Brian Mulligan and Mobilization with Movement (MWM)

About the Founder: Brian R. Mulligan

• Brian R. Mulligan qualified as a physiotherapist in 1954 and earned a Diploma in Manipulative Therapy in 1974.
• In 1996, he was named an Honorary Fellow of The New Zealand Society of Physiotherapists for his contributions to physiotherapy.
• In 1998, he became a life member of The New Zealand College of Physiotherapy.
• Mulligan authored numerous articles on the concept, published in the New Zealand Journal of Physiotherapy and international journals.
• He authored "Manual therapy NAGS, SNAGs, MWMs etc., for Physiotherapists" in 2003.
• He authored "Self-treatment for the back, neck and limbs for the public."

Definitions

• Mobilization with Movement (MWM) involves a therapist applying sustained accessory mobilization along with the patient's active physiological movement to end range.
• Passive end-range overpressure or stretching is applied without causing pain.
• B. Mulligan first coined the concept of MWM for extremities and sustained natural apophyseal glides of the spine.

Important Acronyms

• MWM stands for Mobilization With Movement.
• NAGs stands for Natural Apophyseal Glides.
• SNAGs stands for Sustained Natural Apophyseal Glides.
• SMWLMs stands for Spinal Mobilization With Limb Movements.
• SMWAMS stands for Spinal Mobilization With Arm Movements.
• PRPs stands for Pain Release Phenomenon.

Basic Concepts

• Convex-concave motion rule.
• Treatment plane.

Convex Concave Motion Rule

• When the concave joint partner moves, the glide occurs in the same direction.
• When the convex joint partner moves, the glide occurs in the opposite direction.

Treatment Plane

• A treatment plane passes through the joint and lies at a right angle to a concave joint partner.
• Treatment is always applied parallel to this treatment plane.

Mechanism of Action/Paradigms of Practice - Biomechanical Effects

• Straightens the spine.
• Unlocks locked joints.
• Shifts an IVD fragment and reduces annular distortion.
• Increases proprioceptive feedback.
• Stretches, tears, or ruptures adhesions that limit joint or muscle range.
• Removes blockage or interference of blood flow, nerve compression, sympathetic chain, and cerebrospinal fluid circulation.

Mechanism of Action/Paradigms of Practice - Positional Faults Hypothesis

• Mulligan suggested injuries or sprains create minor positional faults that restrict physiological movements.
• The technique addresses "tracking problems" or positional faults causing subtle biomechanical changes.
• These abnormalities cause pain, stiffness, or weakness. The therapist realigns the joints.
• Transient bone position change.
• Increased ROM.

Mechanism of Action/Paradigms of Practice - Neuro-physiological Effects

• Corrects abnormal reflexes and organ dysfunction.
• Stretches contracted muscles, promoting relaxation.
• Modulates peripheral nociceptors.
• Activates gating mechanisms and neurotransmitters.
• Associated changes in the sympathetic and motor systems.
• Pain is considered a form of aversive memory.
• Exposure to the painful movement without overt danger is fundamental and used to extinguish aversive memories.

Mechanism of Action/Paradigms of Practice

• Progressive mobilization desensitizes the nervous system through habituation.
• The mechansim involves a progressive decline in the ability of the pre-synaptic nerve terminal to transmit impulses.
• Initial endogenous non-opioid hypo-algesia by excitation of the sympatho-excitation through movement.

Principles of Treatment

• A passive accessory joint mobilization is applied, adhering to Kaltenborn's principles; the glide must be pain-free.
• Therapists identify one or more comparable signs during assessment, such as:
  • Loss of joint movement.
  • Pain associated with movement.
  • Pain associated with specific movement.
• Therapists continuously monitor patient reactions to prevent pain recreation, investigating parallel or perpendicular glides to determine the correct treatment plane and accessory movement grade.
• The patient performs the comparable sign while sustaining the accessory glide; it should improve significantly.
• The therapist has not found the correct treatment plane, grade of mobilization, spinal segment, or that the technique is not indicated if the comparable sign does not improve.
• Patients repeat previously restricted/painful motions while therapists maintain the appropriate accessory glide.

Principles of Application of Treatment - The PILL Principle

• While applying MWMs as an assessment, the therapist should look for PILL response to use the same as a treatment technique.
  • P - pain free
  • I - instant result
  • LL – long lasting
• The technique should not be used if there is no PILL response.

Principles of Application of Treatment - The CROCKS Principle

• C- Contra-indications (No PILL response)
• R- Repetitions
• O- Overpressure
• C- Communications
• K- Knowledge (of treatment planes & pathologies)
• S- Sustain the mobilization throughout the treatment

Equipments

• Plinth / couch.
• Mulligan belt.
• Mulligan pads.
• Tape.

Techniques - The Spinal Mobilizations

• Cervical and Upper Thoracic Spines use NAGs, Reverse NAGS, SNAGs, self SNAGS, and SMWLMs.
• Thoracic Spine.
• Lumbar Spine uses SNAGs, self SNAGS.
• Sacroiliac Joints.
• The Rib Cage.
• Other spinal therapies include manipulation and self-treatment.

Techniques

• The Extremities uses MWMs, compression treatments, Pain Release Phenomenon, and other extremity therapies.
• Use 'vee' finger grip positioning for upper thoracic and cervical spine.

Techniques: NAGs

• Used for cervical and upper thoracic spine.
• Consists of oscillatory mobilizations instead of sustained glide, applicable to facet joints between 2nd cervical to 3rd thoracic vertebrae.
• Administered antero-superiorly along the treatment planes of the targeted joint as mid- to end-range facet joint mobilizations.
• Should be Graded based on patient tolerance; useful for grossly restricted spinal movement.

Techniques: Reverse NAGs

• Used for the upper thoracic spine and can show some benefits in the lower cervical spine.
• They replicate passively the head retraction motion.
• The inferior facet glides up on the superior.

Techniques: SNAGs

• SNAGs can be applied to all spinal joints, the rib cage, and the sacroiliac joint.
• The therapist applies the appropriate accessory zygapophyseal glide while the patient performs the physiological symptomatic movement resulting in full pain free movement.
• SNAGs are performed in weight bearing positions but can be adapted for use in non-weight bearing positions.

Techniques: SNAGs - Contraindications

• If the Symptoms are multilevel .
• If the conditions are highly irritable.

Techniques: SNAGs - Criteria for Treatment Approach

• All done in weight-bearing postures.
• Mobilizations with active movements followed by passive overpressure.
• Follow the treatment plane rule.
• The mobilization component is sustained.
• Applied to most spinal joints.
• Painless when indicated.
• Carried out at end range.
• Require thorough knowledge for straight forward procedure for each movement loss.
• No time wasted as the treatment regime is decided within a couple of minutes.

Techniques: Self SNAGs

• Self SNAGs are a useful home routine.
• This is the only manual technique used by the patient presenting for treatment.
• The technique should be demonstrate on an articulated spine or on an assistant.
• Should ideally be taught on the first day of treatment as the patient views it right this way.

Techniques: Self SNAGs - Common Errors

• Forgetting hand placement.
• Placing the bulky towel on the spinous process instead of using just the edge.
• Pulling the towel forwards, not in the superior direction of the facet plane.
• Forgetting to sustain the glide for the full duration of the movement.

Techniques: MWMs

• SNAGs and MWMs both address pain and restriction problems, bring about change at the time of delivery, are painless when indicated, and sustain moment.
• SNAGs are facet mobilizations both in the plane and the direction of the active movement, while in the extremities, the mobilisation plane corrects positional faults in a direction different to the movement of the glide.

Techniques: SMWAMS

• Spinal mobility allows movement at peripheral joints, and mobilization combines extremity joint mobilizations with extremity joint movements.
• When the shoulder girdle moves, spinal movement also occurs due to muscle attachments from the scapula to the cervical and upper thoracic spine.

Techniques: SMWLMs

• SMWLMs allows for transverse pressure to the side of the relevant spinous process as the patient moves the limb through the previously restricted range.
• Restriction of movement is assumed to be of spinal origin but may not imply neural compromise since spinal movement must occur when a limb moves beyond a certain point.
• Self-SMWLMs & self-SMWAMs can be taught to the patient.

Techniques: PRPs

• Involves a combination of movements & compression
• If a combination of movements & compression causes pain, the combination is repeated for 20 seconds, ensuring constant pressure on the articular surface.
• If pain increases, stop immediately apply less/no pressure, and repeat for 20 seconds; repeat the technique with the same pressure if the pain disappears.

Techniques: PRPs - Application

• PRP can be given in chronic conditions when the initial repair has already taken place.
• PRPs: Compression, Traction, Stretch and Contraction There are 4 types of

Techniques: Taping

• Taping provides protection and support to the injured part while allowing optimal movement which is pain-free.
• A zinc oxide tape, which is adhesive, slightly porous, and non-elastic, can be used.
• The benefits of tape includes enhanced circulation, controlled swelling, prevented injury worsening/re-injury.
• It allows the body to be conditioned and strengthened which is lost due to inactivity.

Techniques: Taping - Principles of Application

• Maintain the correction of positional fault allowing the patient to perform the restricted movement in a pain-free way.
• Tape should be applied in such a way that the therapeutic glide is maintained.
• Always reinforce the tape by applying it in exactly the same manner.

Techniques: Neurodynamic MWM

• Neurodynamic MWM addresses neural tissues adhered to surrounding structures, causing a lack of sliding, gliding, and stretching to the nerves.
• Transverse glide promotes vertebral body rotation towards the same side, opening the foramina affected.
• Adding arm movements with the opened foramina mobilizes neural tissues.
• Pain reduces with increased spinal and limb movements.

MWM Prescription Parameters

• Repetitions / Sets: ten repetitions for three sets.
• Frequency: three to six sessions a week or as frequent as a session every two hourly or once in five days.
• Amount of force: although it is an important variable in Mulligan's concept, only one study gave methods of applying force by using a hand held dynamometer where 66% showed maximal gains of the effects.
• Rest periods: this ranges from 30 second to 2 hours between the sets.

Indications

• Green Flags;
  • Pain of a non-inflammatory nature
  • Acute pain from injury
  • Loss of motion due to arthritic conditions
  • Post surgical conditions
  • Headaches due to neck problem
  • Dizziness associated with neck problem
  • TMJ pain & movement restrictions
  • Acute or Chronic Ankle sprains
  • Tennis elbow
  • Sacroilitis
  • Frozen Shoulder
  • Any Neuromusculosketal pain and stiffness
• Any neurological and musculoskeletal condition can be treatment, as long as the therapist follows the basic rule of not causing pain.

Contraindications

• Relative Contraindications: (Yellow Flags)
  • Joint Hypermobility
  • Pregnancy
  • Osteopenia
• Absolute Contraindications: (Red Flags)
• Bone Weakness (Tumour, Osteoporosis, Metabolic Bone Disease)
• Vascular (Anticoagulant Therapy, Aortic Aneurysm)
• Neurological Deficits (multilevel PIVD, Cervical Myelopathy)
• Psychological Disorders.

Summary

• Always treat the patient in weight bearing positions, performing the movement in a pain-free way.
• Movement must be pain-free.
• Always check the resultant vector/ angle of pull/ parallel position of the treatment belt to the floor/ angle and position of the forearm.
• Always sustain the glide till the starting position is achieved.
• Always work in the available range.
• Always apply the overpressure at the end of the range.
• Be parallel to the treatment plane.
• The position / handgrip / belt must not block the patient's movement
• Grip must be firm but painless.
• Hand / belt placement must be always close to treatment plane / joint line. Ensure proper translation and avoid rotation
• There should be proper communication between the therapist and the patient during the session of mobilization.
• Always explain what the treatment is and what the patients requires to do.
• Do not over treat the patient
• Re-assess and compare with earlier assessment
• Teach self-treatment whenever possible.