Comparing the Effects of Mobilization With Movement (MWM), Self MWM, and Dynamic Stretching on Hip Internal Rotation)
Phase: NA
Conditions: Hip; Anomaly
Sponsor: University of South Carolina

 
Examining the effects of a posterolateral mobilization with movement compared to a 
posterolateral self-mobilization with movement and dynamic stretching on hip internal rotation 
limitations: A randomized control trial 
2/16/2020 
 
 
 

University of South Carolina Protocol  
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Study Title:        Examining the effects of a posterolateral mobilization with movement 
compared to a posterolateral self-mobilization with movement and dynamic stretching on hip 
internal rotation limitations: A randomized control trial 
 
 
Principal Investigator Name:     Cathy Arnot   
 
Faculty Mentor Name (if applicable):  Cathy Arnot      
 
1) If there is a written grant proposal, dissertation, or thesis, or your professor has provided you 
with a template, you are not required to use this template. However, this template should be 
used as a reference so that you are aware of the issues that should be addressed. 
2) Texts in italics are instructions, which should be deleted. Modify as appropriate to your study. 
3) Once protocol is complete, save it as a Word document.  Go back to the IRB application and 
upload the protocol.  
 
A. SPECIFIC AIMS  
List the broad, long-term objectives and the goal of the specific research proposed, e.g., to test a stated 
hypothesis, create a novel design, solve a specific problem, challenge an existing paradigm or clinical 
practice, address a critical barrier to progress in the field, or develop new technology. 
 
The goal of this study is to compare the efficacy of three clinical interventions intended 
to treat hip dysfunctions such as hip osteoarthritis. Physical therapists utilize mobilization with 
movement clinically to increase range of motion that has been limited by hip pathology. This 
study will compare mobilization with movement administered by a physical therapist, self-
administered mobilization with movement, in which patients are instructed in the maneuver and 
then perform it at home, and dynamic stretching as instructed by a physical therapist. Efficacy 
will be judged through changes in hip internal rotation range of motion, a motion which is 
typically limited in patients with hip pathology. 
Our objectives are to quantify the effects of two different modalities of hip mobilization 
with movement and dynamic stretching in terms of hip internal rotation increases, and to inform 
current physical therapy practice by filling gaps in the literature surrounding the therapeutic 
effects of hip mobilization with movement. This study is intended to better equip physical 
therapists to select the most appropriate evidence-based interventions, thereby increasing the 
quality of patient care. 
 
B. BACKGROUND AND SIGNIFICANCE 
Briefly sketch the background leading to the present application, critically evaluate existing knowledge, 
and specifically identify the gaps that the project is intended to fill. If the aims of the study are achieved, 
state how scientific knowledge or clinical practice will be advanced. 
 
 
 
Minimal evidence exists comparing the therapeutic effects of variations of 
mobilization with movement on the hip, but the evidence that does exist shows promising 
results, with participants gaining increases in functional range of motion from the interventions. 
There is a significant amount of research regarding mobilization with movement at joints 
throughout the body, but little that specifically examines internal rotation at the hip. Studies 
exist that evaluate and compare physical therapist-directed mobilization with movement and 
self-administered mobilization with movement, with only a single study comparing these two 
interventions specifically for hip internal rotation, and none which include a dynamic stretching 

University of South Carolina Protocol  
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control group. Stretching is a commonly used physical therapy intervention for range of motion 
limitations and provides an appropriate foundation and context with which to compare 
mobilization with movement interventions. 
 
This study will improve physical therapy practice by addressing the nonexistent 
literature comparing the effects of physical therapist-administered mobilization with movement, 
self-administered mobilization with movement, and dynamic stretching. Achieving this study’s 
goals and objectives will provide physical therapists with greater evidence to select the most 
effective treatment interventions to administer to patients, making physical therapy more 
conducive to functional range of motion gains for the patient.  
 
C. PRELIMINARY STUDIES 
Provide an account of the principal investigator’s preliminary studies pertinent to this protocol and/or 
any other information that will help to establish the experience and competence of the investigator to 
pursue the proposed project. 
 
PUBLICATIONS 
Dunning JR, Cleland JA, Waldrop MA, Arnot CF, Young I, Turner M, Sigurdsson G. Upper 
Cervical and Upper Thoracic Thrust Manipulation Versus Nonthrust Mobilization in Patients 
With Mechanical Neck Pain: A Multicenter Randomized Clinical Trial. Journal of Orthopedics 
and Sports Physical Therapy. 2012: 42: 5-18. 
 
Beattie PF, Arnot CF, Donley JW, Noda H, Bailey L. The Immediate Reduction in Low Back 
Pain Intensity Following Lumbar Joint Mobilization and Prone Press-Ups is Associated with 
Increased Diffusion of Water in the L5-S1 Intervertebral Disc. Journal of Orthopedics and 
Sports Physical Therapy. 2010;40:256-264. 
 
Beattie PF, Donley J, Arnot C, Miller R The Immediate Change in the Diffusion of Water in 
Lumbar Intervertebral Discs Following a Single Session of Lumbar Joint Mobilization 
Compared to a Single Session of Prone Lying. Journal of Orthopedics and Sports Physical 
Therapy. January 26, 2009. 
CERTIFICATION-CREDENTIALING 
 
2005 – present Fellow, AAOMPT, FAAOMPT, Am Academy Ortho Manual PT  
2003  Manual Therapy Certification, MTC, University of St. Augustine, Written, Oral, Practical 
Cert. 
2001 – present Orthopedic Clinical Specialist, OCS APTA Board Certified Specialist 
 
PROFESSIONAL EXPERIENCE 
2006- present Clinical Assistant Professor University of South Carolina, Columbia, SC Clinical 
Assistant Professor. Teaching doctoral physical therapy students, including: spinal and 
extremity mobilization/manipulation, range of motion assessment, manual muscle testing, gait 
training, postural assessment, emergency procedures, practice management, documentation 
and ethics.  
 
2002-2003 Doctoral Fellow SportsMedicine of Atlanta, Snellville, GA Fellowship in Manual 
Therapy under the mentorship of Dr. Robert DuVall, PT, DHSc, OCS, MTC, PCC, FAAOMPT. 
Specializing in the manual therapy techniques of Stanley Paris. Supervising Duke University 
and Washington University PT students 
 

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D. RESEARCH DESIGN AND METHODS AND DATA ANALYSIS  
Describe the research design and the procedures to be used to accomplish the specific aims of the 
project, including the following: 
 
Location: University of South Carolina, Blatt Physical Education Building, 1st floor 
 
Surveys/Instruments, Devices, or Other Measures: Baseline bubble inclinometer to measure each 
participant’s hip internal rotation will be used throughout the data collection. A Mulligan mobilization belt 
will also be used for two of the treatment groups in order to apply the mobilization at the hip required for 
the mobilization with movement technique. 
 
Groups will be randomized using a random number generator with a proposed number of approximately 
15-20 participants in each of the three groups. Participants will also be grouped by level of severity of 
the limitation in ROM, ranging from severe limitations to mild limitations. The mild limitation group 
will have from 25-30 degrees of IR at the hip, moderate will be 20-24 degrees, and severe will be <20 
degrees. To ensure that participants are evenly spread out between the three treatment groups in regards 
to the severity of their limitation, they will roll a die which will determine in which of the three 
treatment groups they will be placed in. Only the therapist will know how the participants are grouped 
based on the die roll to make sure the researchers are blinded to the groups. 
 
Data Analysis:  Statistical analysis will be performed using SPSS with a Repeated Measures Analysis 
of Variance (ANOVA) in order to determine significance between the three groups while also using time 
as an outcome pre-and-post-test. Significance will be set at p=<.05 which establishes a 95% 
confidence interval. A one-way ANOVA will be performed first to determine whether the groups are 
different at baseline, followed by a repeated measure ANOVA with a within factor and a between group 
factor. This will reveal the main effects of time, group, and a time by group interaction. ANOVA tests 
are used to determine whether there are significant measures between two or more groups and allows for 
comparison of multiple sample means to assess whether there is a significant difference between groups 
and within the same group from pre and post intervention. F values will be calculated using SPSS 
software to assess for any significant differences. Post-Hoc testing will be conducted if a significant F 
value is found in order to determine where the differences exist using three Paired t-tests, one for each 
group.  
 
      
 
E. PROTECTION OF HUMAN SUBJECTS 
1.  TARGET POPULATION: 
 
Participants will be recruited through in person interview from the University of South Carolina Doctor 
of Physical Therapy program graduate students and Wingate Doctor of Physical Therapy program. The 
targeted population is college-aged individuals. Inclusion criteria will be that participants must have less 
than 30 degrees of hip internal rotation (HIR) in at least one hip. Previous studies have suggested that 
HIR of less than 30 degrees has been correlated with an increase in injuries to the lower back and lower 
extremities.21,22 Exclusion criteria will include any traumatic injury within the last six months, any 
known skeletal deformities limiting activity such as femoro-acetabular impingement or fractures, 
surgeries within the last 6 months, positive findings in the Flexion, Adduction, Internal Rotation 
(FADDIR) or Flexion, Abduction, External Rotation (FABER) tests for hip impingement pathology 
depicted in figures 3 and 4 below, and any presence of OA, rheumatoid arthritis, or neurological 

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conditions which could negatively impact findings. Anticipated sample size is between 45-60 
participants. 
      
 
2.  RECRUITMENT  PLANS:  
 
Participants will be recruited through in-person interview and conversation during the Fall Seminar 
class for DPT students. The study will be described through verbal presentation and a sign-up sheet 
will be passed around for interested participants where they will be asked to provide their name and 
email address for further communication pertaining to the study in terms of location and scheduled 
dates. Only interested participants that fill out the sign-up sheet will be contacted regarding participation 
in the study.  
 
      
 
3. EXISTING DATA/SAMPLES:  
If the investigator plans to utilize data or samples that are in existence (the investigator will not be 
recruiting/consenting subjects), describe where the data/samples are housed, how the investigator will 
gain access to the data/samples, whether the data/samples contain any direct identifiers (e.g., names, 
address, telephone numbers) or are coded and who will have access to the key to the code (i.e., will 
the USC investigator have access to key), whether the investigator will sign any data use agreement, 
and how data will be recorded by USC investigator. 
 
      
 
4.  CONSENT/ASSENT: 
 
All participants will have to sign an informed consent form in order to participate in the study which 
outlines the expected timeline of the study, the requirements of participation, and the option to opt out 
of the study at any time if someone chooses to do so. The informed consent form has been uploaded 
onto the eIRB at this time for review. 
 
      
 
5.  POTENTIAL RISKS: 
 
There are minimal risks that can occur during the study as we are only performing a mobilization with 
movement at the hip joint using external measures such as a Mulligan mobilization belt. The only side 
effects that can occur from performing the technique is increased range of motion at the hip or possible 
discomfort from increased range of motion at the hip. If any participants experiences any pain or 
discomfort during the interventions provided, the technique will be stopped and will be re-assessed 
before continuing with that specific participant to limit any source of discomfort. 
 
      
 
6.  POTENTIAL BENEFITS: 
 
The potential benefits for participants is increased range of motion at the hip, specifically for hip internal 
rotation. The benefit to others includes the potential that clinicians may be able to assign a self-
mobilization with movement for patients at home if it proves to be just as effective as the therapist-
performed-mobilization with movement. This would allow clinicians to focus on other interventions while 
patients are in the clinic and hopefully have better long-term outcomes. 

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7.  CONFIDENTIALITY 
 
The data will be confidential and all recorded data will be stored on a password protected computer 
within a locked office with the only access to the office being through the lead investigator’s keys. No 
names of participants will be used as each participant will be assigned a numerical value to correspond 
with their data in order to maintain participant confidentiality.  
 
      
 
8. COMPENSATION: 
 
There will be no compensation provided to participants. 
 
      
 
9.  WITHDRAWAL: 
 
Each participant will be required to sign an informed consent form and will be allowed to opt out of 
future data collection or to be a part of the study at any time without any negative consequences to the 
participant as they will not be receiving any compensation for participation. 
 
      
 
F. REFERENCES/LITERATURE CITATIONS 
. 
1. Hughes PE, Hsu JC, Matava MJ. Hip Anatomy and Biomechanics in the Athlete. Sports 
Medicine and Arthroscopy Review. 2002;10(2):103-114. doi:10.1097/00132585-200210020-
00002. 
  
2. Moore KL, Dalley AF, Agur AMR. Clinically oriented anatomy. Philadelphia: Wolters 
Kluwer/Lippincott Williams & Wilkins Health; 2014. 
  
3. Byrne DP, Mulhall KJ, Baker JF. Anatomy & Biomechanics of the Hip. The Open Sports 
Medicine Journal. 2010;4(1):51-57. doi:10.2174/1874387001004010051. 
  
4.  G.G. Simoneau, K.J. Hoenig, J.E. Lepley, P.E. Papanek. Influence of hip position and gender on 
active hip internal and external rotation. J Orthopedic Sports Physical Therapy, 28 (1998), pp. 
158-164 
  

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5.  Walsh, R. and Kinsella, S. (2016). The effects of caudal mobilisation with movement (MWM) 
and caudal self-mobilisation with movement (SMWM) in relation to restricted internal rotation 
in the hip: A randomised control pilot study. Manual Therapy, 22, pp.9-15. 
  
6. Sadeghisani, M., Manshadi, F., Kalantari, K., Rahimi, A., Namnik, N., Karimi, M. and Oskouei, 
A. (2015). Correlation between Hip Rotation Range-of-Motion Impairment and Low Back Pain. 
A Literature Review. Ortopedia Traumatologia Rehabilitacja, 17(5), pp.455-462. 
  
7. Hoy, D. , Bain, C. , Williams, G. , March, L. , Brooks, P. , Blyth, F. , Woolf, A. , Vos, T. and 
Buchbinder, R. (2012), A systematic review of the global prevalence of low back pain. Arthritis 
& Rheumatism, 64: 2028-2037. doi:10.1002/art.34347 
  
8.  Van Dillen, L. R., Bloom, N. J., Gombatto, S. P., & Susco, T. M. (2008). Hip rotation range of 
motion in people with and without low back pain who participate in rotation-related sports. 
Physical Therapy in Sport, 9(2), 72-81. 
  
9.  Almeida, G. P. L., de Souza, V. L., Sano, S. S., Saccol, M. F., & Cohen, M. (2012). Comparison 
of hip rotation range of motion in judo athletes with and without history of low back pain. 
Manual therapy, 17(3), 231-235. 
  
10. S. Albertin, Erica & N. Miley, Emilie & May, James & Baker, Russell & Reordan, Don. (2018). 
The Effects of Hip Mobilizations on Patient Outcomes: A Critically Appraised Topic. Journal of 
Sport Rehabilitation. 1-17. 10.1123/jsr.2016-0238. 
  
11. Steultjens, M. P. M., Dekker, J., Van Baar, M. E., Oostendorp, R. A. B., & Bijlsma, J. W. J. 
(2000). Range of joint motion and disability in patients with osteoarthritis of the knee or hip. 
Rheumatology, 39(9), 955-961. 
  
12. Dekker, J., Boot, B., van der Woude, L. H., & Bijlsma, J. W. J. (1992). Pain and disability in 
osteoarthritis: a review of biobehavioral mechanisms. Journal of behavioral medicine, 15(2), 
189-214. 

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13. Shakoor, N., Lee, K. J., Fogg, L. F., & Block, J. A. (2008). Generalized vibratory deficits in 
osteoarthritis of the hip. Arthritis Care & Research: Official Journal of the American College of 
Rheumatology, 59(9), 1237-1240. 
  
14. Bennell, K. L., & Hinman, R. S. (2011). A review of the clinical evidence for exercise in 
osteoarthritis of the hip and knee. Journal of Science and Medicine in Sport, 14(1), 4-9. 
  
15. Beselga, C., Neto, F., Alburquerque-Sendín, F., Hall, T., & Oliveira-Campelo, N. (2016). 
Immediate effects of hip mobilization with movement in patients with hip osteoarthritis: A 
randomised controlled trial. Manual therapy, 22, 80-85. 
  
16. Mulligan, B. R. (1993). Mobilisations with movement (MWM'S). Journal of Manual & 
Manipulative Therapy, 1(4), 154-156. 
  
17. Hsieh, C. Y., Vicenzino, B., Yang, C. H., Hu, M. H., & Yang, C. (2002). Mulligan's mobilization 
with movement for the thumb: a single case report using magnetic resonance imaging to evaluate 
the positional fault hypothesis. Manual therapy, 7(1), 44-49. 
  
18. Kavanagh, J. (1999). Is there a positional fault at the inferior tibiofibular joint in patients 
withacute or chronic ankle sprains compared to normals?. Manual Therapy, 4(1), 19-24. 
  
19. Vicenzino, B., Paungmali, A., & Teys, P. (2007). Mulligan's mobilization-with-movement, 
positional faults and pain relief: current concepts from a critical review of literature. Manual 
therapy, 12(2), 98-108. 
  
20. Yıldırım, M. S., Ozyurek, S., Tosun, O. Ç., Uzer, S., & Gelecek, N. (2016). Comparison of 
effects of static, proprioceptive neuromuscular facilitation and Mulligan stretching on hip flexion 
range of motion: a randomized controlled trial. Biology of sport, 33(1), 89. 
  

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21. Boykin RE, Stull JD, Giphart JE, Wijdicks CA, Philippon MJ. Femoroacetabular impingement in 
a professional soccer player. Knee Surg Sports Traumatol Arthrosc 2013;1(5):1203e11 
  
22. Burns SA, Mintken PE, Austin GP, Cleland J. Short-term response of hip mobilizations and 
exercise in individuals with chronic low back pain: a case series. J Man Manip Ther 
2011;19(2):100e7 
  
23. Abbott JH. Mobilization with movement applied to the elbow affects shoulder range of 
movement in subjects with lateral epicondylalgia. Man Ther 2001;6(3): 170e7 
  
24. Vicenzino, B., Branjerdporn, M., Teys, P., & Jordan, K. (2006). Initial changes in posterior talar 
glide and dorsiflexion of the ankle after mobilization with movement in individuals with 
recurrent ankle sprain. Journal of Orthopaedic & Sports Physical Therapy, 36(7), 464-471. 
25. Bandy, W. D., Irion, J. M., & Briggler, M. (1998). The effect of static stretch and dynamic range 
of motion training on the flexibility of the hamstring muscles. Journal of Orthopaedic & Sports 
Physical Therapy, 27(4), 295-300. 
  
26. Lachtman, D. S., Bartha, D. A., Beltran, M. M., Dominguez, D. N., Messerli, A. R., Miller, S. E., 
... & Nelson-Wong, E. (2015). Rater reliability and concurrent validity of single and dual bubble 
inclinometry to assess cervical lateral flexion. Journal of manipulative and physiological 
therapeutics, 38(8), 572-580. 
  
27. Kolber, M. J., Pizzini, M., Robinson, A., Yanez, D., & Hanney, W. J. (2013). The reliability and 
concurrent validity of measurements used to quantify lumbar spine mobility: an analysis of an 
iphone® application and gravity based inclinometry. International journal of sports physical 
therapy, 8(2), 129. 
  
 
      
 
G. APPENDIX 
 

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Mulligan mobilization belt:
 
 
 
 
 
 
 
 
 
 
Baseline Instruments Bubble Inclinometer: