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

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

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

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

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

Inclusion Criteria:

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

Exclusion Criteria:

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

The study will make individual participant data (IPD) available to other researchers after the conclusion of the study. The IPD shared will include anonymized data related to the primary and secondary outcome measures, including depression scores, biochemical markers (e.g., TNF-α, IL-6, BDNF), EEG data, and other relevant clinical and demographic data collected during the trial. The data will be de-identified to ensure participant confidentiality. The data will be shared through an approved data repository or by direct request to the study's primary investigators.

The data will be made available 6 months after the study's completion and will remain accessible for a period of 5 years to facilitate further research.

Access to the data will be granted to qualified researchers upon submission of a formal request that includes a research proposal outlining the intended use of the data. Requests will be reviewed by the study investigators and ethical review committee to ensure compliance with data privacy regulations.

The study will utilize a single-blinded design, where the patients will be blinded to group allocation.