‘The Mulligan concept is a relatively new method of treatment focusing on correcting altered arthrokinematics by mobilizing joints during active movement’.
Principles for application of the Mulligan concept techniques;
- Physiotherapist must identify the signs; a loss of joint movement, pain associated with movement, or pain associated with specific functional activities during assessment.
- A passive accessory joint mobilization is applied according to the rules of Kaltenborn (i.e. parallel or perpendicular to the joint plane) and this accessory glide must be pain free.
- Physiotherapist must pay an extra attention to the patient’s reaction to ensure no pain is felt.
- While the accessory glide is maintained, the patient is requested to move their complained extremities or spine to the restricted direction to check if the restriction has been improved (i.e. increased range of active motion, muscle contraction and free of the original pain). The goal is to have the movement performed without presence of the original complaint.
- If the pain is still provoking, it indicates that the therapist has not found the correct gliding direction (treatment plane), mobilization grade, spinal segment or that the technique is not indicated.
- Once the therapist discovered the correct pain-free arthrokinematic adjustment glide, the previously limited and/or painful movement is repeated by the patient while the therapist continues to maintain the appropriate accessory glide. Further gains are expected with repetition during a treatment session particularly when pain-free overpressure is applied. This technique is repeated for about 3-4 sets of ten repetitions.
- The patient is encouraged to ‘remember’ the position of the joint when it moves in its pain-free position. The therapist can then gradually reduce the assistance given as the patient is able to actively take over.
Useful Mulligan concept Terms
In the cervical spine, Mulligan describes an occilatory mid to end range manual therapy technique performed in seated weight bearing. As the therapists gliding force is always performed parallel to the surface of the relevant apophyseal joints under treatment they have been termed “Natural Apophyseal Glides” or “NAGS”.
Their application is well described by Mulligan and therapists using these this technique find excellent results in both the mid and lower cervical as well as upper thoracic spine.
NAGS provide the therapist with an opportunity to both assess and treat the patient in the closed kinetic chain weight bearing position where most patients experience their symptoms. They are often indicated in the elderly and highly useful in the management of the acute post-injury patient when other manual therapy techniques would be poorly tolerated.
Mulligan’s other spinal manual therapy treatment techniques involve the concurrent application of both therapist applied accessory apophyseal joint gliding and end range active physiological movement on the part of the patient. As these techniques are sustained at the end of available pain-free range and still follow the plane of the apophyseal joints under treatment, they have gained the name “Sustained Natural Apophyseal Glides”. “SNAGS” was of course the acronym of choice. (6)
Mulligan claims these to be a new and unique approach as they:
1. Are performed exclusively in weight bearing.
2. Are mobilizations which are combined with active or passive physiological movements.
3. Follow the Kaltenborn treatment plane rule that applies to both spinal and extremity joints. (for more information about the Kaltenborn treatment plane rule CLICK HERE).
4. Are sustained at the end of range where pain-free overpressure may be applied.
5. Are applicable to all spinal joints.
6. Allow the therapist to quickly decide if they are indicated and will become part of a given therapy regime. 7. Are painless when performed correctly and clinically indicated.
8. Produce immediate and sustained gains in pain-free function.
[The information was taken and modified by In-hyuk Jo; available from: http://www.itherapies.com/support/support downloads/MulliganConcept_NextStep.pdf]