Introduction to mulligan
Definition: Mulligan's concept involves the application of manual
mobilization to peripheral and vertebral glides combined with active or passive
repeated physiological movements of the affected joint, which are performed
by the patient or the therapist.
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 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
following the principles of Kaltenborn. This
accessory glide must itself be pain free.
2. During assessment the therapist will identify one
or more comparable signs
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.
Principles of Treatment
4. While sustaining the accessory glide, the patient
is requested to perform the comparable sign. The
comparable sign 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
the therapist should look for PILL response to
use the same as a Treatment
* P- Pain free.
* I- Instant result.
* LL- Long Lasting
Techniques:
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.
NAGs
NAGs stand for 'Natural Apophyseal Glides”.
NAGs are used for the cervical and upper thoracic spine.
They consist of oscillatory mobilizations instead of
sustained glide like SNAGs, and it can be applied to the
facet joints between 2nd cervical and 3rd thoracic
vertebrae.
NAGs are mid-range to end range facet joint
mobilizations applied antero-superiorly along the
treatment planes of the joint selected.
Useful for grossly restricted spinal movement.
NAGs for the treatment of choice in highly irritable
conditions
Mobilization with Movement (MWM)
Techniques:
Mobilization with movement (MWM) is the
concurrent application of sustained passive accessory
mobilization applied by a therapist and an active
physiological movement to end range applied by the
patient. Passive end-of-range overpressure, or stretching, is
then delivered without pain as a barrier
This combination allows for a pain-free and smooth range
of motion.
- Repositioning with Movement (RWM) Techniques:
RWM involves repositioning a joint to restore its proper alignment while
the patient performs an active movement. This technique is useful for
conditions like joint malalignment and positional faults.
Combination Techniques: The Mulligan concept often utilizes a
combination of MWM and RWM techniques to maximize treatment
outcomes.
as patient so improvement, the technique can be modified to challenge
their musculoskeletal system further
Indication
1- Acute pain from injury
2-Acute and chronic ankle sprain
3-TMJ pain and restriction
4-Any neuromuscular pain and injury
5-Restricted ROM like frozen shoulder
Contraindication
1-pregnancy
2-Bone tumor or osteoporosis
3-joint hypermobility
4-psychological disorders
5-vascular disorder like aneurysm