MULLIGAN

MOBILIZATION
INTRODUCTION
• Brian R. Mulligan is a registered Physical therapist in Wellington,
New Zealand.
• He was introduced by Stanley Paris early in the 1960s.
• He acknowledges Freddy Kaltenborn as his mentor.
• The Physiotherapy treatment of musculoskeletal injuries has
progressed from its foundation from active exercise to therapist-
applied passive physiological movement and on to therapist-applied
accessory techniques.
INTRODUCTION

• Brian R. Mulligan’s concept of Mobilization with movement

(MWM) is the logical continuance of this evolution with the
concurrent application of both therapist applied accessory and
patient generated active physiological movements.
• It is a manual therapy technique based on the analysis and
correction of any minor positional faults in a joint.
INTRODUCTION

• There are two main theories of Mulligan which accounts for success of
the spinal and peripheral joint technique.
• Positional faults leading to maltracking.
• Normal movement memory restoration.
What is the mulligan concept technique?
The mulligan concept technique is where a joint mobilization
is applied and then the joint is actively moved by the patient.
Important Acronyms
• Mobilization With Movement (MWM)
• Natural Apophyseal Glides (NAGs)
• Sustained Natural Apophyseal Glides (SNAGs)
• Spinal Mobilization With Limb Movements (SMWLMs)
• Spinal Mobilization With Arm Movements (SMWAMs)
• Pain Release Phenomenon (PRPs)
 Basic concepts
1. Convex Motion Rule
When the convex joint moves, the glide occurs
in the opposite direction.

2. Concave Motion Rule

When the concave joint moves, the glide occurs
in the same direction.
POSITIONAL FAULTS
• According to Mulligan, positional faults are due to various soft tissue
or bone lesions in and around the joint.
• Positional faults occur due to injury or changes in the shape of
articular surfaces, thickness of cartilages, orientation of fibers of
ligaments and capsules which lead to maltracking of the joint,
resulting in symptoms such as pain and stiffness.
• Mulligan’s technique corrects this positional faults and makes the joint
to track normally.
 NORMAL MOVEMENT MEMORY
RESTORATION
• Movement is a series of automatic activities that are learned during
growth and development.
• Pain and dysfunction produce abnormal movement patterns that may
become learned and part of automatic action.
• Reeducating normal action with addition of accessory glides enhances
the ability to regain normal movement.
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
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.
RELIEF OF PAIN AND DYSFUNCTION
BY MANUAL THERAPY
• Both protective spasm and inhibition of normal muscle function due to
pain may produce altered joint biomechanics and imbalance in the
normal coordinated group action of muscles.
• The net effect is a potential increase in pain, mal alignments and
inefficient activity.
• Treatment focusing on the reduction of maltracking which
significantly reduces pain and dysfunctions.
PRINCIPLES OF TREATMENT
• Acknowledge contraindications.
• Basic rule of never causing pain.
• Therapist choosing to make use of SNAGS / NAGS in the spine and
MWMs in the extremities must still know and abide by the basic rules
of application of manual therapy techniques.
PRINCIPLES OF TREATMENT
• Assessment as described by Maitland.
• Check the comparable sign.
• These signs may be,
 Loss of joint movement
Pain associated with movement
Pain associated with specific functional activities
PRINCIPLES OF TREATMENT

• The passive accessory joint mobilization is applied following the

principles of Kaltenborn (i.e., parallel or perpendicular to the joint
plane).

• This accessory glide must itself be pain free.

• The therapist must continuously monitor the patient’s reaction to
ensure no pain is reproduced.
PRINCIPLES OF TREATMENT

• Therapist investigates 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 when comparing it
before the treatment.
• 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 or painful motion or activity is repeated while the
therapist continues to maintain the appropriate accessory glide.
Principles of Application of Treatment
• 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

The CROCKS Principle:
 C – Contraindications ( no PILL response)
 R – Repetitions
 O- Overpressure
 C – Communications
 K – Knowledge ( of treatment plans & pathologies)
 S – Sustain the mobilization throughout the movement
Equipments
• Plinth / couch
• Mulligan belt
• Mulligan pads
• Tape
MULLIGAN’S MANUAL THERAPY TECHNIQUE:

• Sustained natural apophyseal glides ( SNAG’S)

• Natural apophyseal glides ( NAG’S)
• Mobilization with movement(MWM’S)
• Spinal mobilizations with limb movements (SMWM’S)
SNAG’S
• SNAGS- Sustained Natural Apophyseal Glides.
• SNAGS can be applied to all the spinal joints, the rib cage and the
sacroiliac joint(mainly cervical and lumbar).
• The therapist applies the appropriate accessory zygapophyseal glide
while the patient performs the symptomatic movement.
• This must result in full range pain free movement.
• They are not the choice in conditions that are highly irritable
EG: Cervical SNAG
Self snags
• It is possible for the patients to SELF SNAG their lumbar spines for
both flexion , extension and sometimes for side flexion.
• The purpose of SNAGS is to bring about an immediate improvement
in the patients movement after they have been completed.
• The patient requires a belt (ideally of car seat belt material or soft
leather).
Eg..cervical extension
• Extension is the most commonly used self snag.
• The patient pulls up on the belt in the direction of the chin and moves
into spinal extension.
• This is repeated ten times
• Another method: the patient clench a fist and place the shaft of the
proximal phalanx of his index finger under the spinous process.
• With the assistance of his other hand he pushes up along the
treatment plane as he extends.
CRITERIA FOR SNAGS
• SNAGS are weight bearing.
• SNAGS are mobilizations with active movement followed by passive over
pressure.
• SNAGS follow the treatment plane rule.
• The mobilization component is sustained.
• SNAGS can be applied to most spinal joints.
• When indicated they are painless.
• They are carried out at end range.
• There is a straight forward procedure for each movement loss.
• No time is wasted.
SNAGs - Lumbar spine
SNAGs - self mobilisation
SNAGs - Lumbar flexion
SNAGs - Lumbar extension
 NAG’S
• NAGS – Natural apophyseal glides.
• NAGS are used for the cervical and upper thoracic spine.
• They consists of oscillatory mobilizations instead of sustained
glide(SNAGS).
• NAGS are mid range to end range facet joints mobilisations.
• Applied antero-superiorly along the treatment planes of the joints
selected.
• Useful for grossly restricted spinal movement.
• Choice of treatment in highly irritable conditions.
EG: CERVIACL NAGS
REVERSE NAGS
• As the name implies these mobilizations are the reverse of “NAGS”.
• Reverse NAGS are applied to the inferior facet.
• In the case of “NAGS” the superior facet glides up the inferior and
with “REVERSE NAGS” the inferior facet glides up on the superior
facet.
• If “NAGS” prove unsuccessful, the “REVERSE NAGS” can be tried.
 SPINAL MOBILISTAION WITH LIMB
MOVEMNT(SMWLM’s)
• A transverse pressure is applied to the side of the relevant spinous
process as the patient concurrently moves the limb through the
previously restricted ROM.
• 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.
EG: SPINAL MWM FOR LUMBAR SPINE
SMWAMS
• SMWAMS is the acronym for Spinal Mobilization With Arm
Movements.
• These are extremely effective when indicated and are completely safe
if basic rules are followed. These are:
• When indicated no pain is experienced with the technique.
• After 6 to 10 repetitions of the arm movement with sustained spinal
mobilization the patient should notice a marked improvement in arm
function.
SMWAMS

• Do not over treat.

• Do not release the mobilization until the patient has returned to the
starting position.
MWM
• MWM refers to Mobilization With Movement.
• MWM is the simultaneous application of therapist generated passive
accessory glides/ mobilization along with patient generated active
physiological movements.
• All applications of “MWMs” for painful restrictions, the direction of
the glide is critical. Pain may be reproduced if the direction is slightly
off the treatment plane.
MWM

• MWMs are same as that of SNAGS in spinal segments.

• Terminal overpressure is essential to gain the maximum benefit from
MWM.
• MWM are pain less to apply.
• It produces immediate result.
• Whenever possible, taping is also applied to the patient’s joint in a
corrected position and it can be repeated as necessary.
MWM

• Before the application of technique, 2 rules should be followed.

• Rules described by Kaltenborn,
• Concavo convex rule.
• Joint plane rule.
• Both will help in deciding the direction of treatment and in achieving
pain-free application of technique.
 PERIPHERAL MWM
• Peripheral MWM –peripheral mobilization with movement.
• Once aggravating movement has been identified, an appropriate glide
is selected.
• Once the glide has been chosen it must be sustained throughout the
physiological movement until the joint returns to its original starting
position.
• Mobilisation 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.
• The decision to use weight bearing or non weight bearing movement
depends upon the severity, irritability and nature of the condition.
EG: PMWM FOR ANKLE DORSI
FLEXION
MWM with weight bearing knee flexion
• Medial knee pain- medial glide
• Lateral knee pain- lateral glide
MWM medial glide with knee flexion
MWM rotation with knee flexion
Fingers
Wrist
Elbow – Lateral glide with movement
Elbow – Rotation with movement
PRPs
• PRPS refers to Pain Release Phenomenon Techniques.
• There are 4 techniques in PRPS.
1. Joint stretch.
2. Joint compression.
3. Joint glide.
4. Static resistant.
PRPs

• PRPS are painful to apply.

• Over a particular duration of application, the pain will be reduced.
• It is repeated for 6-10 times.
• PRPS are very much effective in chronic conditions.
• It is contraindicated for 48 hours after the onset of injury.
INDICATION

Mechanical pain, spasm and muscle guarding

Acute, Sub acute Mobility impairments
Positional faults/Subluxation
Reversible Hypomobility
Progressive limitation
Post surgical status with residual loss of mobility
Cervicogenic headache
Ankle sprain
Adhesive capsulitis
CONTRAINDICATION

ABSOLUTE RELATIVE
Malignancy of spine Excessive pain or swelling
Cauda equina/Spinal cord Neurological involvement
compression
Osteoporosis
Rheumatoid arthritis (acute
Spondylolysthesis
inflammation)
Acute inflammation/Infective Hypermobility
arthritis Patient instability
 Metabolic Bone diseases/Fracture
Osteomyelitis
THANK YOU