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MULLIGAN THERAPY

What is it and
how does it work
INTRODUCTION
 Mulligan Concept developed by Brian R
Mulligan, a New Zealand physiotherapist, in
1960
 First therapy to incorporate movement
(therapist and patient generated) whilst
mobilising joints
 Follows the anatomy and natural movements of
the joints
 Focusing on correcting altered arthrokinematic
by mobilizing joint during movement
Mulligan Concept
1. Identify the issue at joints level (loss of ROM, pain
through range / at EOR)
2. Passive glide is applied according to Kaltenborn rules
(paralel to joint plane) & must be pain free (graded to
patient tolerance)
3. Pay an extra attention to patient respond
4. Apply mobilisation to alleviate pain (if pain not alleviated
check direction of glide, mobilisation grade, spinal
segment, is it indicated?)
5. Perform mobilisation passively through range
6. Perform mobilisation actively through range
7. Perform mobilisation functionally or in weight bearing
8. Encourage patient to “remember” the joint position during
pain-free movement
TERMINOLOGY
SPINAL MOBILISATION
 NAG’s = Natural Apophyseal Glide : oscilation glide
applied in direction of joints natural movements
 REVERSE NAG’s
 SNAG = Sustained Natural Apophyseal Glide :
Prolong pressure applied in direction of joints
natural movements
PERIPHERAL MOBILISATION
MWM = Mobilisation with Movement
Techniques more often used in peripheral joints (shoulder)
NAG’s & SNAG’s
 NAG’s & SNAG’s involves a mid to end-range
facet-joint mobilisation applied along the plane
of treatment within the desired joint.
 NAG’s : oscilation, 1-2 glide/second, 3
set/segment, can be combined with traction
 SNAG’s : sustained glide through movement
 Direction of facet glide is 450 ANTERO-
CRANIAL (toward patient eyes), except for C0-
C1, C1-C2 which is directed more horisontaly
REVERSE NAG’s

• Applied if NAG’s is unable to aleviate the pain.


• If in NAG’s superior facet glide up to inferior 
RevNAG’s : inferior facet glide up to superior
• Suitable for lower cervical & upper thoracal
MOBILISATION WITH MOVEMENT

Think of joints as
similar to a drawer

Sometimes when pulling the drawer out it gets jammed. To


“unstick” the drawer a force from a different angle is
required to get it moving correctly again.
SUMMARY
• Technique that is based purely on the anatomy of
the joint being manipulated
• Utilises progressive grades starting from purely
therapist generated to weight-bearing patient
generated movement
•SNAG’s for spine joints
•MWM’s for peripheral joints
MULLIGAN CERVICAL

Theory and
Practical
FACET JOINT

SUPERIOR FACET  CONCAVE

INFERIOR FACET  CONVEX


CERVICAL MOVEMENT
C0-C1 : NODDING/FLEXION-EXTENSION/YES JOINT
C1-C2 : ROTATION / NO JOINT
C2-C7 : FLEXION-EXTENSION-LATERAL FLEXION-
ROTATION  COUPLED MOVEMENT
FLEXION : ANTERIOR TILT + TRANSLATION of VB
EXTENSION : POSTERIOR TILT + TRANSLATION of VB
LAT FLEXION + IPSILATERAL ROTATION v-v
DIAGNOSIS OF FACET JOINT PAIN
 Separate pathology into up slope or down slope
 Right side pain
– If down slope problem pain will be elicited with
 Extension, right rotation, right side bend
– If up slope problem pain will be elicited with
 Flexion, left rotation, left side bend

 Left side pain


– If down slope problem pain will be elicited with
 Extension, left rotation, left side bend
– If up slope problem pain will be elicited with
 Flexion, right rotation, right side bend
SUPINE CERVICAL MOBILISATION
 Patient lies in supine position
 Therapist places hands behind the cervical spine

 Palpate cervical spine levels and musculature


 Use soft tissue mobilisation if muscles to tight
SUPINE MOBILISATIONS
 Up slope mobilisations
– Facet joint indirect mobilisation (very acute pain)
 Place finger on contralateral side of spinous process
 Pull spinous process towards painful side

– Facet joint direct mobilisation (passive)


 Place finger over the same transverse process
 Pull facet joint anteriorly and superiorly (45 degree angle)

– Facet joint mobilisation with rotation (NAG)


 Perform mobilisation of facet joint (fixing same TP)
 Rotate head whilst maintaining glide of the facet joint
SUPINE MOBILISATION
 Down Slope Mobilisations
– Facet joint indirect mobilisation (very acute pain)
 Place finger on ipsilateral side of spinous process
 Push spinous process away from painful side

– Facet joint direct mobilisation (passive)


 Place finger over the facet joint of lower transverse process
 Pull facet joint anteriorly and superiorly (45 degree angle)

– Facet joint mobilisation with rotation (NAG)


 Perform mobilisation of facet joint (fixing lower TP)
 Rotate head whilst maintaining glide of the facet joint
SEATED CERVICAL MOBILISATION
 Patient sits with feet supported on ground
 Therapist stands behind patient

 Can visualise the area to be treated


 Palpation more difficult due to weight bearing and
muscle being contracted
SEATED MOBILISATIONS
 Stronger due to the weight bearing position
 In sitting patient can more actively engage in the
required movements.
 Possible to do flexion and extension mobs
PRACTICAL – NAGS CERVICAL
1. Therapist stand on the side of seated patient, cradled patient head with abdomen &
chest, forearm diagonally across patient kontralateral TMJ.
2. Place Middle phalanx of right little finger on SP above the joint to be mobilized.
Index, third & fourth fingers wrap the occiput
3. Placed the lateral border of thenar eminence of the left hand over the little finger
4. Facet joint glide is applied by Pushing the little finger toward eye balls
PRACTICAL – REVERSE NAGS
1. Patient & therapist position is the same with NAGs
2. Put index finger of the top hand above suspected
segment
3. Put the bottom hand on “vee” position over SP below
suspected segment
4. Push the “vee” hand to glide the inferior facet over
superior facet
PRACTICAL – SNAGS FLEXION
1. Patient seated, therapist stand behind the patient
2. Put thumb over spinous process above suspected segment, reinforce with the other
thumb
3. Patient flexing the neck, therapist push the SP
4. At the end of movement, patient apply over pressure with by pulling the head his
hand & sustained for 2 second
5. Maintain facet glide until the neck back to neutral position
6. Repeat 6x, re-assess
PRACTICAL – SNAGS EXTENSION
1. Patient seated, therapist stand behind the patient
2. Put thumb over spinous process above suspected
segment, reinforce with the other thumb
3. Patient extend the neck, therapist push the SP
4. At the end of movement, patient apply over
pressure with by pushing his chin up & sustained
for 2 second at the end of range
5. Maintain facet glide until the neck back to neutral
position
6. Repeat 6x, re-assess
PRACTICAL – SNAGS LATERAL FLEXION
1. Patient seated, therapist stand behind the patient
2. Put thumb over spinous process above suspected segment, reinforce
with the other thumb
3. Patient side flexes the neck to restricted/painfull side, therapist push the
SP
4. At the end of movement, patient apply over pressure by pulling the
head & sustained for 2 second at the end of range
5. Maintain facet glide until the neck back to neutral position
6. Repeat 6x, re-assess
PRACTICAL – SNAGS ROTATION
1. Patient seated, therapist stand behind the patient
2. Put thumb over spinous process above suspected segment, reinforce with the other
thumb
3. Placed the other finger just below the mandibula to prevent flexion & assist some
lift
4. Therapist push the SP, Patient ROTATES the neck to restricted/painfull side,
5. At the end of movement, patient apply over pressure by pulling the chin & sustained
for 2 second at the end of range
6. Maintain facet glide until the neck back to neutral position
7. Repeat 6x, re-assess
PRACTICAL – CERVICAL TRACTION
UPPER CERVICAL LOWER CERVICAL  FIST
TRACTION
BASIC RULES FOR JOINT MOBILIZATION
1. HAVE A SOUND KNOWLEDGE OF
ANATOMY & BIOMECHANICS
2. HAVE CONFIDENCE HANDLING &
LANGUAGE SKILLS
3. IF THERE IS A SLACK JOINT & PAINFULL
BEFORE MOBILISING/MANIPULATING,
DO NOT PROCEED
SAFETY PROCEDURE

Test structures for safety


VBI
Ligamentous Tests (Alar, Nuchal, Transversal)

 Ask EVERY cervical patient about these


symptoms.
– Dizziness - Headaches
– Drop attacks - Nausea
– Vision disturbances- Trauma
VBI Testing
 Bilateral hold at EOR rotation in both
directions for 10 seconds
 Observe for 10 seconds post test
 Check for any of following symptoms
– Fainting
– Vertigo
– Nausea
– Diplopia (double vision)
– Blurred/disturbed vision
VBI Testing
 Bilateral hold at EOR rotation in both
directions for 10 seconds
 Observe for 10 seconds post test
 Check for any of following symptoms
– Fainting
– Vertigo
– Nausea
– Diplopia (double vision)
– Blurred/disturbed vision
 Alar Ligament
– Patient in supine
– Fix C2 between fingers
– Side flex head until feel C2 move
– Should be only 5-10º of side flex movement
 Transverse Ligament
– Places fingers above C2 so as to lie over the
arches of C1
– Translate C1 forward with fingers
– If there is ligamentous insufficiency the Dens will
press against spinal cord
– Hold position for 20 seconds, checking for
symptoms (severe and obvious)
 Nuchal ligament test
– Grasp C2 in pincer grip (as with Alar test)
– Perform ‘nodding action”
– Should feel C2 begin to move after 15-20 degrees of
nodding
– After this point the neck will flex as opposed to nod

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