The Th e
Mulligan Concept of
manual therapy textbook of techniques Wayne Hing Toby Hall Darren Rivett Bill Vicenzino Brian Mulligan
is an imprint o Elsevier Elsevier Australia. ACN 001 002 357 (a division o Reed International Books Australia Pty Ltd) ower 1, 475 Victoria Avenue, Chatswood, NSW 2067 Tis edition © 2015 Elsevier Australia Tis publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part o this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission rom the publisher. Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. Te publisher apologises or any accidental inringement and would welcome any inormation to redress the situation. Tis publication has been careully reviewed and checked to ensure that the content is as accurate and current as possible at time o publication. We would recommend, however, that the reader veriy any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability or injury and/or damage to persons or property arising rom any error in or omission rom this publication. National Library of Australia Cataloguing-in-Publication Data 9780729541596
National Library o Australia Cataloguing-in-Publication entry Hing, Wayne, author. Te Mulligan concept o manual therapy : textbook o techniques / Wayne Hing, oby Hall, Darren Rivett, Bill Vicenzino, Brian Mulligan. 9780729541596 (paperback) Physical therapy—Handbooks, manuals, etc Movement therapy—Handbooks, manuals, etc. Manipulation (Terapeutics)—Handbooks, manuals, etc Hall, oby, author. Rivett, Darren, author. Vicenzino, Bill, author. Mulligan, Brian, author. 615.82 Content Strategist: Melinda McEvoy Content Development Specialists: Martina Vascotto Project Manager: Anitha Rajarathnam Edited by Forsyth Publishing Services Prooread by Fiona Van Dam Cover and internal design by Lisa Petroff Index by Robert Swanson ypeset by oppan Best-set Printed by China ranslation & Printing Services Ltd.
In 2011, I had the privilege to write a oreword or a new textbook on my concepts authored by Bill Vicenzino, Wayne Hing, Darren Rivett and oby Hall. Tis was a timely, excellent publication entitled Mobilisation With Movement: Te Art and the Science. My own manual on my concepts, now in its 6th edition, badly needed to be updated to include more detail and an improved ormat. Tis task has been undertaken and led by Wayne Hing, with all the above authors again being involved. It has taken over two years to complete this task. Tese erudite authors also had the wisdom to involve many o my Mulligan Concept international teachers. Tey have contributed by writing much o the text, each being allocated different regions o the body and different techniques. I must here particularly acknowledge and thank my colleagues Mark Oliver and Frank Gargano or the new techniques and material they have contributed. I believe that the contents in this book, in its new ormat, are priceless. All who deal with musculoskeletal conditions and practise manual therapy should have a copy. What makes our concepts so special is that all the Mobilisation With Movement techniques described within this book are only to be used when they produce no pain on application and because they should be immediately effective i indicated. I know o no other manual therapy procedures or the entire body, which ollow these guidelines. What is really special about them is that it only takes about two minutes to decide i they are indicated. Not to be able to use our concepts may be denying patients their best treatment option. I now have many hours o video showing the efficacy o our concepts, personally treating patients on stage in many cities in America beore my peers. Te hundreds who have witnessed these occasions are lef in no doubt as to the efficacy o these techniques because o the regular positive and instant pain-ree outcomes.
Our concepts have come a long way rom 1985 when, by chance, I had an unexpected instant pain-ree success with a traumatised �nger using what are now known as ‘Mobilisations With Movement’. Te patient, who was a young woman in her early twenties, presented with a swollen interphalangeal joint which was painul and would not �ex. I tractioned the joint several times which accomplished nothing. I then applied joint (glide) translations in the recommended biomechanically appropriate direction or �exion. Like the tractions, these glides were also ineffective and painul. I then tried a medial translation accessory movement which was unacceptable to the patient because o pain. Without much enthusiasm I then gently tried a lateral translation which prompted the patient to say ‘it does not hurt’. Something prompted me to sustain this translation and ask her i she could �ex her �nger. o my astonishment and her delight the �nger �exed without pain! She then said something like ‘You have �xed me’. ‘O course!,’ I replied. She still had a small loss o �exion range due to some residual swelling but she departed my rooms with a smile. Te young woman returned two days later and her �nger had completely recovered. Why, I asked mysel? Te only explanation I could come up with or my chance success was that as a result o her trauma there was a minute positional ault o the joint preventing �exion movement. When this positional ault was corrected it enabled a ull recovery to take place. It was a simple hypothesis and because o this I began to look differently at all joints that I treated and experimented to see i I could achieve similar results by repositioning other joint suraces. I began having unbelievable successes in the clinic. A ‘miracle a day’ I called them. Louis Pasteur once said that chance only avours the prepared mind. When I, by chance, had my �rst miracle with the young woman and her painully limited interphalangeal joint, I did indeed have a prepared mind.
oday the concepts that have grown rom this chance �nding have come a long way and guidelines are now in place or their successul clinical use; these are ully described within this textbook. o optimally succeed with our concepts, you need advanced clinical reasoning and excellent handling skills. Te detailed descriptions in this book will help you immensely in both these aspects. Ideally o course, the reader should attend the courses that are available around the world by accredited Mulligan Concept teachers. eachers and courses are listed at www.bmulligan.com While on the topic o teachers, I always acknowledge and thank my mentor Freddy Kaltenborn. Freddy came many times rom Europe to teach in araway New Zealand. He taught me how to manipulate every joint in the spine and to mobilise the extremity joints. His able teachings gave me excellent handling skills. He also increased my knowledge and the importance he placed on the clinical signi�cance o treatment planes led me to successully develop Mobilisations With Movement. I you do not know each joint’s treatment
plane you will never be able to successully manipulate or effectively apply the Mulligan concepts. I must stress that the techniques contained with this book are not set in stone. Tey are all based on repositioning joint suraces, or muscles and their tendons, to see i one can achieve pain-ree resolution o a musculoskeletal problem. Te techniques described in the book are those we in the Mulligan Concept eachers Association have clinically ound to be effective. I any clinicians applying them, who have the requisite knowledge and handling skills, can improve upon these techniques then this would be most welcome. It is hoped they would share their signi�cant worthwhile improvements with other clinicians and teachers. I eel very humble to have the support o such scholars as Wayne, oby, Bill and Darren, and thank them and Elsevier sincerely or this wonderul publication. Brian Mulligan
Tis book entitled Te Mulligan Concept o manual therapy: textbook o techniques presents over 160 Mulligan Concept techniques and includes therapist techniques as well as home exercises and taping techniques. Te book is aimed at being a comprehensive and easy to ollow resource or the novice and experienced clinician, as well as researchers. Te book has been written or the clinician, teacher and student interested in urthering their amiliarity to the wide array o techniques under the Mulligan Concept umbrella. Mulligan Concept techniques are effective and sae when applied in accordance with easy to ollow guidelines and clearly identi�ed underlying principles. When Brian Mulligan �rst described Mobilisation with Movements (MWM) in 1984 he shared his techniques through his original book entitled Manual Terapy: Nags, SNAGs and MWMs o which there have been six editions over the past 30 years. Tis book has been written to expand on and ully describe in a standardised ormat all the techniques mentioned in Brian Mulligan’s aorementioned original texts, as well as include new techniques that were not included in those earlier landmark editions. Tis book is also intended as an accompaniment to our �rst book entitled Mobilisation with Movement: the art and the science which was published in 2011. Our �rst book presented the science underpinning MWM and also described aspects o ‘the art’ inherent in its successul implementation. In that book the basic principles o MWMs were outlined, potential mechanisms underpinning the successul application o MWMs were canvassed, and in depth aspects o its clinical application were critiqued including guidelines on dosage and troubleshooting. Over hal o the �rst text presented the application o MWM in a series o case reports. Tese case studies ocused on the clinical
reasoning underlying the application o the Mulligan Concept, including consideration o the evidence base. Te case studies ollowed the application o the Mulligan concept rom the �rst session to discharge, showing how the techniques were selected, applied and progressed over the treatment program. However, the purpose o that �rst book was not to provide a detailed description o all the techniques under the Mulligan Concept umbrella, which is the scope o this current book as it continues the work o the preceding landmark Mulligan’s Manual Terapy: NAGS, SNAGS and MWMs book. Tere was a real need or a comprehensive presentation o the wide array o techniques under the umbrella o the ‘Mulligan Concept’. Tese techniques include MWM and other Mulligan techniques such as pain release phenomenon (PRP). Each technique has been described in a consistent and logical ormat ully explaining the indications, application and modi�cations or each technique. In addition, we have detailed the current available evidence or each technique and provided Clinical Reasoning Gems, the aim o which is to illustrate pertinent inormation regarding clinical reasoning relating to techniques presented in each chapter. Te book is divided into 14 regional chapters, covering the whole body, and encompassing the whole range o musculoskeletal disorders that present to clinical practice, including apparent non-joint disorders such as lateral epicondylalgia. Te �rst chapters ocus on MWM, exercise and taping techniques or the upper quadrant that include the cervical spine through to the thorax. Tese chapters include cervicogenic headache and cervicogenic dizziness, the temporomandibular joint, shoulder complex, elbow, orearm, wrist and hand. Te subsequent chapters cover the lower quadrant, including the lumbar spine, sacroiliac
joint, hip, knee, ankle and oot. Te �nal chapter covers commonly used PRPs, which are distinct to MWM, but can be very helpul in the right clinical presentation, usually afer the condition being treated have proven resistant to other Mulligan Concept techniques. Te techniques in this text are drawn rom those presented on the Mulligan concept courses taught worldwide and as such orm the curriculum o the different levels o those Mulligan Concept courses. Also presented is a dictionary o annotations or the techniques described, along
with an explanation o the rationale underlying the system o annotations. Professor Wayne Hing Auckland, New Zealand, 2014 Adjunct Associate Professor oby Hall Perth, Australia, 2014 Professor Bill Vicenzino Brisbane, Australia, 2014 Professor Darren A. Rivett Newcastle, Australia, 2014
Wayne Hing , PhD Proessor, Bond University, QLD, Australia
Brian Mulligan , FNZSP (Hon.) Dip M Lecturer, Author, President MCA
Toby Hall, PhD, MSc, Post Grad Dip Manip Ter Adjunct Associate Proessor, School o Physiotherapy and Curtin Health Innovation Research, Curtin University, Perth, WA, Australia Snr eaching Fellow, Te University o Western Australia, Perth, WA, Australia Fellow o the Australian College o Physiotherapists
Bill Vicenzino , PhD, MSc, Grad Dip Sports Phty, BPhty Chair in Sports Physiotherapy, University o Queensland: School o Health and Rehabilitation Sciences: Physiotherapy, QLD, Australia
Darren A Rivett, BAppSc(Phty), GradDipManipTer, MAppSc(ManipPhty), PhD, MAICD, APAM, MMCA(Hon) Proessor o Physiotherapy and Head o the School o Health Sciences, Te University o Newcastle, Australia; Board Director, Australian Physiotherapy Association
Headache is both a symptom and a disorder in its own right, hence classi�cation o headache is important to ensure that correct treatment is administered (Dodick, 2010). Te International Headache Society (IHS) has broadly classi�ed headache as primary, where there is no other causative actor, or secondary where the headache occurs in close temporal relationship to another disorder to which it is attributed (Classi�cation Committee o the International Headache Society, 2004). Cervicogenic headache (CGH) is one orm o secondary headache, which arises rom disorder o the cervical spine. Current medical teaching indicates that each orm o headache has a different pathological basis, the majority o which do not have a musculoskeletal cause (Dodick, 2010). Hence, it is critical that the individual presenting or treatment has their type o headache correctly identi�ed. Tis is particularly important or manual therapist’s considering physical intervention or headache, where such intervention is unlikely to be effective or disorders other than those affecting the musculoskeletal system (Hall, 2011). Mechanisms underlying CGH are those o convergence o afferent input rom the upper three cervical segments with input rom trigeminal afferents in the trigeminocervical nucleus (Bogduk & Govind, 2009). Hence input rom sensory afferents in the cervical spine may be mistakenly perceived as pain in the head (Bogduk & Govind, 2009). Classi�cation o headache disorders based on patient reported symptoms and history is problematic due to the overlap o eatures between CGH and migraine and other headache orms. Headache classi�cation is thereore based on physical examination. Te cervical �exion-rotation test (FR) has been ound to be a useul test to discriminate CGH rom migraine or mixed headache orms (Hall, Briffa, Hopper & Robinson, 2010a). Te positive cut-off point is 32–33° (Hall, Briffa, Hopper & Robinson, 2010b; Hall, Briffa & Hopper, 2010; Ogince, Hall, Robinson & Blackmore, 2007). An MR I study revealed that a positive test primarily indicates limitation o movement at the C1/2 level (akasaki et al., 2010). Te degree o limitation on this test has been shown to correlate with the severity, requency, and duration o headache symptoms (Hall et al., 2010b), as well as being independent o other physiological and liesty le actors (Smith, Hall & Robinson, 2007). Consequently the test has utility regardless o the age, gender or liesty le o the person tested. Further study is required to identiy the FR’s sensitivity to change as an outcome measure. In the presence o a positive FR, a C1/2 sel -SNAG can be applied as a treatment technique to attempt to restore normal range o motion and reduce symptoms. However, i a patient presents to the clinic experiencing a CGH at the time o consultation and has a positive FR, then a trial o Headache SNAG, Reverse Headache SNAG, or upper cervical traction should be administered �rst. On subsequent visits, i symptoms are reduced but the FR remains positive, then a C1/2 sel -SNAG should be considered at that point. Te application o a sel -SNAG to people with chronic CGH and a positive FR was shown to be superior to a placebo treatment in a randomised clinical trial (Hall et al., 2007). Hall et al. (2007) showed that when compared to the placebo the sel -SNAG improved range recorded during the FR by 10° (95% CI: 4.7 to 15.3°) immediately afer application and that at 12 months the treated group were 22 (13 to 31) points superior on the headache severity index (baseline headache severity index approximately 54/100).
Te FR may be perormed in a seated position. However, the supine position is preerred because o the ease o measuring range o movement. As well, there will be less stress on the neuromeningeal system in a supine position.
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Rather than using the sel -SNAG strap, it is also possible to use the sel vedge edge o a towel to perorm the C1/2 sel -SNAG (see Figure 1.4). Alternatively, it is also possible or the therapist to use their thumbs to exert pressure on the C1 transverse process, on the contralateral side (Chapter 2, C1 dizziness technique). A strap or towel is preerred, as the patient will gain optimal bene�t rom sel -treatment, both at the time o treatment, but also in event o recurrence later.
I symptoms are only marginally reduced, try applying the same technique with either more orce, or a slightly different angle to the orce (e.g. angled away rom the side o pain to the contralateral side), or or a longer duration. Te technique may also be applied to the C3 spinous process, although the angle o orce will be approximately 45° to the horizontal plane, in the direction o the patient’s eyes,
On occasions the patient may need to sustain the orce or longer than 10 seconds to achieve a reduction in headache.
I symptoms are only marginally reduced, then try applying the same technique with either slightly more gliding orce, a slightly different angle to the orce and/or or longer duration. Te addition o minimal axial traction may also improve outcomes, as may the prescription o a sel -�st traction as a home programme technique i the patient responds well to reverse headache SNAGs (see sel -�st traction technique described in Chapter 3).
On occasions the patient may need to sustain the orce or longer than 10 seconds to achieve a reduction in headache.
I symptoms are only marginally reduced, then try applying the same technique with either more orce, or a slightly longer duration.
