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textbook of techniques
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Bill Vicenzino
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Brian Mulligan
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 is an imprint of Elsevier

Elsevier Australia. ACN 001 002 357

(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067

This edition © 2015 Elsevier Australia

This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright
Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval

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system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording
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Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been
possible. The publisher apologises for any accidental infringement and would welcome any information to

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redress the situation.

This publication has been carefully reviewed and checked to ensure that the content is as accurate and current

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as possible at time of publication. We would recommend, however, that the reader verify any procedures,
treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the
publisher assume any liability for injury and/or damage to persons or property arising from any error in or
omission from this publication.

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National Library of Australia Cataloguing-in-Publication Data

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9780729541596
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National Library of Australia Cataloguing-in-Publication entry

Hing, Wayne, author.

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The Mulligan concept of manual therapy : textbook of techniques / Wayne Hing, Toby Hall, Darren Rivett,
Bill Vicenzino, Brian Mulligan.
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9780729541596 (paperback)
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Physical therapy—Handbooks, manuals, etc

Movement therapy—Handbooks, manuals, etc.
Manipulation (Therapeutics)—Handbooks, manuals, etc
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Hall, Toby, author.

Rivett, Darren, author.
Vicenzino, Bill, author.
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Mulligan, Brian, author.

615.82
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Content Strategist: Melinda McEvoy

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Content Development Specialists: Martina Vascotto

Project Manager: Anitha Rajarathnam
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Edited by Forsyth Publishing Services

Proofread by Fiona Van Dam
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Cover and internal design by Lisa Petroff

Index by Robert Swanson
Typeset by Toppan Best-set
Printed by China Translation & Printing Services Ltd.
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In 2011, I had the privilege to write a foreword for
a new textbook on my concepts authored by Bill
Vicenzino, Wayne Hing, Darren Rivett and Toby
Hall. This was a timely, excellent publication enti-
tled Mobilisation With Movement: The Art and the
Science.
My own manual on my concepts, now in its 6th
edition, badly needed to be updated to include
more detail and an improved format. This task has
been undertaken and led by Wayne Hing, with all
the above authors again being involved. It has
taken over two years to complete this task. These
erudite authors also had the wisdom to involve
many of my Mulligan Concept international
teachers. They have contributed by writing much
of the text, each being allocated different regions
of the body and different techniques. I must here
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particularly acknowledge and thank my colleagues
Mark Oliver and Frank Gargano for the new tech-
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niques and material they have contributed.
I believe that the contents in this book, in its
new format, are priceless. All who deal with mus-
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culoskeletal conditions and practise manual
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therapy should have a copy.
What makes our concepts so special is that all
the Mobilisation With Movement techniques
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described within this book are only to be used
when they produce no pain on application and
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because they should be immediately effective if
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indicated. I know of no other manual therapy pro-
cedures for the entire body, which follow these
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guidelines. What is really special about them is
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that it only takes about two minutes to decide if
they are indicated. Not to be able to use our con-
cepts may be denying patients their best treatment
option. I now have many hours of video showing
the efficacy of our concepts, personally treating
patients on stage in many cities in America before
my peers. The hundreds who have witnessed these
occasions are left in no doubt as to the efficacy of
these techniques because of the regular positive
and instant pain-free outcomes.
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Our concepts have come a long way from 1985
when, by chance, I had an unexpected instant
pain-free success with a traumatised finger using
what are now known as ‘Mobilisations With
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Movement’. The patient, who was a young woman
in her early twenties, presented with a swollen
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interphalangeal joint which was painful and would
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not flex. I tractioned the joint several times which
accomplished nothing. I then applied joint (glide)
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translations in the recommended biomechanically
appropriate direction for flexion. Like the trac-
tions, these glides were also ineffective and painful.
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I then tried a medial translation accessory move-
ment which was unacceptable to the patient
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because of pain. Without much enthusiasm I then
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gently tried a lateral translation which prompted
the patient to say ‘it does not hurt’. Something
prompted me to sustain this translation and ask
her if she could flex her finger. To my astonish-
ment and her delight the finger flexed without
pain! She then said something like ‘You have fixed
me’. ‘Of course!,’ I replied. She still had a small loss
of flexion range due to some residual swelling but
she departed my rooms with a smile.
The young woman returned two days later and
her finger had completely recovered. Why, I asked
myself? The only explanation I could come up
with for my chance success was that as a result of
her trauma there was a minute positional fault of
the joint preventing flexion movement. When this
positional fault was corrected it enabled a full
recovery to take place. It was a simple hypothesis
and because of this I began to look differently at
all joints that I treated and experimented to see if
I could achieve similar results by repositioning
other joint surfaces. I began having unbelievable
successes in the clinic. A ‘miracle a day’ I called
them. Louis Pasteur once said that chance only
favours the prepared mind. When I, by chance,
had my first miracle with the young woman and
her painfully limited interphalangeal joint, I did
indeed have a prepared mind.
 Today the concepts that have grown from this
chance finding have come a long way and guide-
lines are now in place for their successful clinical
use; these are fully described within this textbook.
To optimally succeed with our concepts, you need
advanced clinical reasoning and excellent han-
dling skills. The detailed descriptions in this book
will help you immensely in both these aspects.
Ideally of course, the reader should attend the
courses that are available around the world by
accredited Mulligan Concept teachers. Teachers
and courses are listed at www.bmulligan.com
While on the topic of teachers, I always
acknowledge and thank my mentor Freddy
Kaltenborn. Freddy came many times from Europe
to teach in faraway New Zealand. He taught me
how to manipulate every joint in the spine and to
mobilise the extremity joints. His able teachings
gave me excellent handling skills. He also increased
my knowledge and the importance he placed on
the clinical significance of treatment planes led me
to successfully develop Mobilisations With Move-
ment. If you do not know each joint’s treatment
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plane you will never be able to successfully manip-
ulate or effectively apply the Mulligan concepts.
I must stress that the techniques contained with
this book are not set in stone. They are all based
on repositioning joint surfaces, or muscles and
their tendons, to see if one can achieve pain-free
resolution of a musculoskeletal problem. The
techniques described in the book are those we in
the Mulligan Concept Teachers Association have
clinically found to be effective. If any clinicians
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applying them, who have the requisite knowledge
and handling skills, can improve upon these tech-
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niques then this would be most welcome. It is
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hoped they would share their significant worth-
while improvements with other clinicians and
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teachers.
I feel very humble to have the support of such
scholars as Wayne, Toby, Bill and Darren, and
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thank them and Elsevier sincerely for this won-
derful publication.
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Brian Mulligan
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This book entitled The Mulligan Concept of
manual therapy: textbook of techniques presents
over 160 Mulligan Concept techniques and
includes therapist techniques as well as home
exercises and taping techniques. The book is
aimed at being a comprehensive and easy to follow
resource for the novice and experienced clinician,
as well as researchers. The book has been written
for the clinician, teacher and student interested in
furthering their familiarity to the wide array of
techniques under the Mulligan Concept umbrella.
Mulligan Concept techniques are effective and
safe when applied in accordance with easy to
follow guidelines and clearly identified underlying
principles.
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When Brian Mulligan first described Mobilisa-
tion with Movements (MWM) in 1984 he shared
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his techniques through his original book entitled
Manual Therapy: Nags, SNAGs and MWMs of
which there have been six editions over the past
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30 years. This book has been written to expand on
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and fully describe in a standardised format all the
techniques mentioned in Brian Mulligan’s afore-
mentioned original texts, as well as include new
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techniques that were not included in those earlier
landmark editions. This book is also intended as
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an accompaniment to our first book entitled
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Mobilisation with Movement: the art and the
science which was published in 2011.
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Our first book presented the science underpin-
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ning MWM and also described aspects of ‘the art’
inherent in its successful implementation. In that
book the basic principles of MWMs were out-
lined, potential mechanisms underpinning the
successful application of MWMs were canvassed,
and in depth aspects of its clinical application
were critiqued including guidelines on dosage and
troubleshooting. Over half of the first text pre-
sented the application of MWM in a series of case
reports. These case studies focused on the clinical
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reasoning underlying the application of the Mul-
ligan Concept, including consideration of the evi-
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dence base. The case studies followed the
application of the Mulligan concept from the first
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session to discharge, showing how the techniques
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were selected, applied and progressed over the
treatment program. However, the purpose of that
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first book was not to provide a detailed descrip-
tion of all the techniques under the Mulligan
Concept umbrella, which is the scope of this
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current book as it continues the work of the pre-
ceding landmark Mulligan’s Manual Therapy:
vi
NAGS, SNAGS and MWMs book.
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There was a real need for a comprehensive pre-
sentation of the wide array of techniques under
the umbrella of the ‘Mulligan Concept’. These
techniques include MWM and other Mulligan
techniques such as pain release phenomenon
(PRP). Each technique has been described in a
consistent and logical format fully explaining the
indications, application and modifications for
each technique. In addition, we have detailed the
current available evidence for each technique and
provided Clinical Reasoning Gems, the aim of
which is to illustrate pertinent information regard-
ing clinical reasoning relating to techniques pre-
sented in each chapter.
The book is divided into 14 regional chapters,
covering the whole body, and encompassing the
whole range of musculoskeletal disorders that
present to clinical practice, including apparent
non-joint disorders such as lateral epicondylalgia.
The first chapters focus on MWM, exercise and
taping techniques for the upper quadrant that
include the cervical spine through to the thorax.
These chapters include cervicogenic headache and
cervicogenic dizziness, the temporomandibular
joint, shoulder complex, elbow, forearm, wrist and
hand. The subsequent chapters cover the lower
quadrant, including the lumbar spine, sacroiliac
joint, hip, knee, ankle and foot. The final chapter with an explanation of the rationale underlying
covers commonly used PRPs, which are distinct the system of annotations.
to MWM, but can be very helpful in the right
clinical presentation, usually after the condition Professor Wayne Hing
being treated have proven resistant to other Mul- Auckland, New Zealand, 2014
ligan Concept techniques. Adjunct Associate Professor Toby Hall
The techniques in this text are drawn from Perth, Australia, 2014
those presented on the Mulligan concept courses Professor Bill Vicenzino
taught worldwide and as such form the curricu- Brisbane, Australia, 2014
lum of the different levels of those Mulligan Professor Darren A. Rivett

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Concept courses. Also presented is a dictionary of Newcastle, Australia, 2014
annotations for the techniques described, along

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(IV\[[OLH\[OVYZ
Wayne Hing, PhD Brian Mulligan, FNZSP (Hon.) Dip MT
Professor, Bond University, QLD, Australia Lecturer, Author, President MCTA

Toby Hall, PhD, MSc, Post Grad Dip Manip Bill Vicenzino, PhD, MSc, Grad Dip Sports
Ther Phty, BPhty

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Adjunct Associate Professor, School of Chair in Sports Physiotherapy, University of
Physiotherapy and Curtin Health Innovation Queensland: School of Health and Rehabilitation

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Research, Curtin University, Perth, WA, Sciences: Physiotherapy, QLD, Australia
Australia

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Snr Teaching Fellow, The University of Western

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Australia, Perth, WA, Australia
Fellow of the Australian College of
Physiotherapists

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Darren A Rivett, BAppSc(Phty),

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GradDipManipTher, MAppSc(ManipPhty), PhD,
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MAICD, APAM, MMCTA(Hon)
Professor of Physiotherapy and Head of the
School of Health Sciences, The University of
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Newcastle, Australia; Board Director, Australian

Physiotherapy Association
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502:725

Headache is both a symptom and a disorder in its own right, hence classification of headache is impor-
tant to ensure that correct treatment is administered (Dodick, 2010). The International Headache Society
(IHS) has broadly classified headache as primary, where there is no other causative factor, or secondary
where the headache occurs in close temporal relationship to another disorder to which it is attributed
(Classification Committee of the International Headache Society, 2004). Cervicogenic headache (CGH)
is one form of secondary headache, which arises from disorder of the cervical spine.
Current medical teaching indicates that each form of headache has a different pathological basis, the

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majority of which do not have a musculoskeletal cause (Dodick, 2010). Hence, it is critical that the
individual presenting for treatment has their type of headache correctly identified. This is particularly

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important for manual therapist’s considering physical intervention for headache, where such interven-
tion is unlikely to be effective for disorders other than those affecting the musculoskeletal system (Hall,

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2011).
Mechanisms underlying CGH are those of convergence of afferent input from the upper three cervical

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segments with input from trigeminal afferents in the trigeminocervical nucleus (Bogduk & Govind,
2009). Hence input from sensory afferents in the cervical spine may be mistakenly perceived as pain in

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the head (Bogduk & Govind, 2009). Classification of headache disorders based on patient reported
symptoms and history is problematic due to the overlap of features between CGH and migraine and

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other headache forms. Headache classification is therefore based on physical examination. The cervical
flexion-rotation test (FRT) has been found to be a useful test to discriminate CGH from migraine or
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mixed headache forms (Hall, Briffa, Hopper & Robinson, 2010a). The positive cut-off point is 32–33°
(Hall, Briffa, Hopper & Robinson, 2010b; Hall, Briffa & Hopper, 2010; Ogince, Hall, Robinson &
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Blackmore, 2007). An MRI study revealed that a positive test primarily indicates limitation of movement
at the C1/2 level (Takasaki et al., 2010). The degree of limitation on this test has been shown to correlate
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with the severity, frequency, and duration of headache symptoms (Hall et al., 2010b), as well as being
independent of other physiological and lifestyle factors (Smith, Hall & Robinson, 2007). Consequently
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the test has utility regardless of the age, gender or lifestyle of the person tested. Further study is required
to identify the FRT’s sensitivity to change as an outcome measure.
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In the presence of a positive FRT, a C1/2 self-SNAG can be applied as a treatment technique to attempt
to restore normal range of motion and reduce symptoms. However, if a patient presents to the clinic
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experiencing a CGH at the time of consultation and has a positive FRT, then a trial of Headache SNAG,
Reverse Headache SNAG, or upper cervical traction should be administered first. On subsequent visits,
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if symptoms are reduced but the FRT remains positive, then a C1/2 self-SNAG should be considered at
that point.
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The application of a self-SNAG to people with chronic CGH and a positive FRT was shown to be
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superior to a placebo treatment in a randomised clinical trial (Hall et al., 2007). Hall et al. (2007) showed
that when compared to the placebo the self-SNAG improved range recorded during the FRT by 10°
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(95% CI: 4.7 to 15.3°) immediately after application and that at 12 months the treated group were 22
(13 to 31) points superior on the headache severity index (baseline headache severity index approxi-
mately 54/100).


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Level 1b: 1 RCT, and 1 case report