Brian Mulligan- Master Class

Mobilization with Movement manual therapy techniques were 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 restoration of function and abolition of pain.
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 of investigations examining the use of MWM in spinal rehabilitation (Hall et al., 2007; Konstantinou et al., 2007; Moutzouri et al., 2008; Richardson, 2009).

Concept of Positional Fault

  • 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 fibres of ligaments and capsule, the direction of pull of muscles and tendons, facilitate free but controlled movement while simultaneously minimising 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

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

  2. During assessment the therapist will identify one or more comparable signs/ outcome meassures. 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 patients 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, 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 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)

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

  • O- Over pressure

  • C- Communications

  • K - Knowledge (of treatment planes and pathologies)

  • S- Sustain the mobilization throughout the movement.

 

 

The Techniques

  • NAGS- Natural Apophyseal Glides.

  • SNAGS - Sustained Natural Apophyseal Glides.

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

 

Peripheral MWM 

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

  • 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

Introduction in Mulligan Concept, The fingers and the wrist joints
The Elbow Joint
The Mulligan Concept for the Shoulder & AC Joints
Mulligan Concept. The Knee Joint
Ankle Sprain

SNAGs

  • SNAGs stand for Sustained Natural Apophyseal Glides.

  • SNAGs can be applied to all the spinal joints, the rib cage and the sacroiliac joint.

  • The therapist applies the appropriate accessory zygapophyseal glide while the patient performs the symptomatic movement.

  • This must result in full range pain free movement.

  • SNAGs are most successful when symptoms are provoked by a movement and are not multilevel.

  • They are not the choice in conditions that are highly irritable.

  • Although SNAGs are usually performed in weight bearing positions they can be adapted for use in non weight bearing positions.

Cervical Transverse SNAGS
THE Lumbar spine & SIJ
Headache SNAG:



If a patient is suffering from a headache of upper cervical origin then one of the mobilisations or the traction to be described should, as it is being applied, stop the pain. Mulligan assumes that if a headache stops with a manual technique involving the upper cervical spine then, this must be diagnostically significant as to the site of the lesion causing the problem and the fact that there is a mechanical component. 


Description:


Position of Patient: sitting .
Position of therapist: stands beside the patient, while his\her head is cradled between your body and your right forearm (when you stand at his\her right side)


Application:


Start with your right index, middle and ring fingers wrap around the base of the occiput and the middle phalanx of the same hand, of the little finger lies over the spinous process of C2. your lateral border of the left thenar eminence lies over your right little finger.
A gentle pressure is now applied in a ventral direction on the spinous process of C2 while the skull remains still due to the control of your right forearm. (The really gentle moving force to do this comes from your left arm via the thenar eminence over the little finger on the spine of C2). 
first thing that happens is that the second finger of the vertebra moves forward under the first until the slack is taken up, then the first vertebra moves forward under the base of the skull. This is quietly taken forward until end range is felt and this position is maintained for at least 10 seconds. If indicated the headache will lift, repeat the HEADACHE SNAG six to ten times. Some patients respond better when the repositioning is sustained for much longer time- up to a minute. 

Cervicogenic headache and dizzness

Spinal mobilization with limb movement (SMWLMs) 

  • Here a transverse pressure is applied to the side of the relevant spinous process as the patient concurrently moves the limb through the previously restricted range of movement.

  • The assumption here is that the restriction of movement is of spinal origin of course.

  • This does not necessarily imply neural compromise since spinal movement must occur when a limb moves beyond a certain point.

  • Thus the technique addresses a spinal structural/ mechanical restriction, but this may have neural implications too.

SMWLMs and GHJ MWM