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INTRODUCTION

Osteoarthritis (OA) is recognized as a progressive, degenerative condition of the joints that does not primarily involve inflammation. It is marked by the breakdown of articular cartilage and the formation of osteophytes at joint surfaces [3]. While OA can affect any joint due to the natural aging process, it is more frequently observed in load-bearing joints such as the knees, hips, spine, and ankles [3].

Several factors contribute to the development of knee OA, including age-related degeneration, excess body weight, and prior trauma or surgical interventions involving the knee joint. A significant proportion of cases—approximately 80%—affect the medial compartment of the knee, often leading to a varus deformity, commonly known as a “bowlegged” posture. Less commonly, OA affects the lateral compartment, resulting in a valgus or “knock-kneed” appearance [2].
The McKenzie method, also known as Mechanical Diagnosis and Therapy (MDT), was introduced by Robin McKenzie in 1981. It is based on the principle that applying targeted, directional forces can alleviate pain and restore function. The approach involves three phases: assessment, treatment, and prevention. During assessment, patients perform repeated movements and assume sustained positions to identify patterns of symptom centralization. Based on their responses, patients are classified into derangement, dysfunction, or postural syndromes. Therapy using this method focuses on symptom reduction, centralization, and full functional recovery [8][2].

Brian Mulligan developed the Mobilization with Movement (MWM) approach, which involves applying a sustained accessory glide to a joint by the therapist, accompanied by the patient’s active movement to the end range. MWM also includes sustained natural apophyseal glides (SNAGs) for spinal joints. The technique incorporates passive end-range overpressure—akin to stretching—while ensuring it remains within a pain-free range [8]. MWM has also been applied to assess and manage knee conditions, including suspected meniscal involvement [8].

Although “positional faults” corrected during MWM have rarely been radiologically confirmed, they are typically identified and addressed based on clinical examination and technique-specific application. According to the Mulligan Concept, correcting these positional misalignments may help resolve clinical symptoms effectively [8].

To evaluate therapeutic outcomes in knee OA, the KOOS (Knee injury and Osteoarthritis Outcome Score) is frequently utilized. This validated tool assesses five subdomains: pain, symptoms, activities of daily living (ADL), sports/recreation function, and knee-related quality of life (QoL). It is commonly used in orthopedic research, including interventions such as meniscectomy, ligament repair, and joint replacement.

A prospective study conducted over three years highlighted a correlation between the narrowing of the joint cavity and the severity of OA symptoms, whereas the presence of osteophytes did not show a strong association with clinical manifestations [8].

In recent years, integrative physiotherapy techniques have emerged for the management of knee OA, aiming to shorten treatment duration while maximizing therapeutic outcomes. While both McKenzie exercises and Mulligan MWM have shown evidence of efficacy in managing knee OA individually, comparative data on their relative superiority remains limited. Therefore, this study aims to evaluate the comparative effectiveness of these two interventions.

OBJECTIVES

1. To evaluate the impact of the McKenzie method on knee osteoarthritis patients in terms of enhancing joint mobility and functional capacity.
2. To determine the effects of Mulligan Mobilization with Movement (MWM) on range of motion and physical function in individuals with knee osteoarthritis.
3. To compare the effectiveness of the McKenzie method and Mulligan MWM in improving mobility and physical function in knee osteoarthritis cases.

REVIEW OF LITERATURE

1. Huibin Long et al. [2022] explored osteoarthritis prevalence using data from the Global Burden of Disease Study 2019, analyzing site-specific patterns across demographics and locations. Their study identified the rising global burden of OA and emphasized the significance of timely preventive strategies and early management [13].
2. Klaus U. Schlüter-Brust and Peer Eysel [2010] conducted a thorough review of recent research on knee OA, utilizing multiple databases. Their analysis highlighted the uncertainty surrounding OA pathophysiology and confirmed the absence of a definitive cure. Treatment strategies span from conservative therapies like physiotherapy to surgical interventions, with a focus on symptom management and joint preservation [14].
3. Nadia A. Abd Elmeged and Amaal H.M. Ibrahim [2021] studied the effects of McKenzie exercises in females with Dowager’s Hump. Conducted over 8 weeks, the trial showed that incorporating McKenzie techniques led to substantial reductions in neck pain and improved functional outcomes in the cervical region [15].
4. Ruqia Manzoor and Muhammad Salman Bashir [2020] performed a randomized control trial comparing McKenzie therapy, Muscle Energy Technique (MET), and their combination in patients with chronic low back pain. The combined intervention proved most effective in enhancing quality of life and decreasing pain severity [16].
5. M. Holmes and T. Neogi [2023] focused on the association between therapeutic alliance, patient adherence, and clinical outcomes in individuals with knee OA undergoing physical therapy. Their findings underscore the role of clinician-patient rapport in improving adherence, which positively influences treatment effectiveness [17].
6. Mariusz Drużbicki and Łucja Kitrys [2024] assessed the post-surgical return to work among working-age individuals who underwent total knee arthroplasty (TKA). Their retrospective pilot study found that return-to-work rates were lower in Poland compared to global figures, partly due to the lack of structured occupational rehabilitation support [18].
7. Yomna F. Ahmed and Rania M. Tawfik [2023] investigated the effects of high-power pain threshold ultrasound (HPPTUS) in patients with stage II knee OA. Results showed that HPPTUS, when combined with conventional therapy, offered more effective pain relief than traditional ultrasound, validating its therapeutic potential [19].
8. Yan Luo and Masoud Rahmati [2024] conducted a systematic review and meta-analysis evaluating the efficacy of therapeutic ultrasound in treating knee OA. They concluded that pulsed ultrasound, particularly under specific parameters, was a safe and effective modality for managing pain and improving joint function [20].
9. Jay Indravadan Patel and Prem Kumar B N [2016] analyzed outcomes of combining McKenzie exercises with TENS in patients with lumbar radiculopathy. Participants receiving the combined treatment demonstrated significantly better improvements in pain, disability, and lumbar range of motion than those treated with general exercise and TENS alone [10].
10. Zeeshan Mehmood and Naveed Anwar [2021] compared Maitland mobilization and Mulligan MWM in knee OA patients. Their quasi-experimental study showed that Mulligan techniques, when paired with supervised exercise, were more effective in reducing pain, enhancing ROM, and improving patient function [6].

MATERIAL AND METHODOLOGY

This randomized controlled trial was carried out over approximately 10 to 12 months following ethical clearance. Participants were selected through convenience sampling from individuals diagnosed with knee osteoarthritis. The data collection took place at the Physiotherapy OPDs of Yogini Vasantdevi Hospital and MDAH, under KPGU, Vadodara.

The sample size was estimated using G*Power software (version 3.1.9.7), taking KOOS and ROM values from a prior study by Dr. Richard Rosedale. The reported means and standard deviations were 52 ± 16 for Group A and 61 ± 17 for Group B, yielding an effect size of 0.36. Based on an alpha error of 0.05 and beta error of 0.30 (i.e., 70% study power), a total of 34 participants were determined to be sufficient (17 in each group).

Inclusion Criteria:

• Males and females aged between 50 to 70 years.
• Diagnosis of knee osteoarthritis confirmed radiographically by an orthopedician.
• Persistent knee discomfort lasting more than three months [4][3].

Exclusion Criteria:

• Inability to participate in physiotherapy involving exercise.
• Neurological, cardiovascular disorders, or comorbidities like fever, tumors, or joint pathologies such as bursitis or tendinitis.
• Recent surgical procedures or intra-articular steroid injections within the last six months.
• Structural deformities affecting mobility, severe burns, or lack of informed consent [4][3].

Materials Used: Couch or plinth, Mulligan mobilization belt, foam mattress, consent and assessment forms, writing materials, goniometer, and support straps.

Participant Allocation: The 34 participants were randomly assigned to two groups:

• Group A: McKenzie Exercise protocol
• Group B: Mulligan’s Mobilization with Movement (MWM)

Group A: McKenzie Exercise Protocol : Pre- and post-treatment physiotherapy assessments were conducted. The treatment protocol followed the Mechanical Diagnosis and Therapy (MDT) approach, focused on derangement classification. Directional end-range exercises were selected based on patient-specific responses to repeated movement testing. Exercises included:

1. Seated Active Knee Extension: The patient, seated with knees at 90°, extends the leg fully, holds the position for 10–15 seconds, then returns to the starting posture.
2. Supine Active Knee Extension with Towel Support: A rolled towel is placed under the knee, and the patient performs full active extension.
3. Passive Overpressure in Sitting: With knees extended while seated, overpressure is applied using the hands above the knee.
4. Standing Knee Extension Over Support: The patient supports the knee over a stool and applies manual pressure to extend the knee.
5. Seated Knee Flexion: From a seated position, the patient bends the knee and draws the heel toward the buttocks.
6. Standing Knee Flexion Using a Chair: The foot is placed on a chair and the patient lunges forward to achieve deep flexion.
7. Kneeling Knee Flexion: The patient shifts backward while in a four-point kneeling position to increase knee flexion.

Adjunct Therapy: Ultrasound therapy at 3 MHz, continuous mode, with a power output of 1.3 W/cm² was administered [11].

Group B: Mulligan’s Mobilization with Movement (MWM) : The intervention involved therapist-assisted MWM techniques with continuous pre- and post-assessments.

1. Lateral Glide for Flexion: The patient is prone with the knee bent. The therapist applies a lateral tibial glide using a belt while passively flexing the knee.
2. Lateral Glide for Extension: With the knee extended, a lateral glide is sustained as the therapist performs passive extension.
3. Medial Glide for Flexion: The tibia is glided medially while the therapist performs passive flexion.
4. Medial Glide for Extension: A medial glide is maintained during passive extension of the knee.
5. Tibial Internal Rotation in Weight-Bearing: The patient stands with the foot on a raised surface and internally rotates the tibia while performing a squat to enhance flexion.

Adjunct Therapy: A similar ultrasound dosage was applied: 3 MHz frequency, continuous wave, at 1.3 W/cm² [11].

OUTCOME MEASURES

Range of Motion (ROM): ROM assessment provides a measure of joint flexibility and mobility. It is fundamental to both diagnosis and the initiation of physiotherapy. Joint range is influenced by the structure of the joint and the surrounding soft tissues, including muscles, ligaments, fascia, and nerves. Using a goniometer, joint movements—such as flexion, extension, abduction, adduction, and rotation—are quantified in degrees.

Knee Injury and Osteoarthritis Outcome Score (KOOS): KOOS is a validated, patient-reported outcome tool used to evaluate the symptoms and impact of knee osteoarthritis. It covers five dimensions: pain, symptoms, daily living activities, sports/recreational function, and quality of life. Originally derived from the WOMAC index, KOOS is designed to better assess younger or more active individuals with knee joint conditions. Multiple international validations support its use.

Figure 1: When sitting, Actively extend your knees     Figure 2: Active knee extension while in a supine position

Figure 3: Sitting with the knee extended                      Figure 4: Knee Extension when standing

Figure5: Sitting Knee Flexion                                        Figure6: Knee flexion while standing

Figure7: Knee flexion while in a kneeling position

RESULTS

Descriptive statistical analysis obtained using frequency, percentage, mean, SD, CI, median and IQR. Paired t- test was used for the comparison of Pre and post data within the group. Unpaired t-test was used for the comparison of data between group A and Group B. Data was analysed at 5% level of significance with confidence interval CI at 95%. All the statistical analysis was performed by using IBM SPSS version 29.0.0.

Table 1: Within Group & between Group Analyses

Table 2: Data representation of Age Distribution among Group A & B

Table 3:Demographic representation of gender wise distribution of participants in Group A & B

Table 4: Intra Group Comparison of parameters in Group A

Table 5:  Intra Group Comparison of parameters in Group B

Table 6: Data represent comparison of post-procedure parameters of Group A and Group B on Week 8. Unpaired t-test

Interpretation:

Unpaired t-test was used for the comparison of ROM and KOOS function between Group A and Group B as given in Table which showed significant improvement with P value at 0.017 and 0.014 respectively. It shows that the treatment given in Group B was more effective as compared to group A. Although there was significant improvement in patients of Group A post-intervention, but the patients of Group B responded better than Group A.

The mean and SD of Group A in ROM is 110.451 and 7.67 and for Group B is 113.902 9.81. Similarly, mean and SD of Group A in KOOS is 59.72 and 6.53 and for Group B is 63.18 and 9.33.

The following tables shows pre- and post- treatment data of both the groups including Standard deviation.

Chart 1: Standard Deviation Of Post 4 week and Post 8 week result of Group A

Chart 2: Standard Deviation Of Post 4 week and Post 8 week result of Group B

DISCUSSION