Mulligan Concept PDF

“MULLIGAN CONCEPT” Intro General principles Directions for practice FME2 3rd course of Physiotherapy Degree Prof. Dr. Pablo C. García-Sánchez 1 1 1. HISTORICAL INTRODUCTION • Brian R. Mulligan qualified as a physiotherapist in 1954 and gained his diploma in Manipulative Therapy in 1974 • He has...

“MULLIGAN CONCEPT” Intro General principles Directions for practice FME2 3rd course of Physiotherapy Degree Prof. Dr. Pablo C. García-Sánchez 1 1 1. HISTORICAL INTRODUCTION • Brian R. Mulligan qualified as a physiotherapist in 1954 and gained his diploma in Manipulative Therapy in 1974 • He has studied K-E • Founded with Robin Mckenzie The New Zealand Manipulative Physiotherapy Association • He has discovered MWM by a chance, but… 2 2 2 1. HISTORICAL INTRODUCTION 3 3 3 1. HISTORICAL INTRODUCTION • Brian Mulligan (Dip. MT, CMP, MCTA), graduated in Physio in 1954 and created with Robie Mckenzie • Mulligan® concept in the 1970s. • MCTA (Mulligan Concept Teachers Association) New Zealand Manipulative Physiotherapy Association (1968) 4 4 4 1. HISTORICAL INTRODUCTION • Important scientific dissemination of the concept in the last 2 decades. • 2008 => Distinction by the WCPT (World Confederation of Physical Therapy). • In addition to numerous scientific publications... - www.comt.es - www.bmulligan.com 5 5 5 1. HISTORICAL INTRODUCTION • Mulligan introduces the mobilizations with movement (MWMs) in extremities and the sustained natural apophyseal glides (SNAGs) in spine as a continuation of this evolution... 6 6 6 2. INTRODUCTION TO THE CONCEPT ACCESSORY MOVEMENTS (therapist) + ACTIVE PHYSIOLOGICAL MOVEMENTS (patient) 7 7 7 2. INTRODUCTION TO THE CONCEPT • 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 • Also includes: passive end-of-range overpressure or stretching, delivered without pain as a barrier 8 8 8 2. INTRODUCTION TO THE CONCEPT • It uses articular mobilizations in the direction parallel to the facet planes (Panjabi 1978) 45º- 60º-90º • From mid-range to the end of joint amplitude. • Usually patient in load!! 9 9 9 Panjabi 1978 45º- 60º-90º 10 10 10 2. INTRODUCTION TO THE CONCEPT • The concept of Mobilization With Movement (MWM) of the extremities and SNAGS (Sustained Natural Apophyseal Glides) of the spine, were first coined by Brian R. Mulligan – NAGS- Natural Apophyseal Glides. – SNAGS - Sustained Natural Apophyseal Glides. – MWM- Mobilization with Movement. 11 11 11 2. INTRODUCTION TO THE CONCEPT 12 12 12 2. INTRODUCTION TO THE CONCEPT • It has shown better results in those subacute and chronic patients featuring pain related to a functional movement or sustained activity • Conditions will include spine and peripheral presentations 13 13 13 2. INTRODUCTION TO THE CONCEPT • Treatment techniques: - Functional. - Immediate effects on mobility and/or pain (if works…) - Manuals, self-treatment and bandages. - Effects demostrated at different levels and by different mechanisms - Relevant clinical evidence and some evidence-based 14 14 14 3. GENERAL PRINCIPLES While applying "MWMS" as an assessment, the therapist should look for PILL response to use the same as a Treatment: P- Pain free. I- Instant result. LL- Long Lasting. If there is No PILL response… that technique should not be use 15 15 15 3. GENERAL PRINCIPLES • 2nd acronymun to remember the key points is CROCKS: – C- Contra-indications (No PILL response is a contraindication) – R - Repetitions (Only x9 for spine and x18 for peripheral on D1 ) – O- Over pressure (usually starts on D3 ) – C- Communication and Cooperation – K - Knowledge (of treatment planes and pathologies) – S- Sustain the mobilization throughout the movement, Skill, Sensibility, Subtle, Common Sense 16 16 16 3. GENERAL PRINCIPLES 1. NO PAIN: The techniques ARE and should be applied without pain. If there is... - Incorrect application (direction, force,...) - Vertebral level / wrong joint. - May not be indicated... 2. Immediate, prolonged and lasting effects. 17 17 17 3. GENERAL PRINCIPLES 3. Contraindications. 4. Repetitions in mobilization (x3 to x10). 3 sets of 6-10 repetitions Location Session Spine 1st session Following Peripheral Joints 1st session Following Repetitions Series 3 3 6-10 3-5 6 3 6-10 3-5 18 18 18 3. GENERAL PRINCIPLES 5. Additional Pressure or Overpressure. (At the end of the active ROM) 6. Communication and Cooperation. 7. Knowledge of the therapist. NMKS, Ehtiology, Pathology, Biomechanics, Pain Science, BioPsychoSocial app 8. Holding, Feeling, Skill and Subtlety. 19 19 19 3.1 IMPLEMENT Belts 20 20 20 3.1 IMPLEMENT Tapings Therabands 21 21 21 4. TREATMENT PRINCIPLES 1. Identification of 1 or more comparable signs (Maitland) => NO self-assessment system Re-evaluate! - Loss of joint movement. Comparable sign: - Pain associated with movement. - Pain in specific functional activities. 22 22 22 4.2 TREATMENT PRINCIPLES 2. Application of accessory motion perpendicular or parallel to the direction of motion. 3. Determine best combination of grade and treatment plan (sporting gesture??). 4. Progression in the prescribed treatment with overpressure. 23 23 23 4. MWM_directions for practice • During interview and the physical assessment, the therapist will identify one or more comparable signs as described by Maitland. • These signs may be, but not limited to: • a loss of joint movement • pain associated with movement • or pain associated with specific functional activities 24 24 24 4. MWM_principles of practice • A passive accessory joint mobilization is applied following the principles of Kaltenborn. • This accessory glide must be, itself, pain free. 25 25 25 4. MWM_principles of practice • A passive accessory joint mobilization is applied following the principles of Kaltenborn. • This accessory glide must be, itself, pain free. 26 26 26 4. MWM_directions for practice • The therapist must continuously monitor the patient's 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. 27 27 27 4. MWM_directions for practice • While sustaining the accessory glide, the patient is requested to perform the comparable sign. • The comparable sign should now be significantly improved. • If the therapist found an accurate one, the previously restricted and/or painful motion or activity is repeated by the patient while the therapist continues to maintain the appropriate accessory glide, during several sets/repetitions • Re-evaluation is critical 28 28 28 4. MWM_directions for practice • If not… 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 therapist should find a correct combination, level or technique. • If not, other approach will be necessary 29 29 29 4. MWM_directions for practice • The treatment will be repeated on the following sessions, ALWAYS reassessing initially the basal/functional condition of the patient. • The treatment will be evolved on the following sessions including: more sets/repetitions, over-pressure, tapings and a tailored home-program. 30 30 30 4. MWM_directions for practice • Progression: – D1- Reps: • 3 sets of x3 for spine and 3 sets of x6-10 for peripheral – D2- Reps: • 3 sets of x3 for spine and 3 sets of x6 for peripheral • If irritability is low, increase reps if necessary 31 31 31 4. MWM_directions for practice • Progression: – D3- Overpressure? • Add, to every repetition, 2/3’’ of overpressure at the end of ROM if it´s pain-free; if not, waits to D4 – D4- Resistance? • Increase number of sets/series • Evaluate the possibility to add resistance, weights, therabands… 32 32 32 4. MWM_directions for practice • Progression: – D5- Home Program? • Teach a self-efficacy way to perform MWM at home alone or helped by someone • These are expert recommendations for the progression waiting 24/48 hours between sessions. • There will be other factors of the presentation to take on account: irritability, severity, nature… 33 33 33 5. ANATOMICAL-BIOMECHANICAL CONCEPT • The "articular reality" is established in 2 differentiated possibilities: 1. Normal Articulation. 2. Articulation with Dysfunction. 34 34 34 5. Normal joint? • Normal motion axis. • Full mobility. • No pain in physiological path. 35 35 35 5. Joint with disfunction • "As a result of acute traumatic injury or repetitive micro-trauma, joints are left in an improper position with minor positional alterations of the articular surfaces." Position Defects 36 36 36 5. Joint with disfunction • Positional alteration (AP or PA, slippage and/or medial or lateral rotation. • Alteration axis movement. • Abnormal stress on periand articular structures. • Pain and limitation of range of motion. 37 37 37 5. POSITIONAL FAULTS OR ALTERATIONS • High relevance of "articular positional alterations" as an essential element in a Joint with Dysfunction... - Do these alterations really exist? - Are they common to all joints? 38 38 38 5. WOULD IT BE POSSIBLE TO CORRECT THESE POSITIONAL ALTERATIONS, IF THEY EXIST, IF THEY CORRELATES WITH PAIN & DISFUNCTION? 39 39 39 6. Neurophysiological Effects. • Lovick and Fanselow's 1991 studies: Analgesia (non-opioid). SPAG dorsal/lateral SNS excitation. • STIMULUS Movement. analgesia (opioid) Ventrolateral SPAG SNS Inhibition. Immobilization. 40 40 40 6. Neurophysiological Effects. • Paungmali et al's 2003 and 2004 studies: - Hypoalgesia demonstrated by an increase in pain-free maximal prehension strength and a decrease in pressureinduced pain. - Sympathetic-excitatory effects demonstrated by alterations in heart rate, blood pressure, and sudomotor and vasomotor skin function. - The hypoalgesic effect of MWM is not related to endogenous opioid systems as it is not antagonized by naloxone. 41 41 41 6. Neurophysiological Effects. • The Wright, Vicenzino and Sterling studies: - Mechanical hypoalgesia is associated with alterations in the sympathetic SN and motor system function. - Comparable to the mechanisms of spinal manipulations involving the interaction of descending pain inhibition systems. - The characteristics of these effects suggest the involvement of endogenous non-opioid mechanisms. 42 42 42 Levels of evidence 43 43 43 . Evidence_General SRs 1. The specific parameters identified for MWM prescription in the literature are variable and, in general, are applied and explained inconsistently. 2. The efficacy of MWMs is well established for various joints and pathologies; however, due to the methodological quality of the studies, it is clear that further research on the specific parameters of MWM is warranted. 44 44 6. Evidence_General SRs 3. In conclusion, this manual therapy technique is widely used and advocated for many aspects of peripheral joint dysfunction. 4. In this systematic review, an evaluation of peripheral joint-specific MTMs has been presented in an attempt to adequately guide the clinician and to provide a basis for future research in this area. 45 45 46 46 Conclusión 1. Mobilization with movement produces certain statistically and clinically important therapeutic results with respect to peripheral joints 2. Mulligan motion mobilisation appeared to produce better therapeutic outcomes in terms of statistical and clinical significance, with respect to reducing peripheral joint pain and disability, compared with sham treatment, passive treatment, sham treatment or no therapeutic intervention and for pain reduction compared to other TM methods. 3. The therapeutic results of Mulligan mobilisation methods should be further examined in future studies of high methodological quality 47 47 Methods Seven electronic databases (MEDLINE (through Ovid), EMBASE (through ovid), CINAHL (through EBSCO), Cochrane (CENTRAL), Web of Science, SPORT Discus (through EBSCO) AND PEDro) were scanned up to November 2017 by searching (RCTs). We rated the quality of the evidence using the GRADE approach. Results We identified seven published trials in which all trials had positive clinical outcomes in pain and MWM function. 48 48 Resultados 1. We found moderate evidence on the effectiveness of MWM on pain and function in people with: 2. Chronic ankle instability (ICT) 3. Osteoarthritis of the hip (OA) 4. Low evidence for shoulder impingement syndrome (SIS) 5. Low and very low evidence for lateral epicondyalgia (LE) 49 49 Conclusions: 1. Overall MWM interventions applied to peripheral joints seems to be superior to placebo and no intervention controls, but not in comparison with other medical or physiotherapy interventions 2. There is a need for more high-quality trials that investigate the short and long-term effect of a series of MWM interventions 50 50 6. Evidence_SR by area/pathology 51 51 6. Evidence_SR by area/pathology 52 52 6. Evidence_SR by area/pathology 53 53 6. Evidence_SR by area/pathology 54 54 6. Evidence_Some significant individual studies Fallo posicional • 1st study: C.-Y. Hsieh “Mulligan’s mobilization with movement for the thumb: a single case report using magnetic resonance imaging to evaluate the positional fault hypothesis”. Manual Therapy (2002) 7(1), 44–49. - Clinical case of patient with pain to flexion of the MTCF of 1st finger. - Positional alteration in medial rotation than with MWM of FLX + Rot. Lateral MTCF eliminates pain immediately. - Correction of the alteration p(x) after tto (MRI and Rx) that REAPPEARS after 3 weeks but without pain... 55 55 55 6. Evidence_Some significant individual studies Fallo posicional 3th study: Ho e Hsu 2008 - MWM generate significant alterations in the displacement of the humerus head of cadavers (recent) during ABD (post 7.7 mm; inf 2.7 mm; lat 0.5 mm). 4th study : Merlin, D. (2005). Mulligan's Mobilisation with movement technique for lateral ankle pain and the use of magnetic resonance imaging to evaluate the "positional fault" hypothesis. - Sup repositioning of the fibula (MRI) in patients with ankle sprain (pre: 6.19 +/- 0.28 cm; post: 6.54 +/- 0.13 cm) 56 56 56 6. Evidence_Some significant individual studies Other mechanisms • Nivel de evidencia 1a: - MWM + ejercicio. - A corto plazo mejor que … “wait and see”. - A largo plazo mayor efectividad que la inyección de cortocoesteroides. Bisset, 2006 • Nivel de evidencia 2b: - MWM (sólo): - Pain-Free Grip Strength. - Efecto inmediato superior al placebo y al grupo control. 57 57 57 Epicondilalgia crónica Lateral epicondylalgia 58 58 Epicondilalgia crónica Lateral epicondylalgia 59 59 Epicondilalgia crónica Lateral epicondylalgia 60 60 SELF-SNAG in cervicogenic headaches 61 61 61 SPINAL COLUMN • SNAG in C1-C2 in cervicogenic headaches and vertigo ... Improve ROM, vertigo and unipodal balance > than placebo laser (short and medium term effect). (RCT) Heterogeneity of studies in CV. 62 62 62 63 63