Blood Flow Restriction Training Versus Mulligan Technique in Treatment of Lateral Epicondylitis : a Randomized Controlled Trial
Phase: NA
Conditions: Lateral Epicondylitis (Tennis Elbow)
Sponsor: Cairo University

 BLOOD FLOW RESTRICTION TRAINING VERSES 
MULLIGAN TECHNIQUE IN TREATMENT OF 
LATERAL EPICONDYLITIS : RANDOMIZED 
CONTROLLED TRIAL 
 
 
 
 
 
 
 
 
 
By 
 
Majed Abdulrahman Alghamdi 
B.sc of musculoskeletal physical therapy, Umm Al-Qura University (2012) 
M.sc of musculoskeletal physical therapy, Umm Al-Qura University (2021) 
 
 
 
 
 
 
 
 
 
 
 
 
Submitted in Partial Fulfillment of the Requirements for the Degree Doctoral 
 
in Physical Therapy, Department of Physical Therapy for 
 
Musculoskeletal Disorders and its Surgery
 
Faculty of Physical Therapy
 
Cairo University
 
2025 

 
SUPERVISION 
 
 
 
 
 
Prof / SALWA FADL ABD EL MAJEED 
Professor of Physical Therapy for Musculoskeletal  
Disorders and its Surgeries 
Faculty of Physical Therapy 
Cairo University 
 
 
 
Prof / Nasr Awad Abd El Kader  
Assistant Professor of Physical Therapy for Musculoskeletal  
Disorders and its Surgeries 
Faculty of Physical Therapy 
Cairo University 
 
 
 
 
Dr. / ABDELGALIL ALLAM ABDELGALIL 
Lecturer of Physical Therapy for Musculoskeletal  
Disorders and its Surgeries 
Faculty of Physical Therapy  
Cairo University 
 
 

 
 
 
 
 
 
 
List of Abbreviations 
 
Abbreviation 
Full Form 
LE 
 
Lateral epicondylitis 
BFR 
Blood-flow restriction  
BFRT 
Blood-flow restriction training  
1-RM 
One repetition maximum  
PrTEE 
patient-rated tennis elbow evaluation  
LL-BFR 
Low-load BFR  
LL-RT 
Low-load resistance training  
HL-RT 
High-load resistance training  
MWM 
Mulligan Mobilization with movement 
 
 
 

 
 
 
 
 
 
 
 
 

1 
 
CHAPTER I 
INTRODUCTION 
Lateral epicondylitis (LE) is a work-related musculoskeletal disorder 
caused by the tendon’s inflammation of either one or both of the extensor carpi 
radialis longus and extensor carpi radialis brevis. It is often referred to tennis 
elbow. It manifests as pain on the lateral side of the elbow and reduced range of 
motion, which results in weakening and impairment in the forearm muscles 
(Ahmad et al., 2013).With no sex predisposition, LE is a widespread ailment 
that affects up to 3% of the population (Vaquero-Picado et al., 2017). 
Etiological factors of LE include overuse, repetitive movements, physically 
forceful occupational activities, exercise errors, misalignments, flexibility 
problems, ageing, muscle imbalances and psychological (e.g. job strain) factors. 
The estimated incidence of LE ranges from 2.0–11.3 per 100 worker-years in 
specific activity sectors (Herquelot et al., 2013; Bongers et al., 2002). 
The prevalence of tendinopathy has risen significantly along with the 
popularity of sports. Treatments and nonoperative methods for various diseases 
are constantly being developed and improved. Up to 3% of adults between the 
ages of 40 and 55 suffer with LE, a prevalent and painful degenerative 
tendinopathy of the lateral elbow (Shiri et al., 2006). With a constantly 
increasing number of players and courts throughout over 40 different countries, 
the sport is becoming more and more popular (Demeco et al., 2022; Escudero-
Tena et al., 2021). However, depending on the disease and sex, medial 
epicondylitis is commonly reported to affect the working population, with a 
frequency ranging from 0.3 to 4.0% (Chiarotto et al., 2023). 
LE is treated with a variety of techniques, such as electrophysical modalities 
(low-level 
laser 
therapy, 
low-frequency 
electrical 
stimulation, 
and 
extracorporeal shockwave therapy), exercise therapy (stretching and resistance 

2 
 
exercises), and manual therapies (massage and joint mobilization), with the 
goals of reducing pain, preserving range of motion, and enhancing the strength 
and endurance of the afflicted muscles (Coombes et al., 2015). 
Blood-flow restriction training (BFRT), which may also be referred to as 
Kaatsu, occlusion or hypoxic training, has become an increasingly popular 
method of resistance training in recent years (Rolnick et al., 2021). BFRT 
involves the application of straps or pneumatic cuffs around an upper or lower 
limb extremity, with cuff pressure aiming to partially restrict arterial blood 
flow, while also occluding venous outflow while the cuff pressure remains 
intact (Patterson et al., 2019; Lorenz et al., 2021). BFRT has been shown to 
be an effective resistance training method for enhancing muscle strength and 
hypertrophy in healthy populations and in the rehabilitation of musculoskeletal 
pathologies and following orthopedic surgery (Hughes et al., 2018; Barber-
Westin & Noyes, 2019; Lowery et al., 2014; Nitzsche et al., 2021). 
According to Baker et al.(2013) mobilization with movement is a 
modern technique  developed by Mulligan to treat the symptoms of tennis 
elbow or LE. Mulligan mobilization with movement (MWM) is a form of 
manual therapy that  includes sustained lateral glide movements to the elbow 
joint along with   physiological movements (Hing et al., 2015; Mani et al., 
2017; Bessler  &  Beyerlein,  2019). MWM has been shown to reduce pain and 
increase  functional activity (Janikowska & Fidut, 2013; Ahuja, 2014).  
Statement of the Problem 
This study will try to answer to the following question: 
What is the comparative effectiveness of BFRT versus Mulligan’s 
technique in improving pain, grip strength, and functional outcomes in patients 
with LE ? 
 
 

3 
 
Gap of knowledge: 
While BFRT has shown promise in improving muscle strength and 
reducing pain in patients with LE, there is no evidence on its effectiveness when 
compared to Mulligan’s technique. Mulligan’s technique has been used to 
address joint dysfunction and pain in various musculoskeletal conditions, but its 
role in LE management, particularly when compared to BFRT, remains unclear. 
Additionally, there is a lack of randomized controlled trials (RCTs) comparing 
the effectiveness of BFRT versus Mulligan’s technique. This study seeks to fill 
this gap by providing evidence on the comparative effectiveness of these 
interventions, which could inform clinical decision-making and optimize 
rehabilitation protocols for LE. 
Purpose of the Study 
The purpose of this study is to evaluate the effectiveness of blood flow 
restriction training (BFRT) verses Mulligan’s technique in improving pain, grip 
strength, and functional outcomes in patients with lateral epicondylitis (LE).  
Significance of the Study 
This study holds significant clinical and practical implications. While 
various treatment modalities, including physiotherapy, corticosteroid injections, 
and surgical interventions, have been explored, there remains a need for non-
invasive, cost-effective, and evidence-based interventions that provide lasting 
relief (Coombes et al., 2015). This study is significant as it investigates the 
comparative effects of Blood Flow Restriction Training (BFRT) and Mulligan’s 
technique, two promising but underexplored approaches in the management of 
LE. 
By evaluating the effectiveness of BFRT versus Mulligan’s technique and 
their combined application, this study aims to provide clinicians with valuable 

4 
 
insights into optimizing rehabilitation strategies for LE. Blood Flow Restriction 
Training has gained attention for its ability to enhance muscle strength and 
promote tissue healing with low-load resistance exercises, potentially reducing 
stress on the affected tendons (Rolnick et al., 2021; Patterson et al., 2019; 
Lorenz et al., 2021). Meanwhile, Mulligan’s technique is known to improve 
pain-free movement and joint function. Understanding whether these techniques 
are most effective individually or in combination could refine rehabilitation 
protocols and enhance patient outcomes (Hing et al., 2015; Mani et al., 2017; 
Bessler  &  Beyerlein,  2019). 
Hypotheses 
It will be hypothesized that: 
1. There will be no significant difference between BFRT or Mulligan’s 
technique on pain in patients with lateral epicondylitis (LE). 
2. There will be no significant difference between BFRT or Mulligan’s 
technique on grip strength in patients with LE. 
3. There will be no significant difference between BFRT or Mulligan’s 
technique on functional outcomes (measured by PRTEE scores) in 
patients with LE. 
Basic Assumptions 
The study is based on the following assumptions: 
1. Participants will adhere to the prescribed BFRT and Mulligan's 
mobilization protocols. 
2. The outcome measures (e.g., pain intensity, grip strength, PRTEE scores) 
are valid and reliable indicators of functional improvement in patients 
with LE. 

5 
 
3. The BFRT or Mulligan's mobilization protocols will be applied 
consistently and safely across all participants. 
4. The effects observed in the study population can be generalized to other 
individuals with LE. 
Delimitations 
The study is delimited by the following factors: 
1. Population: The study will focus on 36 male and female adults aged 
between 18-50 diagnosed with LE, excluding individuals with other 
upper limb conditions or contraindications to BFRT or Mulligan's 
mobilization (e.g., vascular disorders, joint instability). 
2. Intervention: The study will evaluate a specific BFRT protocol (e.g., 20–
30% of 1RM, 50% limb occlusion pressure) and Mulligan's mobilization 
technique, with predefined parameters for frequency, duration, and 
intensity. 
3. Outcome Measures: The primary outcomes will be pain intensity, grip 
strength, and functional ability (measured by PRTEE scores), with 
secondary outcomes including patient-reported global improvement and 
range of motion. 
4. Duration: The intervention will be conducted over a 4-week period, with 
follow-up assessments at 4 weeks to evaluate long-term effects. 
 
 
 

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CHAPTER II 
LITERATURE REVIEW 
The literature review will be written under the following headings: 
1. Lateral epicondylitis 
2. BFRT Application Overview 
3. Mechanisms of BFRT 
4. Musculoskeletal Rehabilitation Outcomes of BFRT 
5. BFRT in Tendinopathy Rehabilitation 
6. Mulligan mobilization concept 
7. Mulligan and LE 
 
Lateral epicondylitis: 
Lateral epicondylitis, a degenerative disorder that compromises the 
extensor tendons originating from the lateral epicondyle, extending infrequently 
to the joint. These are associated with repetitive tasks, forceful exertions, 
vibrations, mechanical compression, and sustained or awkward positions that 
can affect almost any movable part of the human body. Symptoms could restrict 
participation in physical activity, sports, and work, as well as recur and persist 
for years (Ahmad et al., 2013).  It is usually diagnosed through a combination 
of physical examination and, in some cases, imaging tests. A doctor will assess 
the symptoms, including pain and tenderness on the outer elbow, and may 
perform specific tests to reproduce the pain. Imaging, such as X-rays or MRI, 
may be used to rule out other conditions or evaluate the extent of tendon 
damage (Coombes et al., 2015). 

7 
 
Hence, it is conferred that therapists implement a variety of treatment 
techniques to improve range of motion, dexterity, and hand use in daily activity, 
with manual techniques, scar management, and edema control cited among the 
most critical and frequently used interventions. In hand therapy, practitioners 
assess and implement tailored intervention programs to address a range of 
diagnoses with varying severity, complexity, and chronicity (Sloane et al., 
2020).  
BFRT Application Overview: 
The application of BFRT involves key considerations related to training 
parameters, cuff selection, and safety. Training loads typically range between 
20–40% of one repetition maximum (1-RM) to enhance strength and 
hypertrophy. The most common protocol includes four sets of 75 repetitions 
(30, 15, 15, 15), performed to muscular failure or completion, with short inter-
set rest periods of 30–60 seconds while maintaining cuff restriction . Training 
frequency is recommended at 2–4 times per week, similar to traditional 
resistance training, with interventions lasting at least three weeks for optimal 
adaptations (Burton & McCormack, 2022). 
A tourniquet or pressurized cuff is applied to the proximal region of the 
body part being trained during BFRT, a strengthening exercise. After that, the 
tourniquet's cuff is inflated to a predetermined pressure (usually 150 mmHg) to 
provide both partial and complete venous occlusion (Scott et al., 2015). By 
utilizing pressure cuffs to simulate a hypoxic environment, BFRT attempts to 
replicate the effects of high-intensity exercise. It is thought that hypoxic 
conditions speed up the healing process required for injuries to muscles and 
tendons. In addition to being less tolerant of strengthening training regimens, 
those with LE exhibit a marked decline in handgrip function and muscle 
strength, which requires attention. Because low-intensity exercise is generally 
easier for people with pain or other inflammatory conditions, such as LE, to 

8 
 
endure, BFRT can be helpful in situations where it can produce a hypoxic 
environment similar to high-intensity exercise (Scott et al., 2015; Wilson et al., 
2013). 
The mechanisms of action of BFRT in muscular adaptation are not fully 
elucidated but are thought to be related to increased inflammation, mechanical 
tension and metabolic stress which augments plasma growth hormone and blood 
lactate levels (Lixandrao et al., 2018; Teixeira et al., 2018). Due to a paucity 
of research, it is unclear what effects BFRT may have on tendons, but the 
induced muscular milieu in response to ischemia may facilitate adaptations in 
morphological and mechanical tendon properties through enhanced collagen 
metabolism and tendon remodeling (Pearson & Hussain, 2015; Klein et al., 
2001).  
Cuff application is critical, with factors such as pressure, width, and 
material influencing outcomes. Arterial occlusion pressure varies by individual 
and is typically set at 40–80% of arterial occlusion pressure. Cuff widths range 
from 3–18 cm, with wider cuffs requiring lower pressures. Cuff materials (e.g., 
elastic, nylon) do not significantly impact outcomes if occlusion pressure is 
properly applied (Ellefsen et al., 2015). 
Safety is paramount, as BFRT induces systemic cardiovascular and 
vascular responses. While it has a comparable safety profile to traditional 
resistance training, clinicians must monitor for risks like deep vein thrombosis 
(Minniti et al., 2020; Warmington et al., 2016). Tools like the Well’s criteria 
can help assess clotting risk. Despite its benefits, barriers to implementation 
include determining pressures, access to technology, and managing patient 
discomfort. Evidence-based strategies to address these barriers include using 
lower, individualized pressures, preferring narrow cuffs, employing intermittent 
BFRT, avoiding training to failure, incorporating familiarization periods, and 
emphasizing the importance of effort to patients. 

9 
 
Mechanisms of BFRT: 
The exact mechanisms behind BFRT's effects remain unclear, but several 
theories suggest it enhances muscular strength and hypertrophy. The hypoxic 
microenvironment created by BFRT leads to metabolite accumulation, increased 
anabolic signaling, and hormonal responses due to greater muscular fatigue and 
activation. This metabolic stress raises plasma growth hormone and blood 
lactate levels, accelerating neuromuscular fatigue earlier than traditional 
resistance training. Research indicates that low-load BFRT significantly 
increases blood lactate levels, comparable to high-load resistance training. The 
accumulation of metabolites, along with increased inflammatory cytokines and 
myokines, promotes muscle satellite cell activation (Rossi et al., 2018; Shimizu 
et al., 2016). 
In response to reduced oxygen availability, reactive oxygen species such 
as nitric oxide and vascular endothelial growth factor increase, stimulating 
angiogenesis similar to traditional resistance training. Muscular fatigue also 
leads to greater motor unit recruitment. Endocrine responses linked to BFRT 
include elevated free testosterone, serum growth hormone, insulin-like growth 
factor-1, and changes in gene activity, such as decreased myostatin mRNA 
expression (Cook  et al., 2014; Drummond et al., 2008; Sieland et al., 2021). 
While traditional resistance training also induces metabolic stress and hormonal 
responses, the combination of mechanical tension and metabolic effects in 
BFRT may enhance muscular adaptations (Teixeira et al., 2018). 
Beyond muscle growth, BFRT positively affects multiple physiological 
systems, including cardiopulmonary function, vascular compliance, bone health, 
psychological well-being, musculoskeletal and neural function, and anaerobic 
and aerobic capacity, making it a valuable tool in rehabilitation (Burton & 
McCormack, 2022). 

10 
 
Musculoskeletal Rehabilitation Outcomes of BFRT: 
Recent research suggests that low-load BFR (LL-BFR) training may be 
highly effective in early musculoskeletal rehabilitation, promoting muscular 
hypertrophy and being only slightly less effective than high-load resistance 
training (HL-RT) for strength gains (Couppe et al., 2015; Loenneke et al., 
2012; Nielsen et al., 2017; Manini & Clark, 2009). Traditional resistance 
training typically requires loads of 70% or more of 1-RM, whereas BFRT uses 
lower loads (20–40% of 1-RM), making it more suitable for patients unable to 
tolerate high muscle-tendon loads while still preventing muscle atrophy. 
Additionally, BFRT has been shown to induce exercise-related hypoalgesia 
through endogenous opioid and endocannabinoid mechanisms, making it a 
potential tool for pain management in early rehabilitation (Hill, 2020; Hughes 
et al., 2021; Hughes & Patterson, 2020; Hughes & Patterson, 2019). 
Interventional studies have found superior or similar outcomes for pain 
improvement with low-load BFRT compared to conventional high-load 
resistance training for various other musculoskeletal disorders such as 
osteoarthritis (Nitzsche et al., 2021). Recent evidence suggests that low-load 
BFRT may be a superior method for augmenting muscular adaptations in early 
musculoskeletal rehabilitation, which has been found to have comparable 
outcomes for inducing muscular hypertrophy and for increasing muscular 
strength compared to high-load resistance training (Loenneke et al., 2012).  
BFRT has gained increasing attention in clinical populations. A 
systematic review and meta-analysis of 20 studies found it moderately effective 
for strength gains, though slightly less so than HL-RT (Nitzsche et al., 2021). 
However, BFRT was more effective and tolerable compared to low-load 
resistance training (LL-RT). Another review of 10 randomized controlled trials 
on lower limb musculoskeletal conditions reported that LL-BFR increases 
muscle strength and volume while reducing pain at levels comparable to both 

11 
 
LL-RT and HL-RT (Lowery et al., 2014). A meta-analysis on knee 
osteoarthritis found little to no difference between LL-BFR and HL-RT in terms 
of pain relief, function, strength, and muscle size improvements (Hayhurst et 
al., 2021). Similarly, reviews on osteoarthritis and rheumatoid arthritis showed 
LL-BFR to be as effective as moderate and HL-RT for strength, muscle mass, 
and functional outcomes while outperforming LL-RT (Grantham et al., 2021). 
Meta-analysis also support BFRT for rehabilitation following anterior 
cruciate ligament reconstruction, knee surgery, osteoarthritis, muscle atrophy, 
sarcopenia, and various knee conditions, including patellofemoral pain and 
post-arthroscopy recovery (Dos Santos et al., 2021). Research confirms 
BFRT’s safety in rehabilitation, with a systematic review of 19 studies showing 
no increased risk of adverse events compared to standard exercise therapy 
(Hunt et al., 2012). 
The growing body of research also indicates BFRT’s efficacy for a range 
of musculoskeletal conditions, including polymyositis, dermatomyositis, 
rheumatoid arthritis, and muscle atrophy. Additionally, early evidence suggests 
it may benefit ankle sprains, fractures, shoulder injuries, reactive arthritis, 
thoracic outlet syndrome, and spinal cord injury. Beyond musculoskeletal 
rehabilitation, BFRT is being explored for chronic medical conditions such as 
type 2 diabetes, chronic kidney disease, hypertension, cardiovascular disease, 
cancer, and even coma patients (Burton & McCormack, 2022). 
BFRT in Tendinopathy Rehabilitation: 
Three studies have explored LL-BFR for tendinopathy rehabilitation, all 
focusing on patellar tendinopathy. Two case reports and one case series have 
demonstrated positive outcomes. One case report examined two collegiate 
decathletes with patellar tendinopathy who performed LL-BFR using single-leg 
press and decline squat exercises twice per week for 12 weeks (Yow et al., 

12 
 
2018). Both athletes showed improvements in pain, function, strength (leg press 
1-RM), tendon thickness, and hypoechoic tendon regions on ultrasound. 
Another case report investigated LL-BFR in a basketball player, incorporating 
various exercises at 30% of 1-RM for 5–6 days per week. The patient improved 
clinically, returned to competitive basketball, and exhibited reduced tendon 
signal intensity on magnetic resonance imaging, indicating structural 
improvements (Cuddeford & Brumitt, 2020). 
A case series of seven patients with patellar tendinopathy tested a three-
week LL-BFR protocol using single-leg press and knee extension exercises at 
30% of 1-RM. Patients trained three times per week, progressing volume based 
on pain response. Despite the short duration, all participants experienced 
reduced pain, improved function, increased strength, and a 31% decrease in 
tendon vascularity, though tendon thickness remained unchanged. The study 
also reported a high adherence rate of 98%, suggesting LL-BFR is a feasible 
and effective rehabilitation method (Sata, 2005). 
Although no definitive clinical guidelines for BFRT in tendinopathy 
exist, protocols such as Skovlund et al.  may serve as models for 
implementation. The commonly recommended BFRT protocol of four sets (30, 
15, 15, 15 repetitions) has been studied in both tendon pathology cases and 
healthy tendons, making it a potential alternative for Achilles and patellar 
tendinopathy rehabilitation. Few studies showed the direct benefit of BFRT for 
LE; however, several studies show the effectiveness of BFRT in rehabilitation 
for tendinopathy problems. A previous case series (Skovlund et al., 2020), on 
the effect of LL-BFR exercise on chronic patellar tendinopathy, showed similar 
results to this study where through 3 weeks of LL-BFRT, there was a 50% 
reduction in pain scores during single-leg decline squat functional activity. 
Another study found that BFR could activate the mechanistic target of 
rapamycin signaling pathway as an essential cellular mechanism to enhance 

13 
 
muscle-tendon protein synthesis during the tendon healing process (Fujita et 
al., 2007). Thus, LL-BFRT intervention might have facilitated the repair of 
tendon structure in LE patients. 
The main benefit of providing BFRT for the subject is that with a low 
load, it can achieve the same morphological and mechanical changes and 
adaptations as resistance exercise using a high load. Low loads tend to provoke 
little or no symptoms when compared to high loads, so BFRT is best used when 
the goal of treatment is to improve muscle strength, but resistance exercise 
(with high loads) tend to provoke the symptoms, which tends to make the 
subject feel uncomfortable, affects the subject’s psychological condition that 
makes them refuse to do exercises, and can even increase the risk of tendon re-
inflammation (Kinandana et al., 2023). 
The previous meta-analysis study (Slysz et al., 2016), with a total of 400 
participants from 19 different studies, supported this study regarding the 
effectiveness of BFR exercise in increasing muscle size and strength. The 
authors of this study explained that adding BFRT during exercise could 
consistently increase muscle size and strength, although the effect size varied 
among the loads (i.e., low-intensity or moderate-intensity) and types of exercise 
(i.e., aerobic or anaerobic). They suggested the arterial occlusion pressure was 
>150 mmHg and the load applied to BFRT >25% of 1 repetition maximum (1-
RM) to produce muscle hypertrophy (Slysz et al., 2016), which has verified that 
this study used a load range of 20 - 40% of 1-RM and has shown promising 
results compared to high-intensity RE. 
Despite these potential beneficial physiological mechanisms of BFRT on 
tendon healing, BFRT has received a paucity of attention in tendon 
rehabilitation. Reported side-effects include perceptual type responses (ie, 
fainting, numbness, pain, and discomfort), delayed onset muscle soreness, and 
muscle damage. There may be heightened risk to the cardiovascular system, in 

14 
 
particular increased blood pressure responses, thrombolytic events, and damage 
to the vasculature (Brandner et al., 2018). However, while these may be of 
some concern there is no evidence to suggest that BFRT elevates the risk of 
complications any more than traditional exercise modes.  
Several modifiable extrinsic factors for risk minimization include 
selecting the appropriate BFR pressure and cuff width, as well as completion of 
a pre-exercise safety standard questionnaire to determine any contraindications 
to BFR or indeed the prescribed exercise. On the basis of the available evidence, 
the side-effects of using BFR are minimal, and further minimized by the use of 
an appropriate method of application in the hands of a trained practitioner 
(Brandner et al., 2018). 
Mulligan mobilization concept: 
The Mulligan concept of MWM is a manual therapy technique that has 
been designed to address positional faults for restoration of normal 
arthrokinematic and osteokinematic motion. Mulligan hypothesized that a 
positional fault has been identified and corrected when MWM abolishes pain, 
restores function, and provides a long-lasting therapeutic effect (Baker et al., 
2013). MWM may be appropriate for relief of pain, movement impairments, 
reduced muscle length, and positional faults. All precautions and 
contraindications associated with joint mobilization and manual therapy are 
applicable to MWM, which could have an adverse effect on an injured joint. 
MWM involves a sustained passive joint glide while the patient actively moves 
the joint (or motion segment) (Hing et al., 2015). The accessory glide may or 
may not be applied by the clinician while the patient is performing active 
movements (Lucado et al., 2019). Upon completion of the MWM technique, 
the clinician assesses the ability of the patient to perform the same movement 
without manual application of the accessory glide or the patient’s ability to 

15 
 
perform a functional task (e.g., reaching for an object in a range of motion that 
was previously impaired) (Baker et al.(2013).  
Mulligan and LE: 
MWM is more beneficial than comparison groups at improving pain on 
the visual analogue scale in the short term (<3 months) and intermediate term 
on patients with LE (Lucado et al., 2019). Meta-analytic pooling found 
statistically significant models for MWM on the visual analogue scale, and the 
heterogeneity between the studies was low. In addition, MWM is more 
beneficial than control groups at improving grip strength in the short term on 
patients with LE. Meta-analytic pooling found a statistically significant model 
for MWM on grip strength with low heterogeneity. Based on the available body 
of evidence of this meta-analysis, the authors recommend the clinical use of 
MWM directed at the elbow for a moderate positive effect on self-reported pain 
and decreased pain-free grip strength in the short term (Lucado et al., 2019). 
The Mulligan technique, which can be summarized as a combination of active 
movement and mobilization of the joints in the correct position within the 
framework of biomechanical principles, aims at painless recovery. This 
technique includes natural apophyseal glides, sustained natural apophyseal 
glides, and MWM (McDowell et al., 2014). Anap et al. proposed that Mulligan 
MWM technique restored normal tracking of the radius over the capitulum so 
that strengthening of the forearm muscles can be done without painful 
symptoms, which led to pain-free grip strength (Anap et al., 2012). In 2003, 
Paungmali et al. showed that Mulligan MWM produces sensory input sufficient 
to recruit and activate descending pain inhibitory systems that result in most of 
the pain-relieving effects (Paungmali et al., 2003). 
 
 

16 
 
CHAPTER III 
PATIENTS, MATERIALS AND METHODS 
Settings and design: 
This study will be a randomized controlled trial. The study will use a pre-
test and posttest control group design that aims to determine the effectiveness of 
BFRT verses MWM regarding grip strength, pain intensity and functional 
ability in an individual with LE. The study will be conducted in Cure private 
clinics in Egypt and an informed consent will be obtained from each patient 
(Appendix 1).  
Ethical Approval 
The protocol of this study will be reviewed by the ethics committee of 
scientific research at the faculty of physical therapy, Cairo University. 
Participants: 
The inclusion criteria in this study will be: 
1) 36 subjects of both gender aged between 18 and 50 years with a positive test 
of LE (Positive Cozen’s, Maudsley’s, and/or Mill’s test), which has been 
determined based on physical therapy assessment procedures; 2) the presence of 
pain in the lateral epicondyle of the humeral bone; and 3) show decreased 
muscle strength and functional ability. 
While the exclusion criteria of this study will be 1) refusal to be a sample 
in this study; 2) presences of bilateral symptoms; 3) presences of sensory and 
motor impairment of the upper extremities; 4) samples with systemic disease 
and metabolic disorders; 5) history of trauma and surgery on the elbow; 6) 
having a history of malignancy and peripheral vascular disorders. 
 

17 
 
Sample size calculations: 
The sample size for this study was calculated using the G*power program 
3.1.9 (G power program version 3.1, Heinrich-Heine-University, Düsseldorf, 
Germany). A priori: Compute required sample size based on F tests 
(MANOVA: repeated measures, between factors), Type I error (α) = 0.05, 
power (1-α error probability) = 0.80, Pillai V = 0.2350061, and effect size f2 
(V) = 0.32 with 3 independent groups comparison for 3 major variable 
outcomes. The appropriate minimum sample size for this study was 30 patients 
(10 patients in each group as a minimum) and the total sample will be raised to 
account for the dropout, reaching 36, 12 per group (Faul et al., 2009).  
 
Figure 1. Sample size calculation 
    
Procedures: 
According to sample size calculations 36 samples will be included for 
randomization. These samples will be then randomly allocated into the 
intervention group that will receive exercises and BFRT (Group A), Group B 
(exercises+ MWM), and Group C (control group; home exercises) with 12 

18 
 
samples in each group. The home exercises of the participants will be followed 
up by calling them with mobile phones.  
Intervention Groups 
1. BFRT Group (Group A): 
o Low-load resistance training with blood flow restriction (BFR) 
(Appendix 2). 
o Occlusion pressure: 40%-50% of complete arterial occlusion (Figure 
2). 
 
Figure 2. Pressure setting in SAGA application 
The physical therapist will apply the occlusive cuff on the upper arm 
(brachium) with a pressure of 0.5 times of patient’s systolic blood pressure. The 
physiotherapist will use the BFR cuffs from SAGA (Figure 3). The BFR e-
book 
for 
full 
description 
of 
the 
device 
can 
be 
found 
at: 
https://saga.fitness/pages/bfr-ebook.  

19 
 
 
Figure 3. BFR on the brachium. 
The wearable BFRT device can be used as a valid and reliable tool 
to assess the AOP of the limbs in the supine position during BFRT 
(Zhang et al., 2024). After the end of each session, SAGA application 
will send us a report for the session (Figure 4). 
 
Figure 4. Session report from the application. 
2. Group B: In addition to home exercises, the MWM group performed 
MWM three times a week for a total of 12 times according to the 
principle of pain-free movement. The MWM technique will be applied by 
an experienced and certified physical therapist. First, the pain-free angle 
of application will be  determined for each patient. The lateral condyle of 
the humerus will be fixed by the first bar space of the physiotherapist. A 

20 
 
belt is used by the therapist to apply a sustained lateral glide to the elbow 
joint (usually the radial head or proximal forearm), freeing the therapist’s 
hands to assist or guide the patient's movement. (Figure 5). The elbow 
joint will be glided until no pain will be felt in the elbow joint and the 
hand will be in the contracted position. Participants will be asked to 
repeat the movement of the elbow joint and pressing the ball 10 times 
without pain. The same procedure will be performed in three sets, with 
each set consisting of 10 repetitions of the exercise to control pain. The 
pauses between sets will be 15–20 s, and the interval between repetitions 
in each set will be 30 s. 
 
Figure 5. MWM technique 
3. Group C: Stretching and strengthening exercises for the forearm 
extensors will be  performed daily by the control group for four weeks. 
Eccentric training for the extensor carpi radialis brevis muscle, the most 
affected wrist extensor tendon, and static stretching exercises for the 
extensor carpi radialis brevis muscle will be provided as a home exercise 
program. The weight that patients could lift at 10 maximal repetitions for 
eccentric training will be calculated, and they will be asked to work with 
this weight. The best stretching position for the extensor carpi radialis 

21 
 
brevis tendon will be achieved with extension of the elbow joint, 
pronation of the forearm, and flexion of the wrist with ulnar deviation. 
Each participant will be taught to perform each exercise with 10 
repetitions and 10 s. Patients performed these exercises in a sitting 
position. In the control group, the daily exercises will be performed under 
the supervision of a physiotherapist.  
Training Program 
 •Stage 1 (Initial Phase) : 
All exercises performed with BFR, MWM, and the combination group. 
Exercise Protocol : 
▪ Elbow flexion/extension: 4 sets (30-15-15-15 reps) at 30% of 1RM 
▪ Wrist flexion/extension & supination-pronation: 3 sets of 10 
reps with minimum weight (pain monitoring: <2/10) 
▪ Load progression: +0.5-1 kg weekly based on pain tolerance 
▪ Stretching: 3 reps × 30 sec (wrist extensors & flexors) 
• Stage 2 (Progression Phase): 
Initiated after at least 2 weeks if pain-free 
Continuation of Stage 1 exercises 
New exercises : 
▪ Wall push-ups 
▪ Wrist extension-flexion with rubber bar 
▪ Hand grip using a soft ball 
▪ Standing rowing exercises 
 
 •Additional Training Parameters : 
Rest Periods : 
• 30 sec between sets 
• 1 min between exercises 

22 
 
Cuff deflation: Between different exercises, not between sets 
 •Home Exercise & Monitoring 
• Home exercises performed every other day 
• Supervised physiotherapy twice per week (30-45 min/session) for 4 
weeks 
• Weekly diary to track adherence and cointerventions 
Outcome measures: 
• Assessment Timeline: Baseline, immediate and 4-week follow-up. 
• Recorded by a Blinded Assessor: 
o Demographic characteristics (age, duration of symptoms, body 
mass index, previous symptoms, dominant side, cause) 
• Primary Outcome Measures: 
1. Evaluation of grip strength 
The patients’ maximal grip strength will be measured with a hand 
dynamometer (Figure 6). Measurements will be performed in two positions. 
In the sitting position, measurements will be performed in shoulder 
adduction, 90 flexion of the elbow, neutral position of the forearm, 0 –30 
extension of the wrist, and 0 –15 ulnar deviation. While standing, shoulder 
abduction, elbow extension, and neutral position of the forearm will be 
measured. Patients will be asked to press the dynamometer for 3 s with their 
maximum force, and this value will be recorded as the maximum grip force. 
Measurements will be repeated three times at 30-second intervals on the 
affected limb, and the average of the measurements will be recorded. Values 
will be expressed in kilogram (kg) force. 

23 
 
 
Figure 6. Digital hand dynamometer 
 
 
2. Pain Intensity 
• Measured using an 11-point numeric pain-rating scale (Appendix 3). 
• MCID: 2.1 points (>30% reduction from baseline). 
• The Arabic Numeric Pain Rating Scale will be used to assess pain 
intensity (Alghadir et al., 2016). It is a reliable and valid instrument for 
measuring pain, with psychometric properties in agreement with other 
widely used scales. 
3. Patient-Rated Tennis Elbow Evaluation (PRTEE) Score 
• Arabic version of PRTEE questionnaire (Appendix 4). 
• Measures pain and disability (0-100 scale, with 100 = worst pain & 
disability). 
• MCID: 11 points 
• The Arabic version of PRTEE (Abdelmegeed et al., 2022) will be used. 
It has 20 items; 5 items for pain and 15 for function divided into two 
subsections: specific and usual functional activities. The total score of the 
questionnaire is 200 and the higher the scores, the worse the outcome. 
The scores per item will be summed up and divided by 100 to get the 
total score in percentage (%). The PRTEE is a reliable and sensitive 

24 
 
instrument for LE with excellent internal reliability and consistency 
(0.94, 0.93, 0.85 for pain, specific activities, and general activities 
subscales, respectively). 
 
Statistical analysis:  
The mean and standard deviation of patients’ characteristics will be 
calculated in both study groups. The Kolmogorov-Smirnov test will be used to 
examine the normal distribution of the variables. The ANOVA test will be 
conducted to examine the characteristics of the subjects, while the Chi-squared 
test will be utilized to compare the distributions of sex and affected side across 
the groups. Mixed ANOVA will be used to compare the effects of groups on 
Grip strength, Numeric Pain Rating Scale, Patient-Rated Tennis Elbow 
Evaluation (PRTEE) Score. For additional multiple comparisons, a post-hoc 
analysis will be conducted using the Bonferroni correction. A significance level 
of p < 0.05 was established. All statistical analyses will be performed using 
IBM SPSS, Chicago, IL, USA's version 27 of the statistical package for social 
studies (SPSS). 
 
 
 
 
 
 
 

25 
 
References: 
• Ahmad, Z., Siddiqui, N., Malik, S., AbdusSamee, M., Tytherleigh-
Strong, G., & Rushton, N. (2013). Lateral epicondylitis: A review of 
pathology and management. The Bone & Joint Journal, 95(9), 1158-1164. 
https://doi.org/ 10.1302/0301-620X.95B9.29285 
• Ahuja, D. (2014). Efficacy of mobilization with movement (MWM) in 
lateral epicondylalgia: Role of pain mechanisms-a narrative review. 
Journal of Physical Therapy, 2(1), 19–34. 
• Alghadir, A. H., Anwer, S., & Iqbal, Z. A. (2016). The psychometric 
properties of an Arabic numeric pain rating scale for measuring 
osteoarthritis knee pain. Disability and Rehabilitation, 38(24), 2392-2397. 
https://doi.org/10.3109/09638288.2015.1129441 
• Anap DB, Shende ML, Khatri S (2012) Mobilization with Movement 
Technique as an Adjunct to Conventional Physiotherapy in Treatment of 
Chronic Lateral Epicondylits-A Comparative Study. J Nov Physiother 
2:121. doi: 10.4172/2165-7025.1000121 
• Awad, C., Fayaz, N., Kaddah, M., Mostafa, F., & Abdelmegeed, M. 
(2022). The Arabic Patient-Rated Elbow Evaluation Questionnaire has no 
floor or ceiling effect, and the items load on a three-factor structure using 
principal component analysis. The Egyptian Journal of Hospital 
Medicine, 89(2), 6336-6340. https://doi.org/10.21608/ejhm.2022.269782 
• Baker, R. T., Nasypany, A., Seegmiller, J. G., & Baker, J. G. (2013). The 
Mulligan Concept: Mobilizations with Movement. International Journal 
of Athletic Therapy and Training, 18(1), 30-34. Retrieved Mar 9, 2025, 
from https://doi.org/10.1123/ijatt.18.1.30 
• Barber-Westin, S., & Noyes, F. R. (2019). Blood flow-restricted training 
for lower extremity muscle weakness due to knee pathology: A 

26 
 
systematic 
review. 
Sports 
Health, 
11(1), 
69-83. 
https://doi.org/10.1177/1941738118811337 
• Bessler, J., & Beyerlein, C. (2019). Manuelle Therapie nach Mulligan. In 
Manuelle Therapie nach Mulligan. https://doi.org/10.1055/b-006-162310 
• Bongers, P. M., Kremer, A. M., & Laak, J. (2002). Are psychosocial 
factors, risk factors for symptoms and signs of the shoulder, elbow, or 
hand/wrist? A review of the epidemiological literature. American Journal 
of 
Industrial 
Medicine, 
41(5), 
315-342. 
https://doi.org/10.1002/ajim.10050 
• Brandner, C. R., May, A. K., Clarkson, M. J., & Warmington, S. A. 
(2018). Reported side-effects and safety considerations for the use of 
blood flow restriction during exercise in practice and research. 
Techniques 
in 
Orthopaedics, 
33(2), 
114-121. 
https://doi.org/10.1097/BTO.0000000000000259 
• Burton, I., & McCormack, A. (2021). Autoregulated and individualised 
resistance training versus predetermined and standardised resistance 
training in tendinopathy: A systematic review protocol. Musculoskeletal 
Care, 19(4), 533-539. https://doi.org/10.1002/msc.1551 
• Chiarotto, A., Gerger, H., van Rijn, R. M., Elbers, R. G., Søgaard, K., 
Macri, E. M., Jackson, J. A., Burdorf, A., & Koes, B. W. (2023). Physical 
and psychosocial work-related exposures and the occurrence of disorders 
of the elbow: A systematic review. Applied Ergonomics, 108, 103952.  
• Cook, S. B., Kanaley, J. A., & Ploutz-Snyder, L. L. (2014). 
Neuromuscular function following muscular unloading and blood flow 
restricted exercise. European Journal of Applied Physiology, 114(7), 
1357-1365.  
• Coombes, B. K., Bisset, L., & Vicenzino, B. (2015). Management of 
Lateral Elbow Tendinopathy: One Size Does Not Fit All. The Journal of 

27 
 
orthopaedic 
and 
sports 
physical 
therapy, 
45(11), 
938–949. 
https://doi.org/10.2519/jospt.2015.5841 
• Couppe, C., Svensson, R. B., Silbernagel, K. G., Langberg, H., & 
Magnusson, S. P. (2015). Eccentric or concentric exercises for the 
treatment of tendinopathies? Journal of Orthopaedic & Sports Physical 
Therapy, 45(11), 853-863. 
• Cuddeford, T., & Brumitt, J. (2020). In-season rehabilitation program 
using blood flow restriction therapy for two decathletes with patellar 
tendinopathy: A case report. International Journal of Sports Physical 
Therapy, 15(6), 1184-1195.  
• Demeco, A., de Sire, A., Marotta, N., Spanò, R., Lippi, L., Palumbo, A., 
Iona, T., Gramigna, V., Palermi, S., Leigheb, M., & Invernizzi, M. 
(2022). Match analysis, physical training, risk of injury and rehabilitation 
in padel: Overview of the literature. International Journal of 
Environmental Research and Public Health, 19(7), 4153.  
• Faul, F., Erdfelder, E., Buchner, A., & Lang, A. G. (2009). Statistical 
power analyses using G*Power 3.1: Tests for correlation and regression 
analyses. Behavior Research Methods, 4, 1149-1160. 
• Lucado, A. M., Dale, R. B., Vincent, J., & Day, J. M. (2019). Do joint 
mobilizations assist in the recovery of lateral elbow tendinopathy? A 
systematic review and meta-analysis. Journal of hand therapy : official 
journal of the American Society of Hand Therapists, 32(2), 262–276.e1. 
https://doi.org/10.1016/j.jht.2018.01.010 
• Dos Santos, L. P., Santo, R. C. D. E., Ramis, T. R., Portes, J. K. S., 
Chakr, R. M. D. S., & Xavier, R. M. (2021). The effects of resistance 
training with blood flow restriction on muscle strength, muscle 
hypertrophy and functionality in patients with osteoarthritis and 

28 
 
rheumatoid arthritis: A systematic review with meta-analysis. PLoS ONE, 
16(9), e0259574.  
• Drummond, M. J., Fujita, S., Abe, T., Dreyer, H. C., Volpi, E., & 
Rasmussen, B. B. (2008). Human muscle gene expression following 
resistance exercise and blood flow restriction. Medicine & Science in 
Sports & Exercise, 40(4), 691-698.  
• Ellefsen, S., Hammarstrom, D., Strand, T. A., Zacharoff, E., Whist, J. E., 
Rauk, I., Nygaard, H., Vegge, G., Hanestadhaugen, M., Wernbom, M., et 
al. (2015). Blood flow-restricted strength training displays high functional 
and biological efficacy in women: A within-subject comparison with 
high-load strength training. American Journal of Physiology-Regulatory, 
Integrative and Comparative Physiology, 309(8), R767-R779.  
• Escudero-Tena, A., Sánchez-Alcaraz, B. J., García-Rubio, J., & Ibáñez, 
S. J. (2021). Analysis of game performance indicators during 2015–2019 
World Padel Tour seasons and their influence on match outcome. 
International Journal of Environmental Research and Public Health, 
18(9), 4904.  
• Fujita, S., Abe, T., Drummond, M. J., Cadenas, J. G., Dreyer, H. C., Sato, 
Y., et al. (2007). Blood flow restriction during low-intensity resistance 
exercise increases S6K1 phosphorylation and muscle protein synthesis. 
Journal of Applied Physiology, 103(3), 903-910.  
• Grantham, B., Korakakis, V., & O’Sullivan, K. (2021). Does blood flow 
restriction training enhance clinical outcomes in knee osteoarthritis: A 
systematic review and meta-analysis. Physical Therapy in Sport, 49, 37-
49.  
• Gual, G., Fort-Vanmeerhaeghe, A., Romero-Rodriguez, D., & Tesch, P. 
A. (2016). Effects of in-season inertial resistance training with eccentric 

29 
 
overload in a sports population at risk for patellar tendinopathy. Journal 
of Strength and Conditioning Research, 30(7), 1834-1842.  
• Hayhurst, D., Coppack, R. J., Ingram, C., Conway, D., Cassidy, R. P., & 
Ladlow, P. (2021). Integrating blood flow restriction with low-load 
resistance exercise in a UK specialist military primary care rehabilitation 
facility. BMJ Military Health, 168(4), 329-330.  
• Herquelot, E., Gueguen, A., Roquelaure, Y., Bodin, J., Sérazin, C., & Ha, 
C. (2013). Work-related risk factors for incidence of lateral epicondylitis 
in a large working population. Scandinavian Journal of Work, 
Environment & Health, 39(6), 578-588.  
• Hill, E. C. (2020). Eccentric, but not concentric blood flow restriction 
resistance training increases muscle strength in the untrained limb. 
Physical Therapy in Sport, 43, 1-7.  
• Hing, W., Hall, T., Rivett, D., Vicenzino, B., & Brian Mulligan. (2015). 
The Mulligan Concept of manual therapy textbook of techniques. The 
Mulligan Concept of Manual Therapy, p. 512. Retrieved from 
https://pdfroom.com/books/the-mulliganconcept-of-manual 
therapy/NpgpZ0pb5jr 
• Hughes, L., Grant, I., & Patterson, S. D. (2021). Aerobic exercise with 
blood flow restriction causes local and systemic hypoalgesia and 
increases circulating opioid and endocannabinoid levels. Journal of 
Applied Physiology, 131(4), 1460-1468.  
• Hughes, L., Paton, B., Rosenblatt, B., Gissane, C., & Patterson, S. D. 
(2017). Blood flow restriction training in clinical musculoskeletal 
rehabilitation: A systematic review and meta-analysis. British Journal of 
Sports Medicine, 51(13), 1003-1011.  

30 
 
• Hughes, L., Patterson, S. D. (2019). Low intensity blood flow restriction 
exercise: Rationale for a hypoalgesia effect. Medical Hypotheses, 132, 
109370.  
• Hughes, L., Patterson, S. D. (2020). The effect of blood flow restriction 
exercise on exercise-induced hypoalgesia and endogenous opioid and 
endocannabinoid mechanisms of pain modulation. Journal of Applied 
Physiology, 128(4), 914-924.  
• Hughes, L., Rosenblatt, B., Gissane, C., Paton, B., & Patterson, S. D. 
(2018). Interface pressure, perceptual, and mean arterial pressure 
responses to different blood flow restriction systems. Scandinavian 
Journal of Medicine & Science in Sports, 28(7), 1757-1765.  
• Hunt, J. E., Walton, L. A., & Ferguson, R. A. (2012). Brachial artery 
modifications to blood flow-restricted handgrip training and detraining. 
Journal of Applied Physiology, 112(6), 956-961.  
• Janikowska, K., & Fidut, J. (2013). The Role of Mulligan Therapy 
Concept in Treatment of “Tennis Elbow” Symptoms. In New Approaches 
in 
Joints 
Pain 
(pp. 
20–34). 
Retrieved 
from 
http://figshare.com/articles/New_Approach 
es_in_Joints_Pain_Tennis_Elbow/810462 
• Kinandana, G. P., Dewi, A. A., Winaya, I. M., Antari, N. K., Wibawa, A., 
& Adhitya, I. P. (2023). The efficacy of blood flow restriction training for 
grip strength and disability in lateral epicondylitis. Bali Medical Journal, 
12(1), 410-415.  
• Klein, M. B., Pham, H., Yalamanchi, N., & Chang, J. (2001). Flexor 
tendon wound healing in vitro: The effect of lactate on tendon cell 
proliferation and collagen production. Journal of Hand Surgery, 26(5), 
847-854.  

31 
 
• Lixandrao, M. E., Ugrinowitsch, C., Berton, R., Vechin, F. C., 
Conceição, M. S., Damas, F., Libardi, C. A., & Roschel, H. (2018). 
Magnitude of muscle strength and mass adaptations between high-load 
resistance training versus low-load resistance training associated with 
blood-flow restriction: A systematic review and meta-analysis. Sports 
Medicine, 48(2), 361-378.  
• Loenneke, J. P., Abe, T., Wilson, J. M., Ugrinowitsch, C., & Bemben, M. 
G. (2012). Blood flow restriction: How does it work? Frontiers in 
Physiology, 3, 392.  
• Lorenz, D. S., Bailey, L., Wilk, K. E., Mangine, R. E., Head, P., 
Grindstaff, T. L., & Morrison, S. (2021). Blood flow restriction training. 
Journal of Athletic Training, 56(9), 937-944.  
• Lowery, R. P., Joy, J. M., Loenneke, J. P., de Souza, E. O., Machado, M., 
Dudeck, J. E., & Wilson, J. M. (2014). Practical blood flow restriction 
training increases muscle hypertrophy during a periodized resistance 
training programme. Clinical Physiology and Functional Imaging, 34(4), 
317-321.  
• Mani, P., Sethupathy, K., & Habib, H. (2017). Comparison of 
Effectiveness of Movement with Mobilization Using Belt and 
Therapeutic Eccentric Exercise in Patients with chronic Lateral 
epicondylitis: A Randomized Clinical Trial. International Journal of 
Health Sciences and Research, 7(5), 144–150. Retrieved from 
https://www.semanticscholar.org/paper/Co mparison-of-Effectiveness-of-
Movementwith-Using-ManiSethupathy/dfe549fa3234f9d23aa4898c333 
24219165e5819 
• Manini, T. M., & Clark, B. C. (2009). Blood flow restricted exercise and 
skeletal muscle health. Exercise and Sport Sciences Reviews, 37(2), 78-
85. 

32 
 
• McDowell, J. M., Johnson, G. M., & Hetherington, B. H. (2014). 
Mulligan Concept manual therapy: standardizing annotation. Manual 
therapy, 19(5), 499–503. https://doi.org/10.1016/j.math.2013.12.006  
• Minniti, M. C., Statkevich, A. P., Kelly, R. L., Rigsby, V. P., Exline, M. 
M., Rhon, D. I., & Clewley, D. (2020). The safety of blood flow 
restriction training as a therapeutic intervention for patients with 
musculoskeletal disorders: A systematic review. American Journal of 
Sports Medicine, 48(7), 1773-1785.  
• Nielsen, J. L., Aagaard, P., Prokhorova, T. A., Nygaard, T., Bech, R. D., 
Suetta, C., & Frandsen, U. (2017). Blood flow restricted training leads to 
myocellular macrophage infiltration and upregulation of heat shock 
proteins, but no apparent muscle damage. Journal of Physiology, 595(14), 
4857-4873.  
• Nitzsche, N., Stauber, A., Tiede, S., & Schulz, H. (2021). The 
effectiveness of blood-flow restricted resistance training in the 
musculoskeletal rehabilitation of patients with lower limb disorders: A 
systematic review and meta-analysis. Clinical Rehabilitation, 35(9), 
1221-1234.  
• Patterson, S. D., Hughes, L., Warmington, S., Burr, J., Scott, B. R., 
Owens, J., et al. (2019). Blood flow restriction exercise: Considerations 
of methodology, application, and safety. Frontiers in Physiology, 10, 533.  
• Paungmali, A., O'Leary, S., Souvlis, T., & Vicenzino, B. (2003). 
Hypoalgesic and sympathoexcitatory effects of mobilization with 
movement for lateral epicondylalgia. Physical therapy, 83(4), 374-383. 
https://doi.org/10.1093/ptj/83.4.374 
• Pearson, S. J., & Hussain, S. R. (2015). A review on the mechanisms of 
blood-flow restriction resistance training-induced muscle hypertrophy. 
Sports Medicine, 45(2), 187-200.  

33 
 
• Peterson, M., Butler, S., Eriksson, M., & Svardsudd, K. (2014). A 
randomized controlled trial of eccentric vs. concentric graded exercise in 
chronic 
tennis 
elbow 
(lateral 
elbow 
tendinopathy). 
Clinical 
Rehabilitation, 28(9), 862-872.  
• Rolnick, N., Kimbrell, K., Cerqueira, M. S., Weatherford, B., & 
Brandner, C. (2021). Perceived barriers to blood flow restriction training. 
Frontiers in Rehabilitation Sciences, 2, 697082.  
• Rossi, F. E., de Freitas, M. C., Zanchi, N. E., Lira, F. S., & Cholewa, J. 
M. (2018). The role of inflammation and immune cells in blood flow 
restriction training adaptation: A review. Frontiers in Physiology, 9, 
1376.  
• Ruffino, D., Malliaras, P., Marchegiani, S., & Campana, V. (2021). 
Inertial flywheel vs heavy slow resistance training among athletes with 
patellar tendinopathy: A randomised trial. Physical Therapy in Sport, 52, 
30-37.  
• Sata, S. (2005). Kaatsu training for patella tendinitis patient. International 
Journal of KAATSU Training Research, 1(1), 29-32.  
• Scott, B. R., Loenneke, J. P., Slattery, K. M., & Dascombe, B. J. (2015). 
Exercise with blood flow restriction: An updated evidence-based 
approach for enhanced muscular development. Sports Medicine, 45(3), 
313-325.  
• Shimizu, R., Hotta, K., Yamamoto, S., Matsumoto, T., Kamiya, K., Kato, 
M., Hamazaki, N., Kamekawa, D., Akiyama, A., Kamada, Y., et al. 
(2016). Low-intensity resistance training with blood flow restriction 
improves vascular endothelial function and peripheral blood circulation in 
healthy elderly people. European Journal of Applied Physiology, 116(4), 
749-757.  

34 
 
• Shiri, R., Viikari-Juntura, E., Varonen, H., & Heliövaara, M. (2006). 
Prevalence and determinants of lateral and medial epicondylitis: A 
population study. American Journal of Epidemiology, 164(11), 1065-
1074.  
• Sieland, J., Niederer, D., Engeroff, T., Vogt, L., Troidl, C., Schmitz-
Rixen, T., Banzer, W., & Troidl, K. (2021). Effects of single bouts of 
different endurance exercises with different intensities on microRNA 
biomarkers with and without blood flow restriction: A three-arm, 
randomized crossover trial. European Journal of Applied Physiology, 
121(12), 3243-3255.  
• Skovlund, S. V., Aagaard, P., Larsen, P., Svensson, R. B., Kjaer, M., 
Magnusson, S. P., et al. (2020). The effect of low‐load resistance training 
with blood flow restriction on chronic patellar tendinopathy—A case 
series. Translational Sports Medicine, 3(4), 342-352. 
• Slysz, J., Stultz, J., & Burr, J. F. (2016). The efficacy of blood flow 
restricted exercise: A systematic review & meta-analysis. Journal of 
Science and Medicine in Sport, 19(8), 669-675. 
• Sloane R.,Hoenig, H., Rubenstein, L. V., Horner, R., & Kahn, K. (2020). 
What is the role of timing in the surgical and rehabilitative care of 
community-dwelling older persons with acute hip fracture?. Archives of 
Internal Medicine, 157(5), 513-520.  
• Teixeira, E. L., Barroso, R., Silva-Batista, C., Laurentino, G. C., 
Loenneke, J. P., Roschel, H., Ugrinowitsch, C., & Tricoli, V. (2018). 
Blood flow restriction increases metabolic stress but decreases muscle 
activation during high-load resistance exercise. Muscle & Nerve, 57(1), 
107-111.  

35 
 
• Vaquero-Picado, A., Barco, R., & Antuña, S. A. (2017). Lateral 
epicondylitis of the elbow. EFORT open reviews, 1(11), 391–397. 
https://doi.org/10.1302/2058-5241.1.000049 
• Visnes, H., & Bahr, R. (2007). The evolution of eccentric training as 
treatment for patellar tendinopathy (jumper’s knee): A critical review of 
exercise programmes. British Journal of Sports Medicine, 41(4), 217-223.  
• Warmington, S. A., Staunton, C. A., May, A. K., & Brandner, C. R. 
(2016). Blood flow restriction exercise: Acute versus chronic safety. 
European Journal of Applied Physiology, 116(4), 861-862.  
• Wilson, J. M., Lowery, R. P., Joy, J. M., Loenneke, J. P., & Naimo, M. A. 
(2013). Practical blood flow restriction training increases acute 
determinants of hypertrophy without increasing indices of muscle 
damage. Journal of Strength and Conditioning Research, 27(11), 3068-
3075.  
• Yow, B. G., Tennent, D. J., Dowd, T. C., Loenneke, J. P., & Owens, J. G. 
(2018). Blood flow restriction training after Achilles tendon rupture. 
Journal of Foot and Ankle Surgery, 57(4), 635-638. 
• Zhang, W. Y., Zhuang, S. C., Chen, Y. M., & Wang, H. N. (2024). 
Validity and reliability of a wearable blood flow restriction training 
device for arterial occlusion pressure assessment. Frontiers in physiology, 
15, 1404247. https://doi.org/10.3389/fphys.2024.1404247  
 
 
 
 
 
 

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Appendix 1: 
Informed Consent Form 
I am /....................freely and voluntarily consent to participate in a 
research study with title/ Effectiveness of blood flow restriction 
training verses mulligan technique in lateral epicondylitis. a 
randomized controlled trial. A thorough description of the procedure 
has been explained, and I understand that I may withdraw my consent 
and discontinue participation in this research at any time without 
prejudice to me. 
 
Participant Name:  
 
 
 
 
 
 
 
 
Date: