Mulligan Concept

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Introduction about Brian Mulligan

Brian R. Mulligan qualified as a physiotherapist in 1954 and gained his diploma in Manipulative Therapy in 1974. He has been the author of numerous articled published in New Zealand Journal of Physiotherapy. He is also the author of two books:Manual therapy NAGS,SNAGS,MWMS,etc by Brian R.Mulligan, 5th edition, 2004.

"Manual Therapy "NAGS","SNAGS", "MWMS",etc' (2003) for Physiotherapists.
'Self Treatment for the Back, Neck and Limbs' for Public.

Description

NAGS- Natural Apophyseal Glides.
SNAGS - Sustained Natural Apophyseal Glides.
MWMS- Mobilization with Movements.
The concept of Mobilizations with movement (MWM) of the extremities and SNAGS (sustained natural apophyseal glides) of the spine were first coined by Brian R. Mulligan Mulligan, BR: Manual Therapy “NAGS,” “SNAGS,” “MWM’S: Etc., ed 4. Plane View Press, Wellington, 1999
Mobilization with movement (MWM) is the concurrent application of sustained 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.Kisner, Carolyn, and Lynn Allen Colby. Therapeutic exercise: foundations and techniques. FA Davis, 2012.

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 joints have been designed in such a way that the shape of the articular surfaces, the thickness of the cartilage, the orientation of the fibres of ligaments and capsule, the direction of pull of muscles and tendons, facilitate free but controlled movement while simultaneously minimizing the compressive forces generated by that movement Wilson, Ed. "The Mulligan concept: NAGS, SNAGS and mobilizations with movement." Journal of bodywork and movement therapies 5.2 (2001): 81-89.
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

A passive accessory joint mobilization is applied following the principles of Kaltenborn. This accessory glide must itself be pain free.
During assessment the therapist will identify one or more comparable signs as described by Maitland. These signs may be; a loss of joint movement, pain associated with movement, or pain associated with specific functional activities
The therapist must continuously monitor the patients reaction to ensure no pain is recreated. The 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
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 and/or painful motion or activity is repeated by the patient while the therapist continues to maintain the appropriate accessory glide.

While applying "MWMS" as an assessment, the therapist should look for PILL response to use the same as a Treatment .Manual therapy NAGS,SNAGS,MWMS,etc by Brian R.Mulligan, 6th edition, 2010.

P- Pain free.
I- Instant result.
LL- Long Lasting.

If there is No PILL response, that technique should not be advocated.

The second principle is CROCKS

C- Contra-indications (No PILL response is a contraindication)
R - Repetitions (Only three reps on the day one)
O- Over pressure
C- Communications
K - Knowledge (of treatment planes and pathologies)
S- Sustain the mobilization throughout the movement.

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.
Although SNAGs are usually performed in weight bearing positions they can be adapted for use in non weight bearing positions.

Headache SNAG

NAGs:

NAGs stand for 'Natural Apophyseal Glides”.
NAGs are used for cervical and upper thoracic spine.
It consists 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

Peripheral MWM Exelby, Linda. "Peripheral mobilizations with movement." Manual Therapy 1.3 (1996): 118-126.

Once the aggravating movement has been identified, an appropriate glide is chosen.
Decision to use weight-bearing or Non-weight bearing movement depends upon the severity, irritability and nature of the condition.
Once the glide has been chosen it must be sustained throughout the physiological movement until the joint returns to its original starting position
Mobilizations 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

Spinal mobilization with limb movement (SMWLMs)

Here a transverse pressure is applied to the side of the relevant spinous process as the patient concurrently moves the limb through the previously restricted range of movement.
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.

Recent Related Research (from <a href="http://www.ncbi.nlm.nih.gov/pubmed/">Pubmed</a>)

References

<a _fcknotitle="true" href="Category:Interventions">Interventions</a> <a _fcknotitle="true" href="Category:Manual_Therapy">Manual_Therapy</a> <a _fcknotitle="true" href="Category:Spine">Spine</a> <a _fcknotitle="true" href="Category:Pain">Pain</a> <a _fcknotitle="true" href="Category:Musculoskeletal/Orthopaedics">Musculoskeletal/Orthopaedics</a>

Mulligan Concept

Contents

Introduction about Brian Mulligan

Description

Concept of Positional Fault

Principles of Treatment