30 january 2013 international journal of athletic therapy & training

© 2013 Human Kinetics - IJATT 18(1), pp. 30-34

The Mulligan concept of mobilizations with movement (MWM) is a specific therapeutic intervention designed to couple accessory mobilization with physiological motion.1 The concept was developed by Brian Mulligan on the basis of his clinical experiences and the influences of noted physical therapists

Freddy Kaltenborn, Geoff Maitland, Robin McKenzie, and Robert Elvey and orthopedic physician, Dr. James Cyr iax . 1,2 Mul l igan experimented in clinical practice to develop his theory of MWM.1,2 The purpose of this report is to provide an overview of the Mulligan concept of MWM and to present documented therapeu-tic outcomes.

The Mulligan ConceptClinicians often deal with pathology that pro-duces abnormal joint mechanics (e.g., hypo-mobility or hypermobility). The difficulties a clinician faces are determination of the cause of mechanical dysfunction and selection of the most appropriate clinical intervention. A possible cause of mechanical instability

The Mulligan Concept: Mobilizations With Movement

MANUAL THERAPY

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 Baptist University

that is often overlooked is a positional fault, which is a sustained malalignment of a joint or a subluxation that is too subtle to detect through palpation or to visualize on a radio-graph.1-3 Injury can theoretically result in a positional fault that alters joint kinematics of the spine and peripheral joints.3,4 The posi-tional fault can be responsible for pain and decreased range of motion, which should be resolved when the positional fault is cor-rected.1,2, 5

An example of a positional fault is mechanical instability of the ankle following a lateral ankle sprain. A plantar flexion and inversion mechanism of injury is likely to result in a sprain of the anterior talofibular ligament and possibly the calcaneofibular ligament as well.6 Mulligan suggested that mechanical instability and limited function may be caused by a primary injury (e.g., ligament pathology) or a secondary tissue response (e.g., edema) that induces a posi-tional fault.1-3 An anterior positional fault of the fibula may result from either the ATFL pulling its distal portion into an anterior and caudal subluxation,1,2,7 or edema in the ankle joint may be responsible.6 The talus, which lacks muscle attachments, could also be pulled into an anterior subluxation.4 Any combination of these factors may result in a positional fault that would cause pain, insta-bility, and decreased function.

Mobilizations with movement can be used to assess and treat a variety of musculo-skeletal conditions.

Mobilizations with movement can produce immediate and long-lasting therapeutic benefits.

Patients can be taught self-mobilizations with movement to decrease reliance on the clinician.

Key PointsKey Points

international journal of athletic therapy & training january 2013 31

The theory that positional faults occur in the ankle following injury has been supported by comparison of the position of the fibula to that of the tibia with an external measurement device,5 fluoroscopic exami-nation,6,8 and magnetic resonance imaging (MRI).9 Kavanagh5 theorized that an anterior positional fault of the fibula would result in increased anterior-posterior movement of the fibula following a lateral ankle sprain, which was observed in one-third of the subjects who had recently sustained an acute ankle sprain (2/6).5 Hubbard and Hertel6 reported fluoroscopic evidence of significant anterior positional faults in the injured ankles of subjects with subacute lateral ankle sprains compared to their contralateral ankles and compared to the ankles of side-matched control subjects. Hub-bard et al.8 reported that a statistically significant anterior position fault was present in patients suffering from unilateral chronic ankle instability (CAI). Thus, a therapeutic technique that addresses the positional fault may be needed to restore normal joint function.

Technique

The Mulligan concept of MWM is a manual therapy technique that has been designed to address positional faults for restoration of normal arthrokinematic and osteokinematic motion.1 Mulligan hypothesized that a positional fault has been identified and corrected when MWM abolishes pain, restores function, and provides a long-lasting therapeutic effect.3 MWM may

be appropriate for relief of pain, movement impair-ments, reduced muscle length, and positional faults.1,10 All precautions and contraindications associated with joint mobilization and manual therapy are applicable to MWM, which could have an adverse effect on an injured joint.1,2

MWM involves a sustained passive joint glide while the patient actively moves the joint (or motion segment).1,2,4,10 The accessory glide may or may not be 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 mobilizations that produce immediate effects, and achieve long-lasting results.1,2 If a “PILL” response does not occur, the clinician does not continue to administer the MWM technique. Upon completion of the MWM technique, the clinician assesses the ability of the patient to per-form the same movement without manual application of the accessory glide or the patient’s ability to perform a functional task (e.g., reaching for an object in a range of motion that was previously impaired).1,2

MWM for the Distal Tibiofibular Joint (Inversion Ankle Sprain)

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

Table 1: The “CROCKS” Acronym

CROCKS3

C Contraindications: Traditional contraindications to manual therapy and the production of the “PILL” concept.

R 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.

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

C Communication: Explain the “PILL” concept, technique, and expected results to the patient prior to applying MWM; patient immediately reports any discomfort during MWM.

K Knowledge: Knowledge of treatment planes and pathologies.

S 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.

32 january 2013 international journal of athletic therapy & training

clinician places the thenar eminence of one hand over the anterior and distal portion of the lateral malleolus and uses the other hand to support the patient’s leg (Figure 1). The MWM is performed by gliding the fibula posteriorly and obliquely on the tibia. The direction of the glide is performed along the line of the ATFL as a sustained anterior-posterior dorso-proximal glide. While the glide is manually sustained, the patient is instructed to perform a plantar flexion and inversion movement. The clinician then uses his or her abdo-men to generate a force against the dorsum of the patient’s foot (i.e., overpressure) to further displace it beyond the limit of the active movement (Figure 2). If pain is elicited by the glide, the clinician should alter the direction of the manual force until the movement becomes 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 hand and the surface of the patient’s ankle. Upon completing the MWM treatment, the application of tape may help to maintain the fibula repositioning that was achieved (Figure 3).

Treatment Outcomes Although the quality and quantity of available research evidence supporting the use of MWM is insufficient to draw a definitive conclusion about its clinical effec-tiveness, clinicians have reported rapid decreases in

Figure 1 the starting position for the distal tibiofibular MWM. the clinician’s thenar eminence of the right hand is placed over the ventral, distal portion of the lateral malleolus, while the other hand supports the patient’s leg.

Figure 3 the completed application of two strips of 2inch tape applied by the clinician to mimic the sustained MWM of the distal tibiofibular joint.

Figure 2 the sustained distal tibiofibular MWM being applied by gliding the fibula posteriorly along the line of the atfl with clinician overpres-sure being added after the patient plantarflexes and inverts the ankle.

patient self-report of pain and improved function after a single treatment or after completion of a course of treatment.10 Hetherington7 used a sustained distal tib-iofibular joint MWM with active motion and overpres-sure to treat acute ankle sprains, which was followed by tape application for maintenance of fibula position. She reported increased pain-free inversion range of motion, improved gait, and improved postural balance among an unspecified number of patients.7 Stubbs et al.11 utilized the same procedures to treat a lateral ankle sprain in a collegiate soccer player, which immediately relieved the patient’s symptoms and allowed him to

international journal of athletic therapy & training january 2013 33

return to competition without reinjury for the remain-der of the season. O’Brien and Vicenzino12 also utilized the previously described MWM and taping procedures, which were reported to produce rapid improvements in range of motion, pain, and functional outcomes scores for two patients.

Other ankle MWM techniques have also been utilized for treatment of a lateral ankle sprain. Vicen-zino et al.4 reported that both weight-bearing and nonweight-bearing MWM produced significantly improved posterior talar glide and ankle dorsiflexion in 16 subjects with chronic ankle instability when compared to measurements for the same subjects in a control condition. Collins et al.13 also reported signifi-cant improvement in ankle dorsiflexion in 16 subjects who had recently sustained an ankle sprain. Green et al.14 reported a more rapid return to pain-free ankle dorsiflexion among 19 patients with an acute ankle sprain who were treated with MWM (i.e., fewer treat-ments) compared to 19 patients who did not receive the MWM treatment.

Case studies have demonstrated MWM effective-ness for treatment of a locked lumbar zygoapophyseal joint,15 DeQuervain’s disease,16 lateral epicondylalgia,17 chronic thumb pain,18 and chronic shoulder, arm, and neck pain.19 A pilot study on the use of MWM for treat-ment of shoulder impingement provided preliminary evidence that it may help to reduce pain and improve function.20 The use of MWM for treatment of lateral epicondylalgia has generally increased pain-free grip strength.10 Two studies have documented an increase in pain-free grip strength and pressure-pain threshold to a greater extent than that of placebo or control groups.21,22 Abbot23 reported that treatment of the elbow with MWM improved shoulder range of motion in patients with lateral epicondylalgia.

SummaryAlthough 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 physical examination. Positional faults are not present in every patient; however, a search for positional faults can be integrated with other components of a clinical exami-nation to improve therapeutic outcomes. The clinician

should remember to follow Mulligan’s principles, which are represented by the “PILL” and “CROCKS” acro-nyms to achieve the greatest clinical benefit.

The MWM concept has the potential to produce immediate and long-lasting effects, even in patients that had not previously responded to other treatment for an extended period of time. The technique of MWM administration can easily be adjusted (e.g., amount of force and direction of force application), and the patient can be taught to perform self-mobilizations. The current body of evidence supports the use of MWM in clinical practice, but further well-designed research is needed to better understand the positional fault phenomenon and the therapeutic effects of MWM.

References 1. 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. 6th ed. Wellington, New Zealand: Plane View Services LTD; 2010.

4. Vicenzino B, Branjerdporn M, Teys P, Jordan K. Initial changes in posterior talar glide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent ankle sprains. J Orthop Sports Phys Ther. 2006; 36(7):464-471.

5. Kavanagh J. Is there a positional fault at the inferior tibiofibular joint in patients with acute or chronic ankle sprains compared to normal? Man Ther. 1999; 4(1):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 with self-reported chronic ankle instability. J Orthop Sports Phys Ther. 2007; 36(1):3-9.

9. Mavi A, Yildirim H, Gunes H, Pestamalci T, Gumusburun, E. The fibula incisura of the tibia with recurrent sprained ankle on magnetic resonance imagining. Saudi Med J. 2002; 23:845-849.

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

11. Stubbs E, Baker RT, Ramos, C. Utilizing Mulligan’s concept for correcting an 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 study design. Manual Ther. 1998;3(2):78-84.

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

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

34 january 2013 international journal of athletic therapy & training

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 with movement as an adjunct intervention in a patient with DeQuervain’s tenosynovitis: a case report. J Orthop Sports Phys Ther. 2002; 32(3):86-97.

17. Vicenzino B, Wright A. Effects of a novel manipulative physiotherapy technique on tennis elbow: a single case study. Man Ther. 1995; 1(1):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 magnetic resonance imaging to evaluate the positional fault hypothesis. Man Ther. 2002; 7(1):44-49.

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

20. Kachingwe AF, Phillips B, Sletten E, . Plunkett SW. Comparison of manual therapy techniques with therapeutic exercise in the treatment of 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 and sympathoexcitatoy effects of mobilization with movement for lateral epicondylalgia. Phys Ther. 2003a;83:374-383.

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

23. Abbot J. Mobilizations with movement applied to the elbow affects shoulder range of movement in subjects with lateral epicondylalgia. Man Ther. 2001; 6(3):170-177.

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

Alan Nasypany is the Director of Athletic Training Education in the Department of Movement Sciences at the University of Idaho in Moscow, ID.

Jeff Seegmiller is an associate professor and Musculoskeletal Anatomy Chair in WWAMI Medical Education and the Department of Movement Sciences 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.

Tricia Turner, PhD, ATC, University of North Carolina at Charlotte, is the report editor for this article.

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