Effectiveness of Muscle Energy Techniques and Mulligan Mobilization Along With Conventional Physical Therapy in Knee Joint Osteoarthritis Patients

Effectiveness of Muscle Energy Techniques and Mulligan Mobilization Along With Conventional Physical Therapy in Knee Joint Osteoarthritis Patients: A Randomized Controlled Trial

This study aims to evaluate the effectiveness of integrating Muscle Energy Technique (MET) and Mulligan Mobilization with conventional physical therapy in the management of knee osteoarthritis (OA), with a specific focus on improving hamstring flexibility and reducing functional limitations. The findings will help inform clinical decision-making and enhance patient outcomes in OA rehabilitation.

Study Overview

• Status: Completed
• Conditions: Knee Osteoarthritis
• Intervention / Treatment: Procedure: Mulligan Mobilization; Procedure: Muscle Energy Technique (MET)

Detailed Description

Osteoarthritis (OA) is a progressive degenerative joint disease characterized by the destruction of articular cartilage and the formation of bone spurs, leading to pain, joint stiffness, and decreased functional mobility. While its exact cause remains unknown, factors such as age, sex, obesity, sedentary lifestyle, genetics, bone density, smoking, and joint location contribute significantly to its development. As patients experience pain and reduced joint mobility, they often limit movement, particularly of the knee, resulting in muscular tightness-most notably in the hamstring, a two-joint muscle.

Globally, OA is a major public health concern, with knee OA affecting approximately 250 million people in 2010, including 18% of women and 9.6% of men over 60. It has substantial economic impacts, such as costing the United States 1-2.5% of its GDP and Spain €4.7 billion in 2007. Regional data from South Asia show higher prevalence in rural populations, emphasizing the disease's widespread burden.

Physical therapy has been shown to be highly effective in managing knee OA symptoms. Several randomized controlled trials support the use of techniques like Muscle Energy Technique (MET) and Mulligan Mobilization. MET has demonstrated superior efficacy compared to static stretching and whole-body vibration in improving hamstring flexibility and reducing stiffness. Similarly, Mulligan Mobilization, particularly when combined with supervised exercises, has shown better outcomes than Maitland mobilization in improving flexibility and function in OA patients.

However, current literature presents conflicting evidence regarding the individual efficacy of MET and Mulligan Mobilization. This study seeks to address these inconsistencies by investigating the effectiveness of integrating both MET and Mulligan Mobilization with conventional physical therapy in treating knee OA. The goal is to provide evidence-based insights that can guide clinicians in optimizing therapeutic strategies for better functional outcomes and enhanced quality of life for patients with knee osteoarthritis.

• Study Type: Interventional
• Enrollment (Actual): 24
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Pakistan
  • KPK
    • Peshawar, KPK, Pakistan, 25000
      • Hayatabad Medical Complex Peshawar
    • Peshawar, KPK, Pakistan
      • Alkhidmat Hospital Peshawar
    • Peshawar, KPK, Pakistan
      • Bibi Zahida Memorial Hospital, NCS University System

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Diagnosed cases of osteoarthritis (Grade 1 to 3)
• X-ray showing Grades I to III on Kellgren Lawrence scale of Osteoarthritis.
• Residents of Peshawar verified via NADRA CNIC
• Both genders will be included with unilateral or bilateral knee involvement.
• Age group 40 and above.
• Duration of Knee pain for more than 3 months.

Exclusion Criteria:

• History of any previously known neurological conditions i.e. stroke, peripheral neuropathy
• Fractures in treatment limb.
• Suspicious of malignancy around the knee joint.
• Recent under gone surgery
• Recent Intra-articular injection.
• Significant comorbid diseases and disabilities are excluded from the study

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intervention Group; Participants in this group will receive Mulligan Mobilization combined with Conventional Physical Therapy. Mulligan Mobilization includes medial and lateral tibial glides using a Mulligan belt. Each session will consist of 3 sets of 10 repetitions, administered 5 days a week for 3 weeks. In addition, patients will undergo standard conventional physical therapy exercises such as quadriceps strengthening, straight leg raising, and stretching exercises. Each treatment session will last 30 minutes.	Procedure: Mulligan Mobilization; Mulligan Mobilization involves manual tibial glides (medial and lateral) using a mobilization belt. The patient lies supine with the knee flexed between 30°-45°. The therapist applies a sustained glide while the patient actively moves the knee into flexion and extension. The treatment is delivered in 3 sets of 10 repetitions per session, 5 days per week for 3 weeks, along with a conventional physical therapy protocol.
Active Comparator: Control Group; Participants in this group will receive Muscle Energy Technique (MET) targeting the hamstring muscles, in combination with Conventional Physical Therapy. The MET will follow a post-isometric relaxation approach, using both direct and indirect methods depending on patient condition. Each isometric contraction will be held for 10 seconds, followed by a 20-second stretch, repeated for 3 sets. Therapy will be conducted 5 days a week over a 3-week period. Each session will last 30 minutes. The same conventional physical therapy regimen as the intervention group will be applied.	Procedure: Muscle Energy Technique (MET); Muscle Energy Technique involves the application of post-isometric relaxation targeting hamstring muscles. The therapist applies a 10-second isometric contraction at the resistance barrier, followed by a 20-second passive stretch, progressing into a new range of motion. This technique is applied 3 times per session, 5 days per week for 3 weeks, in combination with a conventional physical therapy protocol.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Hamstring Flexibility Measured by Goniometer	Hamstring range of motion (ROM) will be assessed using a goniometer before and after the intervention. The change in ROM will be used to evaluate effectiveness. Outcome improvement categories: Mild Increase: 5-10 degrees Moderate Increase: 10-15 degrees Marked Increase: >15 degrees	Baseline (Day 1) and Post-treatment (End of Week 3)
Change in Pain Score Using Knee Osteoarthritis Outcome Score-12 questionnaire Questionnaire	The function in daily activities subscale of Knee Osteoarthritis Outcome Score-12 questionnaire will assess participants' ability to perform routine activities before and after the intervention.	Baseline (Day 1) and Post-treatment (End of Week 3)
Change in Knee-Related Quality of Life Using Knee Osteoarthritis Outcome Score-12 questionnaire	The quality of life (QOL) subscale of KOOS-12 will evaluate the impact of osteoarthritis on participants' knee-related wellbeing pre- and post-treatment.	Baseline (Day 1) and Post-treatment (End of Week 3)
Change in Activity of Daily Living Function Using KOOS-12	The function in daily activities subscale of KOOS-12 will assess participants' ability to perform routine activities before and after the intervention.	Baseline (Day 1) and Post-treatment (End of Week 3)

Collaborators and Investigators

• Sponsor: Khyber Medical University Peshawar
• Investigators: Principal Investigator: Babar Israr, MSPT, Institute of Physical Medicine and Rehabilitation, Khyber Medical University Peshawar; Study Director: Shakir Ullah, PhD, Institute of Physical Medicine and Rehabilitation, Khyber Medical University Peshawar; Principal Investigator: Samra Farid, MSPT, Alkhidmat Hospital Peshawar

Publications and helpful links

General Publications

• Sanchez-Romero EA, Pecos-Martin D, Calvo-Lobo C, Ochoa-Saez V, Burgos-Caballero V, Fernandez-Carnero J. Effects of dry needling in an exercise program for older adults with knee osteoarthritis: A pilot clinical trial. Medicine (Baltimore). 2018 Jun;97(26):e11255. doi: 10.1097/MD.0000000000011255.
• Farazdaghi M, Kordi Yoosefinejad A, Abdollahian N, Rahimi M, Motealleh A. Dry needling trigger points around knee and hip joints improves function in patients with mild to moderate knee osteoarthritis. J Bodyw Mov Ther. 2021 Jul;27:597-604. doi: 10.1016/j.jbmt.2021.04.011. Epub 2021 Apr 30.
• Ceballos-Laita L, Jimenez-Del-Barrio S, Marin-Zurdo J, Moreno-Calvo A, Marin-Bone J, Albarova-Corral MI, Estebanez-de-Miguel E. Effects of dry needling on pain, pressure pain threshold and psychological distress in patients with mild to moderate hip osteoarthritis: Secondary analysis of a randomized controlled trial. Complement Ther Med. 2020 Jun;51:102443. doi: 10.1016/j.ctim.2020.102443. Epub 2020 May 18.
• Ashraf F, Anwar K, Arshad H. Effects of muscle energy technique along conventional physical therapy after mesenchymal stem cell transplantation in knee osteoarthritis patients. Pak J Med Sci. 2024 Dec;40(11):2558-2564. doi: 10.12669/pjms.40.11.9605.
• Goksen A, Can F, Yilmaz S, Korkusuz F. Comparison of different neuromuscular facilitation techniques and conventional physiotherapy in knee osteoarthritis. Turk J Med Sci. 2021 Dec 13;51(6):3089-3097. doi: 10.3906/sag-2101-298.

Study record dates

Study Major Dates

• Study Start (Actual): April 1, 2025
• Primary Completion (Actual): October 30, 2025
• Study Completion (Actual): November 28, 2025

Study Registration Dates

• First Submitted: April 24, 2025
• First Submitted That Met QC Criteria: April 24, 2025
• First Posted (Actual): May 1, 2025

Study Record Updates

• Last Update Posted (Actual): January 8, 2026
• Last Update Submitted That Met QC Criteria: January 6, 2026
• Last Verified: January 1, 2026

More Information

Terms related to this study

• Keywords: Knee Osteoarthritis; Muscle Stretching Exercises; Range of Motion, Articular
• Additional Relevant MeSH Terms: Musculoskeletal Diseases; Arthritis; Joint Diseases; Rheumatic Diseases; Osteoarthritis; Osteoarthritis, Knee
• Other Study ID Numbers: KMU/DIR/CTU/2024/015

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: The study will make individual participant data (IPD) available to other researchers after the conclusion of the study. The IPD shared will include anonymized data related to the primary and secondary outcome measures, including depression scores, biochemical markers (e.g., TNF-α, IL-6, BDNF), EEG data, and other relevant clinical and demographic data collected during the trial. The data will be de-identified to ensure participant confidentiality. The data will be shared through an approved data repository or by direct request to the study's primary investigators.
• IPD Sharing Time Frame: The data will be made available 6 months after the study's completion and will remain accessible for a period of 5 years to facilitate further research.
• IPD Sharing Access Criteria: Access to the data will be granted to qualified researchers upon submission of a formal request that includes a research proposal outlining the intended use of the data. Requests will be reviewed by the study investigators and ethical review committee to ensure compliance with data privacy regulations.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No