Mobilization with Movement manual therapy techniques was discovered and developed by Brian Mulligan F.N.Z.S.P. (Hon), Dip. M.T., Wellington, New Zealand. This simple yet effective manual approach addresses musculoskeletal disorders with pain-free manual joint “repositioning” techniques for the restoration of function and abolition of pain.

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The Mulligan Concept of manual therapy is based on the application of a sustained accessory joint mobilization, often in a weight-bearing position, which utilizes patient-generated active or functional tasks through a specified range of joint movement (Vicenzino et al., 2011).

As the use of mobilization with movement (MWM) techniques has increased, the number of studies analyzing the efficacy of Mulligan’s techniques has proliferated in the field of peripheral manual therapy (Paungmali et al., 2003; Collins et al., 2004; DeSantis and Hasson, 2006; Vicenzino et al., 2006; Penso, 2008; Teys et al., 2008; Amro et al., 2010; Teys et al., 2013). There is also a corresponding increase in investigations examining the use of MWM in spinal rehabilitation (Hall et al., 2007; Konstantinou et al., 2007; Moutzouri et al., 2008; Richardson, 2009).

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Concept of Positional Fault

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• Mulligan proposed that injuries or sprains might result in a minor "positional fault" to a joint causing restrictions in physiological movement.

• The techniques have been developed to overcome joint `tracking' problems or `positional faults', i.e. joints with subtle biomechanical changes.

• Normal joints have been designed in such a way that the shape of the articular surfaces, the thickness of the cartilage, the orientation of the fibers of ligaments and capsule, and the direction of pull of muscles and tendons facilitate free but controlled movement while simultaneously minimizing the compressive forces generated by that movement.

• Normal proprioceptive feedback maintains this balance. Alteration in any or all of the above factors would alter the joint position or tracking during movement and would provoke symptoms of pain, stiffness, or weakness in the patient. It is common sense then that a therapist would attempt to re-align the joint surfaces in the least provocative way

 

Principles of Treatment

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1. A passive accessory joint mobilization is applied. This accessory glide must be pain-free.

2. During the assessment, the therapist will identify one or more comparable signs/ outcome measures. These signs may be; a loss of joint movement, pain associated with movement, or pain associated with specific functional activities.

3. The therapist must continuously monitor the patient's reaction to ensure no pain is recreated. The therapist investigates various combinations of parallel or perpendicular glides to find the correct treatment plane and grade of accessory movement.

4. While sustaining the accessory glide, the patient is requested to perform the painful movement. The movement (Pain/ ROM) should now be significantly improved.

5. Failure to improve the comparable sign would indicate that the therapist has not found the correct treatment plane, grade of mobilization, or spinal segment or that the technique is not indicated.

6. The previously restricted and/or painful motion or activity is repeated by the patient while the therapist continues to maintain the appropriate accessory glide.

 

While applying "MWMS" as an assessment, the therapist should look for a "PILL" response to use the same as a treatment.

• P- Pain-free.

• I- Instant result.

• LL- Long Lasting.

 

If there is No PILL response, that technique should not be adjusted.

         

The second principle is CROCKS

• C- Contra-indications (No PILL response is a contraindication)

• R - Repetitions (Only three reps on the day)

• O- Overpressure

• C- Communications

• K - Knowledge (of treatment planes and pathologies)

• S- Sustain the mobilization throughout the movement.

 

 

The Techniques

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• NAGS- Natural Apophyseal Glides.

• SNAGS - Sustained Natural Apophyseal Glides.

• MWMS- The concept of Mobilization with movement (MWM) of the extremities and SNAGS (sustained natural apophyseal glides) of the spine.

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Peripheral MWM 

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• Once the aggravating movement has been identified, an appropriate glide is chosen. 

• The decision to use weight-bearing or Non-weight bearing movement depends upon the severity, irritability, and nature of the condition.

• Once the glide has been chosen it must be sustained throughout the physiological movement until the joint returns to its original starting position

• Mobilizations performed are always into resistance but without pain

• Immediate relief of pain and improvement in ROM are expected.

• If this is not achieved, vary the glide parameters