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Bill Vicenzino Wayne Hing Darren Rivett Toby Hall

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National Library of Australia Cataloguing-in-Publication Data


Title: Mobilisation with movement : the art and the science / Bill Vicenzino ... [et al.]

ISBN: 9780729538954 (pbk.)

Subjects: Physical therapy--Australia.

Movement therapy--Australia.

Physical therapy--Handbooks, manuals, etc

Movement therapy--Handbooks, manuals, etc

Other Authors/Contributors: Vicenzino, Bill.

Dewey Number: 615.82


Publisher: Melinda McEvoy

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Project Coordinator: Geraldine Minto
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Foreword by Brian Mulligan vii Chapter 10 Temporomandibular joint dysfunction:
Foreword by Professor G Jull ix an open and shut case 123
Preface xi Chapter 11 Golfers back: resolution of
Authors xiii chronic thoracic spine pain 134
Contributors xiii Chapter 12 Mobilisation with Movement in the
Reviewers xiv management of swimmers
shoulder 143
Acknowledgments xv
Chapter 13 A recalcitrant case of aircraft
ITS APPLICATION 1 Chapter 14 A chronic case of thumb pain and
Chapter 1 Introduction 2 disability with MRI identied
positional fault 164
Chapter 2 Mobilisation with Movement: the art
and science of its application 9 Chapter 15 A chronic case of fear avoidant
low back pain 169
SECTION TWO EFFICACY 25 Chapter 16 Restoration of trunk extension
Chapter 3 A systematic review of the 23 years after iatrogenic injury 179
efcacy of MWM 26 Chapter 17 Hockey hip, a case of chronic
dysfunction 192
SECTION THREE MECHANISMS AND Chapter 18 Thigh pain: a diagnostic
EFFECTS 65 dilemma 199
Chapter 4 Mulligans positional fault Chapter 19 Two single case studies of lateral
hypothesis: denitions, ankle sprain in young athletes 208
physiology and the evidence 66
Chapter 5 A new proposed model of the SECTION FIVE TROUBLESHOOTING 219
mechanisms of action of Chapter 20 Technique troubleshooting 220
Mobilisation with Movement 75
Chapter 6 Pain and sensory system Picture credits 223
impairments that may be amenable
Index 224
to Mobilisation with Movement 86
Chapter 7 Motor and sensorimotor decits and
likely impact of Mobilisation with
Movement 93


Preface to case studies 102
Chapter 8 A headache thats more than
just a pain in the neck 103
Chapter 9 A diagnostic dilemma of dizziness 114

The need for an appropriate textbook on my concepts O stands for overpressure. Basically, the mobilisation
has at last been met. Mobilisation with Movement component of MWM is really a sustained reposition-
(MWM) has been developing for nearly three decades ing of the joint surfaces. This, when indicated, enables
and the evidence base for its use is mounting. Justi- pain-free function to occur and, when restricted joints
cation for its use based on such evidence, clinical are treated, passive overpressure must be given. While
reasoning and reection is within these pages making painless, maximum movement must be gained and this
this volume an excellent reference for the researcher, can only be attained by applying overpressure. With
teacher and clinician, and it will become a worthy stan- longstanding restrictions the movement gained on day
dard text on my concepts. one is usually all passive. If overpressure is not applied
What has enabled the successful teaching of the con- the results will not be long lasting.
cepts to date, without the much needed scientic back- C stands for communication and cooperation. You
ing, has been the fact that MWMs are only to be used as must explain in detail to the patient what you are about
a treatment when, on assessment, they have a PILL to do. They must know to tell you immediately if there
effect. The acronym stands for pain-free, instant result is any discomfort. Without their feedback you will not
and long lasting. succeed.
Pain-free refers to both the mobilisation and move- K stands for knowledge. Manual therapists must
ment components. have an excellent knowledge of musculoskeletal medi-
Instant result means that at the time of delivery there cine. They must know their anatomy and it is critical
is an immediate pain-free improvement in function. that they know all joint congurations and, in particu-
This is not true of many manual therapy techniques lar, joint planes.
taught. S stands for many things. Sustain your mobilisation
Long lasting means that all or most of the improve- throughout the movement. Sustain the repositioning
ment gained is maintained. If the patient regresses until you return to the starting position.
between visits and there is no obvious correctable rea- Skill is required. Handling skills when dealing with
son for this, after three visits you can say that MWMs sensitive painful structures are important. You need a
are not indicated. sensibility in your ngertips to locate accurately and
On this basis MWMs should be used as an assess- rmly without squeezing. Sometimes a plastic sponge
ment tool by all those involved in the eld of musculo- can be used for patient comfort. Handling skills deter-
skeletal therapy to ascertain if they are a valuable and mine how much force you use. With some structures
appropriate treatment tool. the movement taking place may be less than 1 mm.
Another important acronym we use when teach- Sense commonsense and sometimes a sixth sense
ing MWMs is CROCKS, which deals with their are invaluable.
application. Subtle changes in direction are required when repo-
C stands for the contraindications to manual ther- sitioning joint surfaces to completely eliminate any
apy which, of course, will be known by all manual discomfort. This ties in with handling skills.
therapists. To now have this reference book, Mobilisation with
R stands for repetitions. With an extremity joint that Movement: the art and the science, is wonderful. I feel
has been dysfunctional for weeks or even longer, up humble and I am personally indebted to Bill Vicenzino,
to three sets of 10 MWMs can be used. With acute Wayne Hing, Darren Rivett and Toby Hall and all the
injuries, on day one, it is wise because of irritability individual contributors for the immense time and effort
to apply the techniques three to six times. With the that has gone into its creation. I cannot thank them
spine we have the rule of three. On day one only use enough.
MWMs three times. This is because some patients fol- Brian Mulligan 2010
lowing any form of manual therapy get a latent reac-
tion to their treatment. This is minimised by the rule
of three. Even when they get this reaction it is of short
duration and when it settles they are still much better
and further treatment can be given.


The term Mobilisation with Movement, or MWM, is constructed and presented novel paradigms which
in common usage in the vocabulary of manual ther- stand to advance the understanding and applications of
apy practitioners worldwide. MWM is a method of MWM. To advance the eld, they have developed a
manual therapy that is being increasingly incorporated well reasoned clinical paradigm for MWM (Chapter 2)
into management regimes for patients with musculo- and have introduced a model incorporating what they
skeletal disorders. The term is also synonymous with have named the Client Specic Impairment Measure
New Zealand physiotherapist Brian Mulligan, a gifted (CSIM) which acts as a key and central feature of the
and innovative clinician and manual therapist who has approach to patient assessment and management. This
developed the approach over several decades, with the model is well conceived, comprehensive and stands
assistance of his patients. Brian Mulligan has made a to guide the clinicians clinical reasoning in patient
major contribution to the eld of manual therapy. He assessment and management. Importantly, use of such
has generously shared his knowledge, clinical exper- a model can guide design of future research ranging
tise and experience. He has taught the MWM approach from, for example, Phase I to Phase III trials.
widely, nationally and internationally, and importantly It is easy for the enthusiast to laud uncritically
he has trained others to teach the approach. Brian Mul- a management approach and spread the doctrine. What
ligan has also published books and DVDs which detail is appreciated and valuable in this text, is the authors
the indications and applications of techniques for clini- balanced approach between the science and the art and
cians and patients alike. their determination to advance the eld. The available
The therapeutic approach to MWM has undoubt- evidence of benet of MWM has been presented in
edly gained the attention of clinicians because of its an unbiased way using the rigorous methodology of a
effectiveness in the management of patients with mus- systematic review. While some preliminary evidence
culoskeletal pain and movement disorders. There has of benet is emerging, the need for further high qual-
been some research investigating its efcacy and the ity trials is noted. In relation to mechanisms of action
hypotheses for its mechanisms of effect. However, to to explain the effects of MWM, the historical positional
date the MWM approach has had its seminal basis in fault hypothesis of MWM is critically reviewed. While
clinical observation of responsiveness to the clinically appreciating the available evidence, the authors forge
reasoned application of passive movement/position- ahead and present a new model for consideration of the
ing in combination with active movement. While the mechanisms of action of MWM to advance the eld both
primacy of high level clinical reasoning and practical clinically and in research. Importantly and realistically,
skills can never be underestimated, there is a current there is an expansion of the hypothesis for MWM mech-
desire by clinicians, researchers and healthcare agen- anisms from a previously predominantly biomechanical
cies alike for delivery of practice which is also research one, to one which also incorporates the neurosciences
informed and evidence based. This text, Mobilisation (the sensory and motor systems) and the behavioural sci-
with Movement: the art and the science, embarks upon ences, and expert input into the eld has been provided.
the process of providing the nexus between a seem- It is often difcult in a theoretical construct, such as
ingly successful clinical approach and its clinical sci- a book, to bring to life the clinical reasoning and meth-
ence base. odologies of the approach together with the nuances of
The texts authors, Bill Vicenzino, Wayne Hing, Toby patients, especially when dealing with the heterogene-
Hall and Darren Rivett are all highly regarded clini- ity in presentation of musculoskeletal disorders. The
cal researchers and teachers, well versed in the MWM authors have successfully addressed this challenge by
approach. They have all been involved in research into providing several well crafted chapters of patient cases
the efcacy and effectiveness of MWM and thus have presented by leading clinicians in the eld, as well as
a strong and authoritative clinical and research base to the authors themselves. What is of enormous value
explore both the art and science of Brian Mulligans in these chapters for clinicians is the inclusion of the
approach. clinical reasoning process that is integrated with the
A treatment method has a risk of non survival description of the technical aspects of patient manage-
without clinical and research paradigms that can be ment. In addition, the cases serve to display the wide
tested and advanced. The authors are to be congratu- application of the principles and practice of the MWM
lated on the scholarship evident in this text. They have approach in the musculoskeletal eld.


As mentioned, the MWM approach has generated approach will grow and thrive for the benet of future
considerable interest and enthusiasm in the eld of patients and manual therapists. The authors are to be
manual therapy. From a clinical standpoint, it has, over congratulated on the eloquent way they have brought
the past two or more decades, provided an advance to the art and science of MWM together in this text with
the art of manual therapy and assisted many patients due scientic and clinical rigour. It will be appreciated
with painful musculoskeletal disorders. However, as is by clinicians and researchers alike.
commonly encountered, the clinical art of MWM is to Gwendolen Jull MPhty, PhD, FACP
date well in advance of its science and evidence base, Professor of Physiotherapy
which is essentially at the beginning of its journey. This The University of Queensland
text provides a vital basis on which the science can be Australia
developed further to ensure that the Mulligan MWM


We aimed to make this book a comprehensive and The book is essentially in ve parts. The rst part
unique exposition of the state of the scientic evidence introduces the concept of MWM and its principles of
for a relatively new form of manual therapy, Mobilisa- application. Part two provides a systematic review of
tion with Movement (MWM). When Brian Mulligan the evidence for its efcacy. The third part focuses on
rst described MWM in 1984 the only evidence base possible underlying mechanisms of action, an exami-
was his expert opinion and a small number of his case nation of potential sensory and motor effects, and an
reports. In the intervening period the empirical evi- evaluation of Mulligans positional fault hypothesis.
dence has steadily grown to now include randomised Part four is comprised of twelve case reports in which
controlled trials and systematic reviews. Moreover, the the authors and other expert case contributors describe
biological understanding of MWM has evolved from the application (with underpinning clinical reasoning)
Mulligans self-admitted simplistic positional fault of MWM for a wide range of musculoskeletal disor-
hypothesis to the testing of scientic hypotheses in ders of varying complexity. The reader will get most
sophisticated studies involving MRI and controlled value from these case reports if the preceding chap-
laboratory conditions. It is now timely to review and ters have been rst digested, as the cases incorporate
present the evidence for all forms of MWM (including discussion and commentary integrating the scientic
sustained natural apophyseal glides of the spine) from evidence with the clinical guidelines in the context of
the past quarter of a century in one volume. the patients unique presentation. The book concludes
In addition to the science underpinning MWM, this with the fth part; a troubleshooting section that aims
text also describes the art inherent in its success- to guide practitioners in optimising their application of
ful implementation. Basic principles are outlined and MWM.
more advanced aspects of its clinical application are This book has been written for the clinician, teacher
developed and critiqued, including guidelines on dos- and post-graduate student interested in furthering their
age and troubleshooting. Most importantly, the practi- understanding and skill in MWM, and indeed manual
cal art of MWM is illustrated in a series of case studies therapy more broadly. It builds on but does not replace
in which real life clinical presentations elucidate the Mulligans texts as it is not intended to be a catalogue
clinical reasoning underlying its effective application, of techniques. We have also provided the undergradu-
including consideration of the evidence base, and pro- ate student with information that will benet them in
vide detailed descriptions of selected techniques and their studies of manual therapy and evidence-based
home exercises. These cases help bridge the divide that management of musculoskeletal disorders.
typically separates the science and the art of various Professor Bill Vicenzino
approaches in manual therapy. Brisbane, Australia, 2010
Although the primary focus of the book is MWM, Associate Professor Wayne Hing
much of its content is applicable to manual therapy Auckland, New Zealand, 2010
in general. In particular, the chapters describing the Professor Darren Rivett
current understanding of potential mechanisms of Newcastle, Australia, 2010
action provide a summary of the contemporary theo- Dr Toby Hall
ries explaining the clinical benets of manual therapy. Perth, Australia, 2010
Similarly, the case reports stand alone as a resource to
foster the development of skills in clinical reasoning
as they relate to the management of musculoskeletal

Bill Vicenzino PhD, MSc, BPhty, Grad Dip Sports Phty Darren Rivett PhD, MAppSc (ManipPhty),
Professor of Sports Physiotherapy, BAppSc(Phty), Grad Dip Manip Ther
Head of Physiotherapy, School of Health and Professor of Physiotherapy, Head of School,
Rehabilitation Sciences, University of Queensland School of Health Sciences, Faculty of Health,
The University of Newcastle
Wayne Hing PhD, MSc(Hons), ADP(OMT), DipMT,
DipPhys, FNZCP Toby Hall PhD, MSc, Post Grad Dip Manip, FACP
Associate Professor, Head of Research, Specialist Musculoskeletal Physiotherapist,
School of Rehabilitation and Occupation Studies, Adjunct Senior Teaching Fellow (Curtin University),
Auckland University of Technology, New Zealand Senior Teaching Fellow, The University of Western
Australia, Director Manual Concepts

Leanne Bisset PhD, MPhty (Sports Phty), MPhty Tracey OBrien MPhty (Sports Phty), BPhty
(Musculoskeletal Phty), BPhty Former executive member SMA Qld Board of
APA Titled Sports Physiotherapist Directors (20002007), Associate lecturer in
APA Titled Musculoskeletal Physiotherapist Physiotherapy at the University of Queensland
Senior Lecturer, Grifth University
Mark Oliver MSc
Stephen Edmonston PhD, A/Prof. Private Practitioner
Director, Postgraduate Coursework Programs, School
of Physiotherapy, Curtin University of Technology Sue Reid MMedSc (Phty), Grad Dip Manip Phty,
BAppSc (Phty), BPharm
Paul Hodges PhD, MedDr (Neurosci), BPhty (Hons) Faculty of Health Science, The University of
Professor and NHMRC Principal Research Fellow Newcastle, Callaghan
Director, NHMRC Centre of Clinical Research
Excellence in Spinal Pain, Injury and Health Kim Robinson BSc, FACP
University of Queensland Specialist Musculoskeletal Physiotherapist
Adjunct Senior Teaching Fellow, Curtin University
C Hsieh MS, PT, DC, CA Senior Teaching Fellow, The University of Western
Private practice, Owner of John Hsieh Australia
Director Manual Concepts
M Hu
Associate Professor, School and Graduate Institute of Michele Sterling PhD, MPhty, BPhty, Grad Dip
Physical Therapy, National Taiwan University, Taipei, Manip Physio (distinction)
Taiwan, Republic of China Associate Director, Centre for National Research on
Disability and Rehabilitation Medicine (CONROD)
Kika Konstantinou MSc, MMACP, MCSP and Director Rehabilitation Research Program
Spinal Physiotherapy Specialist/Physiotherapy (CONROD)
Researcher, Primary Care Musculoskeletal Research Senior Lecturer, Division of Physiotherapy, School
Centre, Primary Care Sciences, Keele University of Health and Rehabilitation Sciences, University of
Brian Mulligan FNZSP (Hon), Diploma M.T
Registered Physical Therapist
Developer of the concept of Mobilisation with


Pam Teys MPhty (Sports Phty), BPhty, Grad Cert CH Yang

Higher Ed Department of Physical Therapy,
School of Physiotherapy, Bond University Tzu-Chi University, Hualien, Taiwan, Republic of
C Yang
President, Calvin Yang MD Medical Imaging

Dr Nikki Petty Ken Niere
Principal Lecturer, Programme Leader Professional Senior Lecturer, School of Physiotherapy, LaTrobe
Doctorate in Health and Social Care University, Melbourne, Australia
Clinical Research Centre for Health Professions,
School of Health Professions
University of Brighton, UK

Dr Alison Rushton
Senior Lecturer in Physiotherapy, School of Health and
Population Sciences
College of Medical and Dental Sciences, University of
Birmingham, UK

To my wife Dorothy and children Michelle, Louise Christine and Douglas, wife Liz, son Sam and daughter
and Selina. Amy for putting up with me during the writing process.
As testament to my father Romeos belief in the ben- The support of all my family truly means more to me
ets of study and also the support of Mary Vicenzino than anything else.
and Dorothy-May Ritchie. Toby Hall
Bill Vicenzino
Collectively, the authors acknowledge the valuable
Firstly to the centre of my world and love of my contributions of:
life, my little twins Matthew and Philippa. Also to my Brian Mulligan for overseeing the lming of the
parents and family who have always been there and techniques for the DVD and for performing many of
supported me through my journeys. Special mention them. He continues to be an inspiration for the correct
to my extended friends and colleagues of the Mulligan application of his MWM techniques.
Concept Teachers Association and in particular Brian Mark Oliver for performing the MWM techniques
Mulligan for your enormous contribution to my man- for the SIJ and TMJ, his areas of speciality.
ual therapy journey. Lastly a big thanks to the numer- The models who volunteered to participate in the
ous friends and work colleagues at AUT University lming for the DVD: Simon Beagley, Nadia Brandon-
and New Zealand physiotherapy fraternity who have Black, Wolly van den Hoorn, Christopher Newman,
shaped and steered my career. Ben Soon and Jeffrey Szeto.
Wayne Hing The models who volunteered to participate in the
photography sessions for the gures showing MWM
To my children Cameron and Karina, and to my men- techniques: Hans Giebeler, Honi Mansell, Katrina
tor in manual therapy and father Dr Howard Rivett. Mercer and Katherine Taylor.
Darren Rivett Assistance from the following was also greatly
appreciated: Renee Bigalow, Toni Bremner, Marion
Many people unknowingly helped steer my career, Duerr, Robin Haskins and Kerry Melifont.
which ultimately enabled me to contribute to this book. We are grateful for the specialist assistance provided
Notable are Bob Elvey, Kim Robinson, Brian Mulligan by Dr Natalie Collins in the conduct of the systematic
and Kate Sheehy, but there are many others. Thanks review and quality analyses in Chapter 3.
to you all. Special thanks go to my family: my parents

Mobilisation with
Movement: its
Chapter 1

Darren Rivett, Bill Vicenzino, Wayne Hing and Toby Hall

In the history of manual therapy revolutionary changes years studies testing this hypothesis using cutting-edge
in clinical practice have appeared from time to time. imaging and other research tools. It is timely that this
The individuals responsible for such impacting emerging science is linked to the clinical art of MWM;
changes have each contributed innovative and origi- that is, the evidence for MWM should be integrated
nal insights, and developed novel manual therapeu- with its clinical practice.
tic approaches and techniques. Maitland, McKenzie, Bogduk and Mercer[1] contend that any form of treat-
Kaltenborn, Paris, Jull and Elvey are just a few of the ment can be appraised against three distinct, comple-
leading practitioners who, utilising their sophisticated mentary axes of evidence: convention, biological basis
skills in clinical observation, palpation and reasoning, and empirical proof. A substantial part of this text will
opened new elds in manual therapy which effectively be concerned with the latter two forms of evidence;
shifted practice paradigms and transcended profes- that is, the biological mechanisms that may explain
sional boundaries. Indeed, their names have over the effects of MWM reported by practitioners and
time become synonymous with manual therapy itself. increasingly observed in empirical quantitative trials
Almost without exception, these outliers of manual of its efcacy. The remaining axis of convention, albeit
therapy exhibited self-deprecation and a continual the weakest type of evidence, is clearly supported by
drive to share their ideas, techniques and experiences the widespread uptake of MWM by manual thera-
with other practitioners. Brian Mulligan (Figure 1.1) pists, the increasing number of publications describ-
is a recent addition to this pantheon of leading man- ing the techniques including entry-level professional
ual therapy practitioners, with his unique Mobilisa- texts (Petty, for example[2]), and the growing number
tion with Movement (MWM) concept signicantly of Mulligan courses run annually across 25 countries
impacting on manual therapy practice worldwide over (see www.bmulligan.com for current courses), as well
the last two decades. as the incorporation of MWM into undergraduate and
In Chapter 2 we explain in detail the nuances of postgraduate university curricula. Moreover, there is
MWM, however, simply, MWM can be described as now a regular international conference on the Mulli-
a combination of a sustained passive accessory joint gan Concept and an international teachers association,
mobilisation with an active or functional movement. with a hierarchy of practitioner credentialing.
This book is a complete and comprehensive presenta- Before further discussing MWM and to truly under-
tion and exploration of the principles of application, stand the concept, it is arguably rst necessary to
potential underpinning mechanisms and evidence base appreciate the history of the individual who initiated
for Mulligans MWM. Since the early 1990s when and developed this original form of manual therapy,
MWMs rst come to prominence, there has been a Brian Mulligan himself.
rapid expansion in the number of techniques described
which can be used for differing clinical scenarios, and BRIAN MULLIGAN
a steady increase in the quantity and quality of support- The following historical recount is based on an inter-
ing research. Indeed, from Mulligans early descriptive view with Brian Mulligan.
case reports and videotaped patient treatments from Brian Mulligan began his career as a physiothera-
his clinic in New Zealand, scientic investigation pist after a chance conversation with a work colleague
into MWM has progressively advanced such that we early in 1951. A friend was about to take up physio-
now have high quality randomised controlled trials therapy studies in Dunedin on the South Island of New
being published in top ranked peer-reviewed interna- Zealand, when the conversation took place. This life-
tional journals (see Chapter 3). Similarly, from Mul- changing discussion regarding physiotherapy com-
ligans relatively simple positional fault hypothesis pletely changed the course of Mulligans life and set in
as to the possible mechanistic basis for the clinically place a chain of events that had major implications for
observed effects of his techniques, there are in recent manual therapy.

1 Introduction

similarly developing their interests in manual therapy.

Both Paris and McKenzie went to Europe to study with
Freddy Kaltenborn and returned to New Zealand to
teach this new approach in physiotherapy to Mulligan
and other physiotherapists. These were exciting times
for young ambitious physiotherapists, but there was
still a great deal of frustration with more to be learnt
about when to apply these new manual therapy tech-
niques in clinical practice.
The signicance of these developments in phys-
iotherapy should be considered in the context of the
times. The Otago school and indeed almost all under-
graduate programs in physiotherapy in the 1950s did
not include any form of manual therapy. Treatments
largely consisted of exercise therapy and massage, as
well as modalities such as ultraviolet radiation. Fara-
dism, microwave and short-wave diathermy were also
Figure 1.1 Brian Mulligan, creator of Mobilisation common treatments. Ultrasound was a latter addi-
with Movement tion to the therapeutic armamentarium that required a
special licence in New Zealand. In those heady days,
manual therapy was a very new and exciting advance
Mulligan was in his early 20s in 1954 when he in physiotherapy.
graduated from the Otago School of Physiotherapy in Mulligan sought to expand his knowledge in manual
Dunedin. This was the same era that two other well therapy and was keen to learn about peripheral joint
known physiotherapists also graduated in Dunedin, mobilisation. In 1970 Mulligan was New Zealands
Robin McKenzie and Stanley Paris. Mulligans rst representative at the World Confederation for Physical
job was at Wellington Hospital on the North Island of Therapy (WCPT) conference. Following this he trav-
New Zealand, but he quickly moved out of the public elled to Helsinki to attend a Kaltenborn peripheral joint
hospital system into private practice. His rst private mobilisation course. It was the rst time he had been
practice work was a two-week private clinic locum exposed to mobilisation techniques for the extremity
position for Robin McKenzie. At that time there were joints. Shortly after his return to New Zealand he was
only ve private physiotherapy practices in Welling- asked to teach the new skills he had learnt to the local
ton. Mulligan enjoyed the experience immensely, and private practitioners group. He ran his rst weekend
decided that this type of physiotherapy practice would course on Kaltenborn mobilisation techniques in 1970.
be his career path in the future. Accordingly, he started Shortly afterwards, in 1972, he was asked to teach a
his own private practice in Wellington and was very similar course in Perth and Sydney, in Australia. Mul-
well supported by the local referring medical practi- ligan then taught regularly in Australia, especially Mel-
tioners. bourne, where he visited for 15 consecutive years.
Mulligan was very active in the New Zealand Soci- In 1984 Mulligan had his rst MWM success, which
ety of Physiotherapists (NZSP). He joined the NZSP completely changed his whole approach to manual
after graduation, becoming the secretary of the local therapy. The patient was someone he had been treat-
Wellington Branch at the end of his rst year, and took ing for some time but could not alter the status of their
on the presidency soon after. He attended as many condition. The patient presented with a grossly swollen
meetings as he could in those early years to increase his nger with painfully limited exion and extension fol-
clinical knowledge and to develop his skills in practice, lowing a sporting injury. Mulligan used contemporary
being acutely aware of the general lack of understand- treatment techniques of the day, which included ultra-
ing in managing patients with musculoskeletal prob- sound and traction as well as medial and lateral joint
lems at that time. glide mobilisations. Nothing appeared to signicantly
In the late 1950s, Jennifer Hickling from London improve the patients condition.
gave seminars in New Zealand on Dr James Cyriaxs Mulligan again attempted a medial glide technique
approach to orthopaedic medicine, which included but the patient reported this as being painful. He then
spinal manipulation (high velocity thrust) and passive applied a lateral glide, which the patient stated did not
joint mobilisation techniques.[3] Mulligan attended hurt. In a moment of inspired lateral thinking, Mulli-
those seminars and was deeply impressed by Hick- gan asked the patient to try to ex the injured nger
lings knowledge and expertise. Mulligans interest while he sustained the pain-free lateral glide (Figure
in manual therapy was greatly stimulated by these 1.2). The technique was immediately successful and
seminars. About this time, Paris and McKenzie were restored the full range of pain-free movement to the


joint in both exion and extension. Further repeti- Mulligan wrote his rst textbook on his concept
tions rendered the patient symptom-free after only one of manual therapy in 1989.[4] Every few years a new
treatment session. A telephone call several days later updated version was written as more and more tech-
revealed that the pain had not returned and the swelling niques were being developed. Currently the book is
had completely reduced following this single applica- in its sixth edition[5] and has sold more than 75 000
tion of MWM. For Mulligan, this was a Louis Pasteur copies worldwide. It has also been translated into 10
moment: Chance favours the prepared mind. languages, including Mandarin, Polish, Korean, Portu-
All MWMs that have since been developed arose guese and Spanish. A further publication followed in
from this single observation of a recalcitrant clini- 2003 based on self-treatment techniques entitled Self
cal problem. Mulligan thought a great deal about this treatments for the back, neck and limbs, and is currently
patient, and soon realised the whole concept of posi- in its second edition. Techniques from the Mulligan
tional faults and MWM. He was keen to apply the Concept are also now described in CDROM and DVD
same idea to all his patients with nger joint problems, products (see www.bmulligan.com for a description of
and then to other joints. Medial and lateral glides and these products). Mulligan started to teach his new tech-
rotations with movement were developed rst in the niques in many other countries, starting with Australia
ngers, shortly followed by the wrist. The concept and the USA. From the beginning, an important focus
of MWM was rapidly evolving. Sustained Natural of these courses has been actual patient treatment dem-
Apophyseal Glides (SNAGs) were also being devel- onstrations to clearly show the benets of the concept.
oped in the spine at the same time. Mulligan realised In 1990 Mulligan lectured at Curtin University of
that the effects of MWM in the peripheral joints were Technology in Perth, Western Australia. Three UK
similar to the effects of SNAGs in the spine. All these physiotherapists, Toby Hall, Linda Exelby and Sarah
techniques essentially involved sustained accessory Counsel were attending postgraduate courses at the
joint glides together with physiological movement. university at the time and were impressed by the
He rationalised that the techniques somehow restore approach Mulligan presented. These three physiother-
a positional fault which arose from either trauma or apists took Mulligans techniques back to the UK and
muscle imbalance. started teaching them to their colleagues. Such inter-
Momentum gathered quickly from this early incep- est was generated that this eventually led to invitations
tion of MWM. Mulligan was very excited by his for Mulligan to teach in the UK and Europe and to the
discovery and knew he had to share it with other development of the international Mulligan Concept
physiotherapists. He started to teach these new tech- Teachers Association (MCTA), which had its inaugu-
niques at courses in New Zealand through the manual ral meeting in Stevenage, UK in 1998. This teaching
therapy special interest group of the NZSP known as group was set up to standardise the teaching of the
the New Zealand Manipulative Therapists Association Mulligan Concept around the world. There are now
(NZMTA). At that time Mulligan was teaching a range more than 47 members of MCTA providing courses
of techniques from different concepts, including those for physiotherapists all over the world. In addition, due
of Geoff Maitland and Kaltenborn, but gradually his to the demand from clinicians in the USA, and even-
own techniques replaced these other concepts. His rst tually elsewhere, who wished to be acknowledged as
Mulligan Concept course was held in 1986. competent Mulligan Concept practitioners, Certied

Figure 1.2 (a) Manual application of a lateral glide MWM for a loss of exion of the proximal inter-phalangeal
joint of the index nger
(b) Application of a lateral glide MWM for a loss of hip exion using a treatment belt

1 Introduction

Mulligan Practitioner (CMP) competency examina- may follow the convexconcave rule of joints[6] but in
tions were established. To date, there are over 300 cli- some cases in the opposite direction to the mechanism
nicians worldwide who have gained this certication. of injury movement. Sometimes a little trial and error
In recognition of his signicant contribution to man- is needed to nd the right direction. One distinction
ual therapy and the physiotherapy profession, Mulli- with SNAGs, which are effectively the MWM of the
gan has received a number of awards. In chronological spine, is that the gliding motion is always in the direc-
order of presentation these include: Life Membership tion of the facet joint plane. Mulligan generally recom-
of the NZMTA (1988); Honorary Teaching Fellow- mends three sets of 10 repetitions of MWM, or fewer if
ship from Curtin University of Technology (1991); the impaired task is pain-free on reassessment follow-
Honorary Fellowship of the NZSP (1996); Life Mem- ing the application of a set of MWM or if irritability or
bership of the New Zealand College of Physiotherapy acuteness is a factor in the spine when using SNAGs.
(1998); Life Membership of the NZSP (1999); Honor- There are many nuances to the successful application
ary Teaching Fellowship from the University of Otago of MWM and these are covered in depth in Chapter 2.
(2003); WCPT Award for International Services to the MWM can be easily integrated into the standard
Physiotherapy Profession (2007). The impact that the manual therapy physical examination to evaluate its
Mulligan Concept has had on clinical practice was potential as an intervention. A seamless integration
highlighted when Mulligan was named one of The can be undertaken after examining the active/func-
Seven Most Inuential Persons in Orthopaedic Man- tional movements, static muscles tests in some cases,
ual Therapy as the result of a poll of members of the and passive accessory movements. They can be readily
American Physical Therapy Association. trialled and implemented in the treatment. Reassess-
ment is generally just a matter of the practitioner tak-
MOBILISATION WITH MOVEMENT ing their hands off the patient and asking them to move
The fundamental components of the MWM techniques (without having to change position), and frequently
are still as they were when in 1984 Mulligan rst observed the treatment and its reassessment can be applied in
immediate full restoration of pain-free movement after he weight-bearing positions for lower limb and lumbo
sustained a lateral glide mobilisation to an inter-phalan- pelvic problems. Mulligan recommends discarding the
geal joint and asked the patient to actively ex that joint. technique immediately if no positive change is evident
Furthermore, he observed that it only took one session on initial reassessment.[7]
of this rst MWM to bring about long lasting changes. The indications for MWM in both the physical
This was especially impressive because the nger joint examination and for treatment are essentially the same
had not responded to a range of contemporary physical as for other hands-on manual therapy approaches,
therapies applied over several sessions. This immediate, as are the contraindications. This is discussed more
pain-free and long lasting response has become the key comprehensively in Chapter 2. Generally, mobilisation
principle guiding MWM application today. techniques, including MWM have been conceptualised
MWM can be dened as the application of a sus- as being indicated for mechanically induced joint pain
tained passive accessory force to a joint while the and joint stiffness limiting ROM. However, MWM has
patient actively performs a task that was previously also been proposed by Mulligan to effect what appear
identied as being problematic. A critical aspect of to be soft tissue conditions, such as lateral epicondylal-
MWM is the identication of a task that the patient gia of the elbow and lateral ankle ligament sprain, and
has difculty completing, usually due to pain or joint indeed there is growing evidence to support his asser-
stiffness (see Chapter 2 for more detail). This task is tion (see Chapter 3). The various potential mechanisms
most frequently a movement or a muscle contraction by which MWM may exert its effects are considered in
performed to the onset of pain, or to the end of avail- Chapters 4, 5, 6 and 7.
able range of motion (ROM) or maximum muscle con- While innovative and original in nature, the MWM
traction. In this text, we will refer to this as the Client concept has parallels to other traditional mainstream
Specic Impairment Measure (CSIM, see Chapter 2 for approaches to manual therapy that would facilitate
more detailed description). The passive accessory force ready adoption by the experienced manual therapist.
usually exerts a translatory or rotatory glide at the joint For example, the consideration of joint mechanics in
and as such must be applied close to the joint line to some MWM techniques is akin to the approach advo-
avoid undesirable movements. It may be applied manu- cated by Kaltenborn,[6] and the strong emphasis on
ally or sometimes via a treatment belt (Figure 1.2b). self-management using repeated movements would
The direction of the accessory movement that is used be familiar to McKenzie practitioners.[8] This is not
is the one that effects the greatest improvement in the surprising given that Mulligan was heavily inuenced
CSIM. It is somewhat surprising that a lateral glide is early in his career by both these practitioners through
the most commonly cited successful technique used in direct mentoring. In common with both the Maitland[9]
peripheral joints, but if this direction is not effective and McKenzie approaches a change in pain response is
then other directions may be tested. Alternate glides used as an indication that the correct technique is being


applied, although rather than provoking or localising systematic review of such trials, where this is limited
pain the aim of MWM is its immediate and total elimi- or not available we must use the next best external evi-
nation. In contrast, there are no grades of mobilisa- dence (see Chapter 3, Table 3.1 for the various levels
tion in MWM as there are in the Maitland approach and of evidence), whether it be a case report or from the
some other approaches,[10] and MWM combines both basic sciences. We therefore prefer the term evidence-
passive and active elements rather than just focusing on informed practice, and particularly use this in the
one (e.g. passive joint movement as per Kaltenborn) or case studies which comprise the latter part of the text,
the other. In regard to the latter, there is some similar- as the cases strive to illustrate how expert clinicians
ity to the combined movement approach described by apply the external research evidence for MWM within
Brian Edwards[11] in which pain-free joint positioning a clinical reasoning framework and without losing the
is used to enable end-range passive mobilisation. The uniqueness and individuality of the patient. The patient
other interesting parallel is the story about how Mul- is considered an active and equal partner in the clini-
ligan discovered MWM, not dissimilar to the account cal problem-solving exercise, as they bring their own
given by McKenzie as to how he chanced upon the beliefs, understandings, expectations and experiences
therapeutic value of lumbar spine extension for low to the unfolding clinical journey. In addition, consis-
back pain.[8] These outliers of the manual therapy tent with the biopsychosocial model of healthcare, the
world appear to share an ability to creatively clinically patient is required to actively engage in their treatment
reason or think outside the box. and management, as opposed to just passively receiv-
ing the laying on of hands implicit in many traditional
MWM AND CLINICAL REASONING manual therapy approaches.
Some approaches to manual therapy have been criti- The MWM concept arguably promotes patient-cen-
cised for fostering recipe book clinical practice. That tred clinical reasoning in several ways:
is, rather than promoting skilled clinical reasoning in Collaborative clinical reasoning in treatment, as pro-
autonomous practitioners, some approaches could be mulgated by Jones and Rivett[12] is central to MWM.
considered to relegate the role of the manual therapist First, the patient needs to understand that the tech-
to that of a technician, required simply to deliver a pre- nique is completely pain-free and that they must
determined course of therapeutic action. A cursory view report any pain immediately to the therapist. Second,
of the MWM concept might similarly suggest it simply in most MWM applications, the patient is required to
requires the clinician to routinely follow several basic perform an active movement or functional task that
rules (e.g. the treatment plane rule, convexconcave is problematic and for which treatment was sought
rule) and therefore is at odds with the development of (e.g. a painful or limited movement). Third, many
skilled clinical reasoning. However, on closer inspection MWM techniques involve the patient applying over-
it is clear that MWM actually incorporates many of the pressure at the end of range, and indeed Mulligan[7]
desirable aspects of contemporary, exemplary clinical considers this component critical in effecting an
reasoning. In particular, these relate to a patient-centred optimal response. Finally, and perhaps most impor-
approach to healthcare and promotion of the ongoing tantly in this context, some MWMs can be adapted
development of the practitioners clinical skills. for home exercise as self-MWMs or by using tape
to simulate the accessory movement (or mobilisa-
MWM promotes patient-centred tion) component of the technique. Of course, all of
reasoning the above elements of MWM necessitate that the
patient understands the principles of MWM and is
Jones and Rivett[12] have advanced a model of clini- willing to actively participate in their own manage-
cal reasoning in manual therapy that places the patient ment; thereby rendering the patient a central and
rmly at the centre of the clinical encounter and the necessary factor in successful MWM treatment. The
associated clinical reasoning processes. Their model importance of collaboration and patient cooperation
is consistent with the patient-centred approach to evi- to the success of MWM is highlighted in an acronym
dence-based medicine advocated by Sackett et al.[13, 14] favoured by Mulligan (personal communication,
Evidence-based medicine has been dened by Sack- 2009) in his teaching CROCKS:
ett et al (p.71)[14] as the conscientious, explicit, and Contraindications to manual therapy as for any
judicious use of current best evidence in making deci- manual therapy techniques
sions about the care of individual patients. These Repetitions of the technique are required, but with
authors further stress that evidence-based medicine is care on initial application and in acute injuries for
an integration of the practitioners clinical expertise which three to six repetitions are recommended
with both the best external clinical research evidence Overpressure to ensure optimal ongoing improve-
and the patients preferences in making decisions ments
about their care. While for treatment the gold stan- Communication and cooperation is essential
dard for evidence is the randomised clinical trial or a for safe and effective MWM application with

1 Introduction

practitioners informing patients of expected relation to MWM recognises the unique clinical pre-
effects and for patients informing practitioners of sentation of the individual patient.
any discomfort or pain Arguably, MWM provides a means by which vari-
Knowledge of musculoskeletal medicine, biome- ous types of clinical reasoning hypotheses[12] can be
chanics and anatomy tested, aside from the obvious one of management
Sustain the glide for the entire duration of the rep- and treatment. Most notably, the degree of response
etition. S also stands for skill in the manual han- to MWM can potentially expedite and rene the clin-
dling of the physical application of the MWM, ical prognosis.
sensibility of the sensing ngertips to accurately
locate MWM forces and to detect movement, sub- MWM promotes knowledge organisation
tle changes in glide direction are often required, A well-organised knowledge base has been identied as
and common sense. one of the hallmarks of clinical expertise. It is not just
The practitioner can facilitate patient compliance the degree of knowledge in its three main types prop-
with treatment, especially the self-management com- ositional (essentially basic and applied science), non-
ponent, by demonstrating to the patient that applica- propositional (including practical and other professional
tion of MWM can produce an immediate pain-free skills) and personal (an individuals life experiences)
response in their worst movement or activity. that is important in clinical reasoning, but how these
Moreover, such a powerful response has signicant understandings and skills are stored and held together
potential to change any negative beliefs or expecta- using clinical patterns.[12] A well-organised knowledge
tions that the patient may have brought to the clinical base will facilitate the application of advanced clinical
encounter. Another of the acronyms that Mulligan reasoning processes, particularly that of pattern recog-
(personal communication, 2009) uses when teaching nition which has been shown to be more accurate than
MWM is PILL, indicating the desired response from hypotheticodeductive processes in manual therapy
the techniques application: diagnosis and is typically used by experts.[16]
Pain-free application of the mobilisation and It can be argued that the MWM concept promotes
movement components knowledge organisation by:
Instant result at the time of application Stimulating research and a growing evidence base
Long Lasting effects beyond the techniques which can be used to help guide and inform clini-
application. cal reasoning. As later chapters demonstrate, there
Effective communication is pivotal to the effective is a burgeoning evidence base, both biological and
application of MWM. The patient must immediately empirical for MWM.
communicate the onset of any pain with either the Highlighting and integrating key physical exami-
Mobilisation or the Movement component, or nation ndings, most notably passive accessory
else the technique will be rendered ineffectual. Simi- movement ndings (the Mobilisation) with the
larly, the therapist must clearly communicate what is comparable active/functional movement ndings
expected of the patient, as outlined in the previous (the Movement).
point. Effective communication is also unambigu- Facilitating clinical pattern acquisition through the
ously the foundation of effective collaborative clini- immediate response to the application of MWM.
cal reasoning. Effectively this constitutes feedback to the therapist
Central to the MWM concept is that each patient on the accuracy of the related clinical decision(s) and
is an individual and their clinical presentation is helps to reinforce the association of key clinical nd-
unique, although they may share some common fea- ings with correct clinical actions.
tures with others. This consideration of individuality Fostering the development of metacognitive skills
and uniqueness is consistent with the mature organ- through the need to continually adapt the applica-
ism model[15] which proposes that each patients ill- tion of MWM on the basis of the patients initial and
ness or pain experience is inuenced by their own changing responses. Metacognitive skills are higher
life experiences and immediate contextual circum- order thinking skills of self-monitoring and reec-
stances, and therefore their clinical presentation can- tive appraisal of ones own reasoning, and are a well-
not be exactly the same as that of another patient. recognised characteristic of clinical expertise.[12]
The Movement component of MWM requires that While the Mulligan Concept as it relates to MWM
a movement or functional activity be identied that may promote the development of skills in clinical rea-
is most painful or limited for that individual, and soning, there is a risk that an unquestioning inexibil-
which has a signicant impact on their daily life. ity of thinking may set in if vigilance is not maintained.
This movement is also used in reassessment as a The writings of Mulligan should be used as a guide to
comparable sign (i.e. a clinical sign that relates the application of MWM with the techniques adapted
to their functional limitation and pain) as described for the needs of a particular patient, and not treated as
by Maitland et al.[9] Similarly, the use of a CSIM in gospel from which heated debates arise over differing


interpretations and trivial technical issues. The history do so with an open but healthily sceptical mind. The
of manual therapy is replete with examples where a case studies comprising the bulk of the chapters will
far-sighted pioneer has been feted like a guru by his provide the novice reader with the condence to take
followers, who with the fervour of religious zealots the concept of MWM into their clinic, and the experi-
then proceed to construct a framework that sties cre- enced clinician with the opportunity to develop their
ativity and the further evolution of the protagonists clinical reasoning skill by comparing their reasoning to
approach,[17] and which misdirects future practitioners that of other Mulligan Concept practitioners.
and advocates of the approach away from the origina-
tors fundamental underpinning concepts. References
1 Bogduk N, Mercer S. Selection and application of treat-
AIMS AND STRUCTURE OF THIS BOOK ment. In: Refshauge KM, Gass EM (eds) Musculoskele-
The primary aim of this book is to present a comprehen- tal Physiotherapy: Clinical Science and Evidence-Based
sive and contemporary discourse on Mulligans MWM Practice. Oxford: Butterworth-Heinemann 1995.
2 Petty N. Neuromusculoskeletal Examination and Assess-
management approach for musculoskeletal pain, injury ment. Edinburgh: Churchill Livingstone 2005.
and disability. In particular, it strives to integrate the 3 Cyriax J. Cyriaxs Illustrated Manual of Orthopaedic
evidence base for MWM into clinical practice, with Medicine (2nd edn). Oxford: Butterworth-Heinemann
an emphasis on explicating the underpinning clinical 1993.
reasoning. 4 Mulligan B. Manual Therapy NAGS, SNAGS,
This book will cover the spectrum of the MWM PRPS etc. Wellington: Plane View Services 1989.
treatment approach from: (a) the evidence base for its 5 Mulligan B. Manual Therapy - NAGS, SNAGS,
clinical efcacy, clinical and laboratory based effects, MWMS etc. (6th edn). Wellington: Plane View Ser-
and underlying mechanisms; (b) best evidence guide- vices 2010.
lines for MWM treatment selection and application; 6 Kaltenborn F. Manual Mobilisation of the Extremity
Joints. Basic Examination and Treatment Techniques.
and (c) the current state of play with regard to Mul- Norway: Olaf Norlis Bokhandel 1989.
ligans positional fault hypothesis, as well as other 7 Mulligan B. Manual Therapy - NAGS, SNAGS,
impairments/decits in the pain, sensory, sensorimo- MWMS etc. (5th edn). Wellington: Plane View Services
tor and motor systems that may well be plausibly 2003.
addressed by the MWM approach; through to (d) a 8 McKenzie R, May S. The Lumbar Spine Mechanical
series of case studies (Chapters 8 to 19) that demon- Diagnosis and Therapy (2nd edn). New Zealand: Spinal
strate how the former considerations can be utilised Publications 2003.
in the clinical reasoning process. The latter will also 9 Maitland GD, Hengeveld E, Banks K, English K.
demonstrate the framework within which the practitio- Maitlands Vertebral Manipulation (6th edn). Oxford:
ner is able to design and implement customised MWM Butterworth-Heinemann 2001.
10 Boyling J, Jull G. Grieves Modern Manual Therapy:
techniques for the individual patient, as illustrated The Vertebral Column (3rd edn). Edinburgh: Churchill
by some prominent Mulligan Concept practitioners. Livingstone 2004.
By presenting these cases within a clinical reasoning 11 Edwards B. Manual of Combined Movements: Their
framework it is further intended to demonstrate that the Use in the Examination and Treatment of Mechani-
use of MWM is very much dependent on the individ- cal Vertebral Column Disorders. Edinburgh: Churchill
ual patients presentation and requires a sophisticated Livingstone 1992.
level of thinking by the practitioner. These are not 12 Jones M, Rivett D. Introduction to clinical reasoning.
recipe book treatments. Key MWM techniques, par- In: Jones M, Rivett D (eds) Clinical Reasoning for
ticularly those for which evidence is supportive, will Manual Therapists. Edinburgh: Butterworth-Heinemann
be described in detail and depicted. In the event that 2004:324.
13 Sackett D, Straus S, Richardson W, Rosenberg W,
a practitioner confronts issues in putting into practice Haynes R. Evidence-based Medicine: How to Practice
the MWM techniques, we have included a technique and Teach EBM (2nd edn). Edinburgh: Churchill
troubleshooting section (Chapter 20), which is geared Livingstone 2000.
towards practitioners self-reecting and appraising 14 Sackett DL, Rosenberg WM, Gray JA, Haynes RB,
their performances in order to develop strategies and Richardson WS. Evidence-based Medicine: What it is
solutions to these issues. and what it isnt. BMJ. 1996;312:712.
This book will be of benet for students of manual 15 Gifford L. Pain, the tissues and the nervous system: a
therapy and for the various health professionals work- conceptual model. Physiotherapy 1998;84:2736.
ing clinically in this eld, and it should provide a valu- 16 Miller P. Pattern Recognition is a Clinical Reasoning
able resource for instructors and researchers. It is not Process in Musculoskeletal Physiotherapy (Masters
Thesis). Newcastle: The University of Newcastle,
intended to replace the technical books of Mulligan, Australia 2009.
but rather is complementary. To make the most of this 17 Rivett D. Manual therapy cults (editorial). Manual
book, the reader should strive to rst understand the Therapy 1999;4:1256.
principles and evidence underpinning MWM, and to