique and Ultrasound on Pain and Functional Ability in

Shoulder Impingement Condition at EMC Sentul Hospital

204

is conducted, which involves measuring again with the same parameters. Data col-

lection procedure: each respondent undergoes anamnesis to determine the medical

history, physical examination: specific tests such as Hawkin test, Neer test, and fill-

ing out SPADI and NRS questionnaires.

After collecting data, the degree of pain and functional ability values of each

respondent from both groups are analyzed using IBM SPSS version 25:

1. Descriptive and respondent characteristics: age, gender, duration of com-

plaint, and degree of pain and functional ability with mean, median, and

standard deviation.

2. Homogeneity test with Levene Test to determine if the sample from the pop-

ulation has homogeneous variances with a result of p > 0.05.

3. Hypothesis testing with paired two-sample t-test to assess the effect of pre

and post-test treatment in both groups (p < 0.05) and Independent two-sample

T-test to compare the difference in degree of pain and functional ability before

and after treatment (p < 0.05).

RESULT AND DISCUSSION

Descriptive statistics and characteristics of respondents

Descriptive respondents by gender

Table 1. Descriptive respondents by gender

All respondents from both groups, more female respondents (60%) than men

(40%).

Descriptive respondents by age

Table 2. Descriptive respondents by age

Gender

Frequency

Percentage

Male

40%

Female

60%

Total

n = 30

n = 100%

Age Category

Frequency

Percentage

19 – 30 year

31 – 40 year

41 – 50 year

51 – 60 year

16,7%

40%

26,6%

Total

n = 30

n = 100%

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From the table of age groups of respondents with the most shoulder

impingement complaints in the age range of 41 – 50 years (40%).

Descriptive old complaints

Table 3. Descriptive respondents based on the length of the complaint

Respondents with the most shoulder impingement with a complaint length of

less than 1 month, as many as 16 respondents (53.3%)

Average degree of pain of respondents before treatment

Tabel 4. Derajat nyeri rata-rata responden sebelum perlakuan

Group

Mean

Median Std Deviation

Intervention (n =15)

6,6

7 1,502

Control (n=15)

6,13

6 1,060

Based on the data above, the average pain picture of respondents before

treatment in the intervention group was 6.60 on the NRS scale. While in the control

group, the average degree of pain of respondents was 6.13 on the NRS scale.

The average degree of pain of respondents after treatment

Table 5. The average degree of pain of respondents after treatment

Group

Mean

Median Std Deviation

Intervention (n =15)

1,3

1 0,488

Control (n=15)

3,6

4 0,507

Based on the table above, the average degree of pain of respondents after

treatment in the intervention group dropped to 1.3 on the NRS scale, while in the

control group it dropped to 3.6 on the NRS scale.

Average functional ability of respondents before treatment

Table 6. Average Functional Ability of Respondents Before Treatment

Group

Mean

Median Std Deviation

Intervention (n =15)

62,6

62 10,857

Control (n = 15 )

63,8

61,5 9,73

The table above illustrates the average condition of respondents' functional

ability in the intervention group before treatment of 62.6%, while in the control

group the average functional ability of respondents was 63.8% on the SPADI scale.

Average functional ability of respondents after treatment

Table 7. Average Functional Ability of respondents after treatment

Group

Mean

Median Std Deviation

Intervention (n =15)

11,8

7,0 17,83

Control (n = 15 )

40,2

42 4,91

Length of Complaint

Frequency

Percentage

< 1 month

1 - < 3 month

y ≥ 3 month

53,3%

36,7%

10%

Total

n = 30

n = 100%

Widiani Retnaningsih, Yuli Peristiowati, Nurwijayanti

The Effects of Mulligan Technique and Ultrasound on Pain and Functional Ability in

Shoulder Impingement Condition at EMC Sentul Hospital

206

Based on the table above, an overview of the average functional ability of

respondents after treatment from the intervention group was 11.8% on the SPADI

scale. While in the control group it was 40.2% on the SPADI scale.

1. Homogeneity Test

Table 8. Levene Test

Variable

PreTest

sig

Post Test

sig

Pain

Functional Ability

0,151

0,750

0,478

0,287

From the Levene test it was found that the p - level test value of each group

obtained a p value of > 0.05, so it can be interpreted that the sample comes from a

population with homogeneous variance (similiar).

2. Hypothesis Test

Table 9. Paired two-sample t-test

Group

Pain ( sig )

Pre test Post

test

Functional Ability (sig)

Pre Test Post test

Intervention

Control

0,000 0,000

From the hypothesis test with the T Test of two paired samples of sig values

from both groups of 0.000 each, which means a p value of < 0.05, the treatment

given has an influence on the pain and functional ability of each group.

Table 10. Independent Two Sample T Test

Group

Speakers

(Mulligan &; Ultrasound

Technique)

Control

(TENS & Conventional

Training Therapy )

Pain

Functional Ability

1,333

11,85%

3,600

40,2%

From the results of the comparison test above, there are differences in the

effect of the treatment given, that the administration of Mulligan Technique and

Ultrasound is more significant in reducing pain compared to the administration of

TENS and conventional exercise therapy.

DISCUSSION

Analyzing the degree of pain in shoulder impingement conditions before

and after administration of Mulligan and Ultrasound Techniques

Based on the results of statistical tests using the T test of two paired samples,

the results of a sig value of 0.000 from both groups (p value < 0.05) this means

that the treatment in the intervention group and the control group has an influence

on pain in the condition of shoulder impingement. Meanwhile, based on the T test

of two independent samples to test the difference in the effect of treatment on pain,

a sig result of 0.000 (p value < 0.05) means that there is a difference in average pain

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between the control group and the intervention group, where the Mulligan

Technique and Ultrasound are more meaningful and effective in reducing pain

compared to the administration of TENS and conventional exercise therapy in

shoulder impingement conditions.

Based on descriptive data, the average decrease in respondents' pain degrees

in the intervention group was significant, which was 1.3 on the NRS scale from

before treatment by 6.6 on the NRS scale. Pain pathology occurs due to stimulation

of nociceptors (pain receptors) that deliver pain signals to the brain (Bahrudin,

2018). In the condition of shoulder impingement, stimulation of the nociceptor

occurs due to lesions / injuries to the shoulder. These injuries/lesions occur due to

incorrect positioning when lifting items, injuries due to sports, or repetitive

overhead activities. The Mulligan technique (mobilization with movement) can

reduce pain, because according to (Dharmawan et al., 2018) repetitive

movements mobilization with movement (MWM) will stimulate mecanorspetor so

that it can inhibit pain stimuli in nociceptive.

In addition, repeated MWM movements allow changing anti-inflammatory

mediators so as to inhibit pain nociceptors. In addition, based on research (Lirio

Romero et al., 2015), the provision of mobilization with movement (MWM) can

restore minor position faults of the shoulder joint by performing specific techniques

in the form of gliding manually, so that the maneuver can reduce pain and increase

joint mobility. Mobilization in peripheral joints produces hypoalgesion and

excitation simultaneously in the motor system and parasympathetic system.(Lirio

Romero et al., 2015). What is meant by Minor position fault in shoulder

impingement conditions is a change in the gap in the subacromial space that occurs

due to mechanical trauma from the subacromial bursa located in the antero-inferior

part of the acromion and clamping occurs when the shoulder joint moves flexion

and internal rotation (Dharmawan et al., 2018). It can be assumed that the

administration of the Mulligan Technique (mobilization with movement / MWM)

for 6x, will gradually be able to restore the minor position fault that occurs, so that

if the minor position fault has been corrected, it will be able to reduce pain and

improve the patient's functional ability.

In addition, ultrasound can help reduce pain, this is in accordance with studies

that say that the physiological effects of ultrasound administration are to improve

local blood circulation, increase vascular permeability, increase local metabolism

of tissues so as to reduce muscle pain and spasm.(Gürsel et al., 2004). In addition,

the effects of ultrasound can increase the speed of conduction of sensory and motor

nerves, which can increase the excitatory threshold for pain. Ultrasound in this

condition is given for 8 minutes with an intensity of 1.5w/cm2. After being given

ultrasound, the Mulligan technique is carried out, with mobilization with movement,

that is, the physiotherapist performs a manual technique in the direction of

dorsolateral gliding in the patient's humeral caput, while the patient moves the

shoulder in the direction of flexion (in the sagittal plane), and the physiotherapist

Widiani Retnaningsih, Yuli Peristiowati, Nurwijayanti

The Effects of Mulligan Technique and Ultrasound on Pain and Functional Ability in

Shoulder Impingement Condition at EMC Sentul Hospital

208

still maintains the direction of the dorsolateral gliding movement force vector

that, while following the patient's shoulder flexion movements.

This movement is carried out in 3 sets with 10x reps interspersed with breaks

of about 30' in each set. the combination of Mulligan technique and ultrasound has

a positive effect in reducing pain compared to TENS and conventional exercise

therapy in shoulder impingement conditions at EMC Sentul Hospital. Where with

the administration of Mulligan Technique and Ultrasound, respondents' pain

dropped significantly.

Analyzing functional ability in shoulder impingement conditions before

and after Mulligan and Ultrasound Techniques

Based on the results of statistical tests using the T test of two paired samples

to analyze functional ability in shoulder impingement conditions in both groups,

the results of sig values of 0.000 or p – value < 0.05 were obtained, this means that

the treatment in both groups had an effect in improving functional ability in

shoulder impingement conditions . Meanwhile, from the results of the T test

analysis of two independent samples to compare the difference in the effect of each

treatment on the functional ability of the two groups, a sig value of 0.000 or p value

of < 0.05 was obtained, this means that there is a difference in the effect of

Mulligan and Ultrasound Techniques compared to the administration of TENS and

conventional exercise therapy.

Based on descriptive data, the average functional ability of respondents from

the intervention group before treatment was 62.6% and after treatment was 11.85%.

On average, respondents in the intervention group after receiving treatment,

experienced low shoulder disability with functional ability to carry out activities

that were still good and independent. While in the control group the average

functional ability of respondents before treatment was 61.3% and after treatment

was 40.2%, which means that the average respondents in the control group

experienced moderate shoulder disability, with slightly limited functional ability,

but still able to do most daily activities.

The increase in the average functional ability of respondents with the

provision of the Mulligan Technique, according to (Dharmawan et al., 2018) is

influenced by several aspects, namely biomechanical aspects where there is a

correction of minor position faults in the shoulder joint. MWM movements that are

done repeatedly will correct the position error, so that joint mobility increases. In

addition, in terms of arthrokinematics, there is a proprioceptive repair of the joint

and an improvement in the physiological motion of roll glide in the glenohumeral

joint. In addition, based on the thermal effect of ultrasound, which increases the

colagen extensibility of tendons, joint capsules and connective tissue scars,

stretching exercises will be more effective.

From the results of data analysis tests and descriptive data, that the

administration of Mulligan and Ultrasound Techniques is more effective than the

administration of TENS and conventional exercise therapy in improving functional

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abilities in shoulder impingement conditions. The Mulligan Technique will affect

the mechanical changes of the joints with intraarticular repositioning so as to reduce

pain and increase the range of motion of the shoulder joint. While the administration

of ultrasound in addition to its physiological effects, the thermal effects of

ultrasound can help the process of tissue regeneration, reduce inflammation and

reduce muscle stiffness.

CONCLUSION

Based on the analysis of the data conducted and the study of existing theories,

it can be concluded that: 1. Mulligan technique combined with ultrasound is

effective in reducing pain in shoulder impingement conditions at EMC Sentul

Hospital. 2. Mulligan technique combined with ultrasound shows improved

functional ability that has a positive impact on patients with shoulder impingement

conditions at EMC Sentul Hospital, so that patients are able to carry out daily

activities independently better.

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patients with rotator cuff disease. Journal of Physical Therapy Science, 27(10),

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technique for adhesive capsulitis of the shoulder. Journal of Rehabilitation

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Gürsel, Y. K., Ulus, Y., Bilgiç, A., Dinçer, G., & Van Der Heijden, G. J. M. G.

(2004). Adding Ultrasound in the Management of Soft Tissue Disorders of the

Shoulder: A Randomized Placebo-Controlled Trial. Physical Therapy, 84(4),

336–343. https://doi.org/10.1093/ptj/84.4.336

Lirio Romero, C., Torres Lacomba, M., Castilla Montoro, Y., Prieto Merino, D.,

Pacheco da Costa, S., Velasco Marchante, M. J., & Bodes Pardo, G. (2015).

Mobilization With Movement for Shoulder Dysfunction in Older Adults: A

Pilot Trial. Journal of Chiropractic Medicine, 14(4), 249–258.

https://doi.org/10.1016/j.jcm.2015.03.001

Steuri, R., Sattelmayer, M., Elsig, S., Kolly, C., Tal, A., Taeymans, J., & Hilfiker,

R. (2017). Effectiveness of conservative interventions including exercise,

manual therapy and medical management in adults with shoulder

Widiani Retnaningsih, Yuli Peristiowati, Nurwijayanti

The Effects of Mulligan Technique and Ultrasound on Pain and Functional Ability in

Shoulder Impingement Condition at EMC Sentul Hospital

210

impingement: A systematic review and meta-analysis of RCTs. British

Journal of Sports Medicine, 51(18), 1340–1347.

https://doi.org/10.1136/bjsports-2016-096515

Analan, P. D., Leblebici, B., & Adam, M. (2015). Effects of therapeutic ultrasound

and exercise on pain, function, and isokinetic shoulder rotator strength of

patients with rotator cuff disease. Journal of Physical Therapy Science, 27(10),

3113–3117. https://doi.org/10.1589/jpts.27.3113

Bahrudin, M. (2018). Patofisiologi Nyeri (Pain). Saintika Medika, 13(1), 7.

https://doi.org/10.22219/sm.v13i1.5449

Dharmawan, P. K., Tirtayasa, K., -, W., Ngurah, I. B., Sandi, I. N., -, S., & -, S.

(2018). Kombinasi Caudal Traction Dan Mobilization With Movement Lebih

Baik Daripada Kombinasi Caudal Traction Dan Scapular Stability Exercise

Dalam Meningkatkan Kemampuan Fungsional Pada External Shoulder

Impingement Syndrome. Sport and Fitness Journal, 6(2), 38–50.

https://doi.org/10.24843/spj.2018.v06.i02.p05

Doner, G., Guven, Z., Atalay, A., & Celiker, R. (2013). Evaluation of mulligan’s

technique for adhesive capsulitis of the shoulder. Journal of Rehabilitation

Medicine, 45(1), 87–91. https://doi.org/10.2340/16501977-1064

Gürsel, Y. K., Ulus, Y., Bilgiç, A., Dinçer, G., & Van Der Heijden, G. J. M. G.

(2004). Adding Ultrasound in the Management of Soft Tissue Disorders of the

Shoulder: A Randomized Placebo-Controlled Trial. Physical Therapy, 84(4),

336–343. https://doi.org/10.1093/ptj/84.4.336

Lirio Romero, C., Torres Lacomba, M., Castilla Montoro, Y., Prieto Merino, D.,

Pacheco da Costa, S., Velasco Marchante, M. J., & Bodes Pardo, G. (2015).

Mobilization With Movement for Shoulder Dysfunction in Older Adults: A

Pilot Trial. Journal of Chiropractic Medicine, 14(4), 249–258.

https://doi.org/10.1016/j.jcm.2015.03.001

Steuri, R., Sattelmayer, M., Elsig, S., Kolly, C., Tal, A., Taeymans, J., & Hilfiker,

R. (2017). Effectiveness of conservative interventions including exercise,

manual therapy and medical management in adults with shoulder

impingement: A systematic review and meta-analysis of RCTs. British

Journal of Sports Medicine, 51(18), 1340–1347.

https://doi.org/10.1136/bjsports-2016-096515