MANUAL THERAPY

The Mulligan Concept:Mobilizations With Movement

Russell T. Baker, MS, MS, ATC; Alan Nasypany, EdD, ATC, LAT; and Jeff G. Seegmiller,EdD, ATC, LAT • University of Idaho and Jayme G. Baker, DPT, ATC • California BaptistUniversity

e Mulligan concept of mobilizations withmovement (MWM) is a specific therapeuticintervention designed to couple accessorymobilization with physiological motion.' Theconcept was developed by Brian Mulliganon the basis of his clinical experiences andthe influences of noted physical therapists

Freddy Kaltenborn,Geoff Maitland, RobinMcKenzie, and RobertElvey and orthopedicphysician. Dr. JamesCyriax.'-2 Mulliganexperimented in clinicalpractice to develop histheory of MWM.''̂ Thepurpose of this report isto provide an overviewof the Mulligan conceptof MWM and to presentdocumented therapeu-tic outcomes.

KEY POINTS

Mobilizations with movement can be usedto assess and treat a variety of músculo-skeletal conditions.

Mobilizations with movement can produceimmediate and long-lasting therapeuticbenefits.

Patients can be taught self-mobilizationswith movement to decrease reliance on theclinician.

The Mulligan Concept

Clinicians often deal with pathology that pro-duces abnormal Joint mechanics (e.g., hypo-mobility or hypermobility). The difficulties aclinician faces are determination of the causeof mechanical dysfunction and selection ofthe most appropriate clinical intervention.A possible cause of mechanical instability

that is often overlooked is a positional fault,which is a sustained malalignment of a Jointor a subluxation that is too subtle to detectthrough palpation or to visualize on a radio-graph.''' Injury can theoretically result in apositional fault that alters Joint kinematics ofthe spine and peripheral Joints.̂ '* The posi-tional fault can be responsible for pain anddecreased range of motion, which shouldbe resolved when the positional fault is cor-rected.'-̂ ^ s

An example of a positional fault ismechanical instability of the ankle followinga lateral ankle sprain. A plantar flexion andinversion mechanism of injury is likely toresult in a sprain of the anterior talofibularligament and possibly the calcaneofibularligament as well.̂ Mulligan suggested thatmechanical instability and limited functionmay be caused by a primary injury (e.g.,ligament pathology) or a secondary tissueresponse (e.g., edema) that induces a posi-tional fault.'"' An anterior positional fault ofthe fibula may result from either the ATFLpulling its distal portion into an anteriorand caudal subluxation,'•2'' or edema in theankle Joint may be responsible.^ The talus,which lacks muscle attachments, could alsobe pulled into an anterior subluxation."* Anycombination of these factors may result in apositional fault that would cause pain, insta-bility, and decreased function.

<D ZOB Human Kinetics - UATT 18(1), pp. 30 -3 / ,

30 I JANUARY 2013 INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING

The theory that positional faults occur in the anklefollowing injury has been supported by comparison ofthe position of the fibula to that of the tibia with anexternal measurement device,^ fluoroscopic exami-nation,^-^ and magnetic resonance imaging (MRI).''Kavanagh^ theorized that an anterior positional fault ofthe fibula would result in increased anterior-posteriormovement of the fibula following a lateral ankle sprain,which was observed in one-third of the subjects whohad recently sustained an acute ankle sprain (2/6).^Hubbard and Hertel^ reported fluoroscopic evidenceof significant anterior positional faults in the injuredankles of subjects with subacute lateral ankle sprainscompared to their contralateral ankles and comparedto the ankles of side-matched control subjects. Hub-bard et al.*̂ reported that a statistically significantanterior position fault was present in patients sufferingfrom unilateral chronic ankle instability (CAI). Thus, atherapeutic technique that addresses the positionalfault may be needed to restore normal joint function.

Technique

The Mulligan concept of MWM is a manual therapytechnique that has been designed to address positionalfaults for restoration of normal arthrokinematic andosteokinematic motion.' Mulligan hypothesized thata positional fault has been identified and correctedwhen MWM abolishes pain, restores function, andprovides a long-lasting therapeutic effect.^ MWM may

be appropriate for relief of pain, movement impair-ments, reduced muscle length, and positional faults.''°All precautions and contraindications associated withjoint mobilization and manual therapy are applicableto MWM, which could have an adverse effect on aninjured joint.''2

MWM involves a sustained passive joint glidewhile the patient actively moves the joint (or motionsegment).'•^•''•'ö The accessory glide may or may notbe applied by the clinician while the patient is per-forming active movements. The acronyms "PILL" and"CROCKS" (Table 1 ) guide the administration of MWM.The "PILL" acronym refers to Pain-free mobilizationsthat produce Immediate effects, and achieve Long-Lasting results.'-2 If a "PILL" response does not occur,the clinician does not continue to administer the MWMtechnique. Upon completion of the MWM technique,the clinician assesses the ability of the patient to per-form the same movement without manual applicationof the accessory glide or the patient's ability to performa functional task (e.g., reaching for an object in a rangeof motion that was previously impaired).''^

MWM for the Distal Tibiofibular Joint(Inversion Ankle Sprain)

Following an inversion ankle sprain, MWM for the distaltibiofibular joint can be used as a test or a treatment.To perform the MWM, the patient is positioned supinewith the heel off the end of the treatment table. The

CROCKS^

c

R

O

TABLE 1 : THE "CROCKS" ACRONYM

Contraindications: Traditional contraindications to manual therapy and the production of the"PILL" concept.

Repetitions: Typically three repetitions on the first day followed by 10 repetitions on subse-quent visits for the lumbar spine; commonly three sets of 10 repetitions for the extremities;err on the side of safety for irritable Joints.

Overpressure: Passive overpressure applied at end range of motion by patient or therapist forlong-lasting success.

Communication: Explain the "PILL" concept, technique, and expected results to the patientprior to applying MWM; patient immediately reports any discomfort during MWM.

Knowledge: Knowledge of treatment planes and pathologies.

Sustain, sense, skills, success: Stands for many things: sustain the mobilization from the initia-tion of movement through the return to the starting position, sense through your touch, han-dling skills to perform MWM correctly, and common sense to guide the clinician to success.

INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING JANUARY 2013 I 31

clinician places the thenar eminence of one hand overthe anterior and distal portion of the lateral malleolusand uses the other hand to support the patient's leg(Figure 1 ). The M WM is performed by gliding the fibulaposteriorly and obliquely on the tibia. The directionof the glide is performed along the line of the ATFL asa sustained anterior-posterior dorso-proximal glide.While the glide is manually sustained, the patient isinstructed to perform a plantar flexion and inversionmovement. The clinician then uses his or her abdo-men to generate a force against the dorsum of thepatient's foot (i.e., overpressure) to further displace itbeyond the limit of the active movement (Figure 2). Ifpain is elicited by the glide, the clinician should alterthe direction of the manual force until the movementbecomes pain-free. If the pain is caused by the pres-sure of the clinician's thenar eminence on the fibula,a foam pad can be used between the clinician's handand the surface of the patient's ankle. Upon completingthe MWM treatment, the application of tape may helpto maintain the fibula repositioning that was achieved(Figure 3).

Treatment Outcomes

Although the quality and quantity of available researchevidence supporting the use of MWM is insufficientto draw a definitive conclusion about its clinical effec-tiveness, clinicians have reported rapid decreases in

figure 2 The sustained distal tibiofibular MWM being applied by glidingthe ñbula posteriorly along the line of the ATFL with clinician overpres-sure being added after the patient plantarflexes and inverts the ankle.

figure 1 The starting position for the distal tibioñbular MWM. Theclinician's thenar eminence of the right hand is placed over the ventral,distal portion of the lateral malleolus, while the other hand supportsthe patient's leg.

figure 3 The completed application of two strips of 2inch tape appliedby the clinician to mimic the sustained MWM of the distal tibiofibularjoint.

patient self-report of pain and improved function aftera single treatment or after completion of a course oftreatment.'" Hetherington^ used a sustained distal tib-iofibular joint MWM with active motion and overpres-sure to treat acute ankle sprains, which was followedby tape application for maintenance of fibula position.She reported increased pain-free inversion range ofmotion, improved gait, and improved postural balanceamong an unspecified number of patients.^ Stubbs etal." utilized the same procedures to treat a lateral anklesprain in a collegiate soccer player, which immediatelyrelieved the patient's symptoms and allowed him to

32 I JANUARY 2013 INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING

return to competition without reinjury for the remain-der of the season. O'Brien and Vicenzino'^ also utilizedthe previously described MWM and taping procedures,which were reported to produce rapid improvementsin range of motion, pain, and functional outcomesscores for two patients.

Other ankle MWM techniques have also beenutilized for treatment of a lateral ankle sprain. Vicen-zino et al.'* reported that both weight-bearing andnonweight-bearing MWM produced significantlyimproved posterior talar glide and ankle dorsiflexionin 16 subjects with chronic ankle instability whencompared to measurements for the same subjects in acontrol condition. Collins et al.'^ also reported signifi-cant improvement in ankle dorsiflexion in 16 subjectswho had recently sustained an ankle sprain. Green etal.'"* reported a more rapid return to pain-free ankledorsiflexion among 19 patients with an acute anklesprain who were treated with MWM (i.e., fewer treat-ments) compared to 19 patients who did not receivethe MWM treatment.

Case studies have demonstrated MWM effective-ness for treatment of a locked lumbar zygoapophysealjoint,'^ DeQuervain's disease, '"̂ lateral epicondylalgia,'^chronic thumb pain,'** and chronic shoulder, arm, andneck pain.'^ A pilot study on the use of MWM for treat-ment of shoulder impingement provided preliminaryevidence that it may help to reduce pain and improvefunction.20 The use of MWM for treatment of lateralepicondylalgia has generally increased pain-free gripstrength.'° Two studies have documented an increasein pain-free grip strength and pressure-pain thresholdto a greater extent than that of placebo or controlgroups.2'-22 Abbot^^ reported that treatment of theelbow with MWM improved shoulder range of motionin patients with lateral epicondylalgia.

Summary

Although MWM has demonstrated potential therapeu-tic benefits for patients with a variety of musculoskel-etal conditions, it is not appropriate for every patient.To increase clinical success and minimize clinical fail-ures, the clinician must complete a thorough physicalexamination. Positional faults are not present in everypatient; however, a search for positional faults can beintegrated with other components of a clinical exami-nation to improve therapeutic outcomes. The clinician

should remember to follow Mulligan's principles, whichare represented by the "PILL" and "CROCKS" acro-nyms to achieve the greatest clinical benefit.

The MWM concept has the potential to produceimmediate and long-lasting effects, even in patientsthat had not previously responded to other treatmentfor an extended period of time. The technique of MWMadministration can easily be adjusted (e.g., amountof force and direction of force application), and thepatient can be taught to perform self-mobilizations.The current body of evidence supports the use of MWMin clinical practice, but further well-designed researchis needed to better understand the positional faultphenomenon and the therapeutic effects of MWM. I

References1. Folk. B. Crowell. R. Mulligan. B. Introduction to the Mulligan Concept

Workbook. East Hampstead. NH: Northeast Seminars; 2012.

2. Paolina J, Mulligan B. Mulligan Concept: Foot. Ankle. & Knee Workbook.East Hampstead. NH: Northeast Seminars; 2012.

3. Mulligan. BR. Manual Therapy: 'NAGS,"SNAGS," MWMS," etc. 6* ed.Wellington. New Zealand: Plane View Services LTD; 2010.

4. Vicenzino B. Branjerdporn M, Teys P. Jordan K. Initial changes inposterior talar glide and dorsiflexion of the ankle after mobilizationwith movement in Individuals with recurrent ankle sprains.y OrrtopSports Phys Ther. 2006; 36(7):464-471.

5. Kavanagh J. Is there a positional fault at the inferior tibiofibular jointin patients with acute or chronic ankle sprains compared to normal?Man Ther. 1999; 4(0:19-24.

6. Hubbard TJ. Hertel J. Anterior positional fault of the fibula after sub-acute lateral ankle sprains. Man Ther. 2008; 13:63-67.

7. Hetherington B. Lateral ligament strains of the ankle, do they exist?Man Ther. 1996; 1(5):274-275.

8. Hubbard TJ, Hertel J, Sherbondy P. Fibular position in individuals withself-reported chronic ankle instability.J Orthop Sports P/rys Ther. 2007;36(l):3-9.

9. Mavi A. Yildirim H. Gunes H. Pestamaici T. Cumusburun. E. Thefibula incisura of the tibia with recurrent sprained ankle on magneticresonance imagining. Saudi MedJ. 2002; 23:845-849.

10. Vicenzino B, Paungmali A, Teys P Mulligan's mobilization-with-movement, positional faults and pain relief: current concepts from acritical review of literature. Man Ther. 2007; 12:98-108.

11. Stubbs E, Baker RT, Ramos. C. Utilizing Mulligan's concept for correctingan anterior positional fault of the fibula following a lateral ankle sprain:a case report. Paper presented at: 2012 Far West Athletic Trainers'Association Annual Meeting and Clinical Symposium; April 12-15.2012, San Diego, CA.

12. O'Brien T, Vicenzino B. A study of the effects of Mulligan's mobiliza-tion with movement treatment of lateral ankle pain using a case studydesign. Manual Ther. 1998;3(2):78-84.

13. Collins N, Teys P, Vicenzino B. The initial effects of a Mulligan'smobilization with movement technique on dorsiflexion and pain insubacute ankle sprains. Man Ther. 2004; 9:77-82.

14. Creen T, Refshauge K, Crosbie J. Adams R, A randomized controlledtrial of a passive accessory joint mobilization on acute ankle sprains.Phys Ther. 2001 ; 81:984-994.

INTERNATIONAL JOURNAL OF ATHLETIC THERAPY S. TRAINING JANUARY 2013 I 33

15. Exelby L. The locked lumbar facet joint: intervention using mobiliza-tions with movement. Man Ther. 2001: 6(2):116-121.

16. Backstrom K. Mobilization vi/ith movement as an adjunct interventionin a patient with DeQuervain's tenosynovitis: a case report.y OrthopSports Phys Ther. 2002; 32(3):86-97.

17. Vicenzino B, Wright A. Effects of a novel manipulative physiotherapytechnique on tennis elbow: a single case study. Man Ther. 1995:l(l):30-35.

18. Hsieh CY, Vicenzino B, Yang CH, Hu MH,. Yang C. Mulligan's mobiliza-tion with movement for the thumb: a single case report using magneticresonance imaging to evaluate the positional fault hypothesis. ManTher. 2002: 7(I):44-49.

19. Scaringe j , Kawaoka C, . Studt T. Improved shoulder function afterusing spinal mobilisation with arm movement in a 50 year old golferwith shoulder, arm, and neck pain. Top Clin Chiroprt. 2002: 9:44-53.

20. Kachingwe AF, Phillips B. Sletten E, . Plunkett SW. Comparison ofmanual therapy techniques with therapeutic exercise in the treatmentof shoulder impingement: a randomized controlled pilot clinical trial.J Man Manip Ther. 16(4):238.247.

21. Paungmali A, O'Leary S, Souvlis T, .Vicenzino B. Hypoalgesic andsympathoexcitatoy effects of mobilization with movement for lateralepicondylalgia. Phys Ther. 2003a;83:374-383.

22. Vicenzino B. Paungmali A, Buratowski S. Wright A. Specific manipu-lative therapy treatment for chronic lateral epicondylalgia producesuniquely characteristic hypoalgesia. Man Ther. 2001: 6(4):205-212.

23. Abbot j . Mobilizations with movement applied to the elbow affectsshoulder range of movement in subjects with lateral epicondylalgia.Man Ther. 2001: 6(3): I 70-1 77.

Russell Baker is an assistant professor in the Department of Kinesiol-ogy at California Baptist University. He is also a doctoral student atthe University of Idaho in the Doctor of Athletic Training program..Moscow, ID.

Alan Nasypany is the Director of Athletic Training Education in theDepartment of Movement Sciences at the University of Idaho inMoscow. ID.

Jeff Seegmiller is an associate professor and Musculoskeletal AnatomyChair in WWAMI Medical Education and the Department of MovementSciences at the University of Idaho in Moscow, ID.

Jayme Baker is an adjunct professor with the Department of Kinesiol-ogy at California Baptist University in Riverside, CA.

Trida Tumer, PhD, ATC, University of North Carolina at Charlotte, isthe report editor for this article.

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