MULLIGAN TECHINIQUE.pptx

Mulligan Technique basic concepts.

1. MULLIGAN TECHINIQUE Submitted By : Sakshi Upadhyay MPT Sports

2. About the Founder Brian R. Mulligan qualified as a physiotherapist in 1954 and gained his Diploma in Manipulative Therapy in 1974. In 1996, he was made an Honorary Fellow of The New Zealand Society of Physiotherapists for his contributions to physiotherapy. In 1998, he was made the life member of The New Zealand College of Physiotherapy.

3. Definitions  Mobilization with Movement (MWM) is the concurrent application of sustained accessory mobilization applied by a therapist and an active physiological movement to end range applied by the patient. Passive end of the range overpressure or stretching is then delivered without any pain as a barrier. The concept of MWM of the extremities and sustained natural apophyseal glides of the spine was first coined by B. Mulligan. 

4. Convex Motion Rule When the convex joint partner moves, the glide occurs in the opposite direction.  

5. Concave Motion Rule When the concave joint partner moves, the glide occurs in the same direction.

6. Treatment plane A treatment plane passes through the joint and lies at a right angle to a concave joint partner. Treatment is always applied parallel to this treatment plane.

7. Mechanism of Action Biomechanical Effects: Straightens the spine Unlocking the lock joints Shifts an IVD fragment & reduces annular distortion Increases the proprioceptive feedback Stretching, tearing or rupturing adhesions that limit joint or muscle range Remove blockage or interference of blood flow, nerve compression, sympathetic chain and cerebrospinal fluid circulation

8. Positional Faults Hypothesis Mulligan proposed that injuries or sprains resulted in minor positional fault to the joint causing restrictions in physiological movements. The technique overcomes joint “tracking problems” or positional faults (joints with subtle biomechanical changes). These abnormalities provoke pain, stiffness or weakness in the joint. The therapist works to re-align the joints. Response Transient change in bone position Increase ROM

9. Neuro-physiological Effects Corrects abnormal reflexes and organ dysfunction Stretches contracted muscles causing relaxation Modulates peripheral nociceptors Activates gating mechanism, neurotransmitters. Associated changes in sympathetic and motor system.

10. Theory of extinction and habituation Pain is considered as a form of aversive memory. Here, exposure to painful movement in the absence of any overt danger, is fundamental and is used in the EXTINCTION of the aversive memories. Progressive mobilization desensitizes the nervous system through HABITUATION. The mechanism involves a progressive decline in the ability of the pre- synaptic nerve terminal to transmit impulses. Response Initial endogenous non- opoid hypo-algesia by excitation of the sympatho -excitation through movement.

11. Principles of Treatment A passive accessory joint mobilization is applied following the principles of Kaltenborn. This accessory glide must itself be pain free. During assessment the therapist will identify one or more comparable signs as described by Maitland. These signs may be : A loss of joint movement Pain associated with movement Pain associated with specific movement.

12. The therapist must continuously monitor the patients reaction to ensure no pain is recreated. The therapist must investigate various combinations of parallel or perpendicular glides to find the correct treatment plane and grade of accessory movement. While sustaining the accessory glide, the patient is requested to perform the comparable sign. The comparable sign should now be significantly improved. 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. The previously restricted and/or painful motion or activity is repeated by the patient while the therapist continues to maintain the appropriate accessory glide.

13. The PILL Principle While applying MWMs as an assessment, the therapist should look for PILL response to use the same as a treatment technique. P - pain free I- instant result LL – long lasting If there is No PILL response, the technique should not be advocated.

14. The CROCKS Principle C- Contra-indications ( No PILL response) R- Repetitions O- Overpressure C- Communications K- Knowledge (of treatment planes & pathologies) S- Sustain the mobilization throughout the movement.

15. Equipment's Plinth / couch Mulligan belt Mulligan pads Tape

16. Indications Pain of a non-inflammatory nature Acute pain from injury Loss of motion due to arthritic conditions Post surgical conditions Headaches due to neck problem Dizziness associated with neck problem TMJ pain & movement restrictions Acute or Chronic Ankle sprains Tennis elbow Sacroiliitis Frozen Shoulder Any Neuromusculosketal pain and stiffness Any neurological and musculoskeletal condition can be treatment, as long as the therapist follows the basic rule of not causing pain.

17. Contraindications   Relative Contraindications: Joint Hypermobility Pregnancy Osteopenia Absolute Contraindications: Bone Weakness ( Tumour, Osteoporosis, Metabolic Bone Disease) Vascular (Anticoagulant Therapy, Aortic Aneurysm) Neurological Deficits (multilevel PIVD, Cervical Myelopathy) Psychological Disorders.

18. Techniques   The Mulligan’s mobilizations are categorised into : The Spinal Mobilizations Cervical and Upper Thoracic Spines: NAGs, Reverse NAGs, SNAGs, self SNAGs, SMWLMs. Thoracic Spine Lumbar Spine: SNAGs, self SNAGs Sacroiliac Joints The Rib Cage Other spinal therapies: manipulation, self treatment

19. The Extremities MWMs Compression treatments Pain Release Phenomenon Other extremity therapies Grips: ‘vee’ finger grip positioning for upper thoracic and cervical spine.

20. Natural Apophyseal Glides (NAGs) These are used for cervical and upper thoracic spine. It consists of oscillatory mobilizations instead of sustained glide and it can be applied to facet joints between 2nd cervical to 3rd thoracic vertebrae. NAGs are mid to end range facet joint mobilizations applied antero-superiorly along the treatment planes of the joint selected. Graded according to the tolerance of the patient and is useful for grossly restricted spinal movement. NAGs can be used for treatment of choice in highly irritable conditions after application of manual traction.

21. Reverse NAGs These are used for the upper thoracic spine and shows some benefits in the lower cervical spine. They replicate passively the head retraction motion. So, in case of NAGs the superior facet glides up the inferior. In reverse NAGs, the inferior facet glides up on the superior.

22. Sustained Natural Apophyseal Glides (SNAGs)  SNAGs can be applied to all spinal joints, the rib cage and the sacroiliac joint. The technique is performed when the therapist applies the appropriate accessory zygapophyseal glide while the patient is asked to do the physiological symptomatic movement resulting in a full pain free movement. Although SNAGs are performed in weight bearing positions they can be adapted for use in non weight bearing positions.

23. Criteria for SNAGs Treatment Approach They are all done in weight bearing postures. They are mobilizations with active movements followed by passive overpressure. The follow the treatment plane rule. The mobilization component is sustained. They are applied to most spinal joints. When indicated they are painless. They are carried out at end range. They require thorough knowledge to allow straight forward procedure for each movement loss. No time is wasted as the treatment regime is decided within a couple of minutes.

24. Self SNAGs Self SNAGs are a useful home routine . It is the only manual technique used by the patient who presents for treatment. The technique should be demonstrated on an articulated spine or on an assistant. Should ideally be taught on the first day of treatment as the patient will get it right this way.

25. Self SNAGs Errors Common errors that the patients do: They may forget the placement of their hands. They place the bulky towel on the spinous process instead of using just the edge. They tend to pull the towel forwards and not in the superior direction of the facet plane. They forget to maintain the glide for the full duration of the movement.

26. Mobilization With Movement (MWM) SNAGs and MWMs are similar in that they both address the problems of pain and restriction, both bring about change at the time of delivery , both are painless when indicated and both are sustained mobilizations with movement. There is very little difference between SNAGs & MWMs as SNAGs are facet mobilizations which are normally both in the plane and the direction of the active movement whereas in the extremities, the mobilization plane to correct the positional fault is in the direction different to the movement of the glide.

27. Spinal Mobilization With Limb Movements (SMWLMs) SMWLMs allows for the 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 is that restriction of movement is of spinal origin which may not imply neural compromise since spinal movement must occur when a limb moves beyond a certain point. Self-SMWLMs & self-SMWAMs can be taught to the patient.

28. Spinal Mobilization With Arm Movements (SMWAMs)  The spinal mobility allows the movement at the peripheral joints. The mobilization combines the extremity joint mobilizations with the extremity joint movements. So, when the shoulder girdle is moved, the spinal movement also takes place because of the muscle attachments from the scapula to the cervical and upper thoracic spine.

29. MWM Prescription Parameters Repetitions / Sets : ten repetitions for three sets. Frequency : three to six sessions a week or as frequent as a session every two hourly or once in five days. Amount of force : although it is an important variable in Mulligan's concept, only one study gave methods of applying force by using a hand held dynamometer where 66% showed maximal gains of the effects. Rest periods : this ranges from 30 second to 2 hours between the sets.

30. Pain Release Phenomenon (PRPs) If a combination of movements & compression causes pain, then the combination is repeated for 20 second to see if the pain disappears during the time, the pressure on the articular surface should remain constant. If pain increases, STOP immediately. Apply less or no pressure and then , repeat it for 20 seconds. If the pain disappears, then repeat the technique with the same amount of pressure. PRP can be given in chronic conditions when the initial repair has already taken place. There are 4 types of PRPs: Compression, Traction, Stretch and Contraction.

31. References https://www.researchgate.net/publication/329949215_Mulligan_Concept_of_Manual_Therapy The Mulligan Concept of Manual Therapy by Wayne Hing, Toby Hall, Brian Mulligan