MULLIGAN CONCEPT AND MOBILIZATION OF SPINE

Mulligan Mobilisation concept

1. Mahesh
MULLIGAN CONCEPT

2. LEARNING OBJECTIVES
At the end of the lecture the students should be able to
ExplainRelevantConceptsInofStatePrinciplesAnd
GuidelinesRelatedToMulliganConcept.

3. INTRODUCTION
BrianMulligan'sconceptofmobilizationswith
movement (MWMS)intheextremitiesand
sustainednaturalapophysealglides(SNAGS)in
thespinearethelogicalcontinuanceofthis
evolutionwiththeconcurrentapplicationofboth
therapistappliedaccessoryandpatientgenerated
activephysiologicalmovements.

4. INTRODUCTION…..
Increasedfunctionanddecreasedpainare
expectedtobeimmediateandsustainedwiththe
applicationofthesetechniqueswithnopain
experiencedduringtheirutilization.

5. PRINCIPLES OF TREATMENT
Contraindicationstotreatmentexistandshouldberespectedatall
times.
Mustabidebythebasicrulesofapplicationofmanualtherapy
techniques.

6. BASIC PRINCIPLES (INDICATIONS)
Duringassessmentthetherapistwillidentifyoneormore
comparablesigns.Thesesignsmaybealossofjointmovement,pain
associatedwithmovement,orpainassociatedwithspecificfunctional
activities.

7. BASIC PRINCIPLES (INDICATIONS)….
Apassiveaccessoryjointmobilizationisapplied.Thisaccessory
glidemustitselfbepainfree.

8. BASIC PRINCIPLES (INDICATIONS)….
Thetherapistmustcontinuouslymonitorthepatient'sreactionto
ensurenopainisrecreated.

9. BASIC PRINCIPLES (INDICATIONS)….
Whilesustainingtheaccessoryglide,thepatientisrequestedto
performthecomparablesign.Thecomparablesignshouldnowbe
significantlyimproved(i.e.,increasedrangeofmotion,anda
significantlydecreasedorbetteryet,absenceoftheoriginalpain).

10. BASIC PRINCIPLES (INDICATIONS)….
Failuretoimprovethecomparablesignwouldindicatethatthe
therapisthasnotfoundthecorrectcontactpoint,treatmentplane,
gradeordirectionofmobilization,spinalsegmentorthatthe
techniqueisnotindicated.

11. BASIC PRINCIPLES (INDICATIONS)….
Thepreviouslyrestrictedand/orpainfulmotionoractivityis
repeatedbythepatientwhilethetherapistcontinuestomaintainthe
appropriateaccessoryglide.Furthergainsareexpectedwith
repetitionduringatreatmentsessiontypicallyinvolvingthreesetsof
tenrepetitions.

12. BASIC PRINCIPLES (INDICATIONS)….
Furthergainsmayberealizedthroughtheapplicationofpassive
overpressureattheendofavailablerange.Itisexpectedthatthis
overpressureisagain,pain-free.

13. BASIC PRINCIPLES (INDICATIONS)….
Self-treatmentisoftenpossibleusingMWMprincipleswithadhesive
tapeand/orthepatientprovidingtheglidecomponentoftheMWM
andthepatient'sowneffortstoproducetheactivemovement.

14. NAGS(NATURAL APOHYSEAL GLIDING)
Inthecervicalspine,Mulligandescribesanoscillatorymidtoend
rangemanualtherapytechniqueperformedinseatedweightbearing.
Asthetherapistsglidingforceisalwaysperformedparalleltothe
surfaceoftherelevantapophysealjointsundertreatmenttheyhave
beentermed"NaturalApophysealGlides"or"NAGS".

15. NAGS(NATURAL APOHYSEAL
GLIDING)….
TheirapplicationiswelldescribedbyMulliganandtherapistsusing
thesetechniquefindexcellentresultsinboththemidandlower
cervicalaswellasupperthoracicspine.

16. NAGS(NATURAL APOHYSEAL
GLIDING)….
NAGSprovidethetherapistwithanopportunitytobothassessand
treatthepatientintheclosedkineticchainweightbearingposition
wheremostpatientsexperiencetheirsymptoms.

17. NAGS(NATURAL APOHYSEAL
GLIDING)….
Theyareoftenindicatedintheelderlyandhighlyusefulinthe
managementoftheacutepost-injurypatientwhenothermanual
therapytechniqueswouldbepoorlytolerated.

18. SNAGS(SUSTAINED NATURAL APPOHYSEAL
GLIDING)
Mulligan'sotherspinalmanualtherapytreatmenttechniquesinvolve
theconcurrentapplicationofboththerapistappliedaccessory
apophysealjointglidingandendrangeactivephysiologicalmovement
onthepartofthepatient.

19. SNAGS(SUSTAINED NATURAL
APPOHYSEAL GLIDING)….
Asthesetechniquesaresustainedattheendofavailablepain-free
rangeandstillfollowtheplaneoftheapophysealjointsunder
treatment,theyhavegainedthename"SustainedNaturalApophyseal
Glides".

20. BENEFITS OF MULLIGHAN APROACH
Areperformedexclusivelyinweightbearing.
Aremobilizationswhicharecombinedwithactiveorpassive
physiologicalmovements.
FollowtheKaltenborntreatmentplanerulethatappliestobothspinal
andextremityjoints.
Aresustainedattheendofrangewherepain-freeoverpressuremay
beapplied.

21. BENEFITS OF MULLIGHAN APROACH….
Areapplicabletoallspinaljoints.
Allowthetherapisttoquicklydecideiftheyareindicatedandwill
becomepartofagiventherapyregime.
Arepainlesswhenperformedcorrectlyandclinicallyindicated.
Produceimmediateandsustainedgainsinpain-freefunction.

22. PERIPHERAL MWMS
Mobilizationswithmovementintheperipheraljointsarealsothe
simultaneouscombinationoftherapist-appliedaccessorygliding
techniquesandpatientand/ortherapistgeneratedphysiological
movements.
Theyareapplicabletomostextremityjointsandresultinimmediate
andsustainedimprovementinmobilityandfunction.

23. CLINICAL EXAMPLES
SNAGS for Cervical Extension
Acommonlyseenclinicalpresentationisthepatientwhofollowing
anaccelerationrear-endautocollisionexperiencesanongoing
painfulandsignificantlossofactiveandpassivecervicalextension.

24. CLINICAL EXAMPLES……
SNAGSforextensionareareliablemeanstosafelyandefficiently
restoretherangeofcervicalextensionanddecreasethepain
associatedwiththismaneuver.

25. CLINICAL EXAMPLES…..
Inordertoaccomplishoneorbothofthedesiredtasksofpain
reductionandrecoveryoffunction,thepatientisseatedina
supportivelowbackchairwiththetherapistpositionedbehind.Itmay
beusefultohavethepatientsitfacingalargewallmountedmirroras
itallowsthetherapisttoobservethepatientsfacialexpressionand
thereforereactionduringtheearlystagesofthetechnique.

26. CLINICAL EXAMPLES…..
Thecurrentrangeofcervicalextension(thecomparablesign)is
checkedforrange,rhythm,deviationandlimitingfactorssuchas;
increasingpainduringrange,painatendoftheavailablerangeor
painlessstiffnessattheendofareducedrangeofmotion.

27. CLINICAL EXAMPLES…..
Thetherapistusesthemedialborderofonethumbreinforcedbythe
padoftheotherthumbtoapplyananterosuperioraccessoryglide
throughthesuperiorspinousprocessoftheinvolvedmotion
segment.

28. CLINICAL EXAMPLES…..
Thedirectionofthismobilizationmustfollowtheplanedescribedby
thesurfacesoftheapophysealjointsundertreatment.
Thecervicalapophysealjointplanesaredirectedantero-superiorly
withtheinclinationincreasingatlowerlevels.

29. CLINICAL EXAMPLES…..
Whilesustainingthispain-freeaccessoryglide,thepatientis
instructedtoactivelyperformthecomparablesignofcervical
extension.Theexpectationisthattherangedisplayedwill
significantlyincreaseandanypainpreviouslyexperiencedwillbe
virtuallyabolished.

30. CLINICAL EXAMPLES…..
Asthepatientprogressesthroughtheincreasingphysiological
range,thetherapistmust"track"withthespinousprocessto
maintainhis/herglideparalleltothechangingtreatmentplane.As
such,thetherapists'forearmscircumscribeanarcwhoseapexfaces
antero-superiorly.

31. CLINICAL EXAMPLES…..
Theendrangephysiologicalmovementissustainedforseveral
seconds.Overpressuremaybegivenattheendofrangebythe
patienttoenhancetheeffectandtheprocedureisrepeatedinsetsof
fivetoten.

32. CLINICAL EXAMPLES…..
Thepatient'spost-treatmentrangeshouldnowbere-evaluatedto
observetheoverallgainwithouttheapplicationofthemobilization
component.

33. HOME PROGRAMME
Ahomeprogrammaybeperformedbetweentreatmentsessions
utilizingtheSNAGS.
principlesandatoweltoimparttheglidecomponenttomaintain
gainsachievedduringtreatment.

34. SELF-SNAGS FOR CERVICAL
EXTENSION
UnilateralSNAGSoverthearticularpillarsmayalsobeattemptedfor
symptomsnotrespondingtocentrallyappliedtechniques.

35. SELF-SNAGS FOR CERVICAL
EXTENSION…
OneofthemostexcitingaspectsofSNAGSmobilizationsisthe
abilitytotreatapatientdynamicallythrougharangeofmovement.
Painfularcsordeviationsofmovement maybeaddressed
dynamicallythroughtheaffectedrangeasopposedtostaticallyina
seriesofpositions.
ThepossibilitiesfortreatmentofcombinedmovementswithSNAGS
aremostrewarding.

36. HIP INTERNAL ROTATION MWM
Appropriatemusclebalancingexerciseswouldbegivenincluding
stretchestomaintaintheimprovedrangebetweentreatment
sessions.
SeveraltreatmentsessionsofthreetofoursetsoftenMWMswillsee
progressiveandlastingimprovementinrangeanddecreaseinpain.

37. HIP INTERNAL ROTATION MWM
AlthoughindividualMWMsmaybeappliedforthevariouslossesin
hipjointrangeofmotionobserved,restoringinternalrotationwill
oftenresultinaresolutioninanotherhipmovementdysfunction.

38. HIP INTERNAL ROTATION MWM….
Thosepatientswithconcurrenthipandlumbarsignsoftenrespond
welltotreatmentinitiallydirectedtothehipthroughthistechnique.