MULLI

GANCONCEPT
HI
STORY
Mul
li
gan’
suniqueMov ementwit
hMobil
i
zati
on(MWM)concepthassi
gni
fi
cant
lyi
mpact
edon
manualt
her
apypract
iceworldwi
deov
erthelastt
wodecades.

Thisconceptwasdev el
opedbyBr ainMull
i
gan, aPhysicalTherapistf
rom NewZealand.He
beganhiscar eerasaphysiotherapistaf
tergraduat
ingf r
om theOt agoSchoolofphysi
otherapy
i
nDunedi nin1954.Inthelate1950sheat tendedsemi narsbyDr.JamesCy ri
axwhichincluded
spi
nal manipulati
onandpassi v
ej ointmobili
zat
iontechnique.Afterwhichhequi
cklydevel
oped
hi
si nt
erestformanualtherapy.

Thenhegai nedt heknowledgeofKal t

ernborn’smobi li
zati
ontechni
quesf rom Mckenzieand
StanleyvPariswhohav eor i
ginal
lyl
earnedt het echni
quef r
om kal
ternbornitsel
f.Fol
lowing
whichheexpandedhi sknowledgebyat tendingKal t
ernborn’
speri
pheraljointmobili
zat
ion
courseandaf terwhichhestartedpracti
cingt hesetechniquesi
ntensivel
yandal sobeganto
teachthepr i
vatepracti
ti
onersandst udents.

In1985Mul li
ganhadhi sfirstMWM success, whichulti
mat elychangedhi swhol eappr oacht o
manual ther
apy .Aft
erappl yingaser iesofcont empor ar
yt reatmentst echniquesofpassi vejoi
nt
nd
mobi l
izationandul t
rasoundt oapai nful2 pr oximalint
er phalangealjointwi thli
ttl
e
i
mpr ov ement,outoff rustrationmul l
igant r
iedansust ai
npai n-fr
eelater alglidewithact i
ve
fl
exion.Thet echniquewasi mmedi atelysuccessfulandr estoredaf ullrangeofpai n- f
ree
mov ementwi t
hcompl eteret urnt
of unctionandr esolut
ioni nswelli
ngf ollowi ngthi
ssi ngle
appli
cat i
onoft reatment.Theconceptofappl yi
ngasust ainedgl i
det oaj ointandmai ntai
ning
thisdur i
ngactivemov ementwasbor nandappl i
edinothercl i
nicalsituati
on.Al lMWM t hathave
sincebeendev elopedar osef rom asi ngl
eobser vati
onofar ecalci
tr
antcl inicalproblem.
Def
ini
ti
onofMWM
AnMWM isdefi
nedastheappl
icat
ionofsust
ainedpassi
veaccessoryf
orce/
gli
det
oajoi
nt
whi
l
ethepati
entact
ivel
yper
for
msat askthatwasprevi
ousl
yidenti
fi
edasbeingpr
obl
emati
c.

Thetaski
smostfr
equent
lyamovementper
for
medt otheonsetofpai
nortotheendof
avai
l
ableROM.Thi
staski
sref
err
edtoasCli
entSpeci
fi
cImpairmentMeasure(CSI
M).

Andthef
orce/gl
idecanbeappl
i
edmanuall
ybythether
api
st’
s/pat
ient
’shandsorv
iaa
tr
eat
mentbeltorevenwi
thspor
tst
apeappl
iedonskin.

I
NDI
CATONS

Neuro/Musculoskel
etalpain
Postoperati
vehypomobi l
it
y
Traumati
cjointsti
ff
ness
Tomai nt
ainmobi l
it
y
Todelayhypomobi l
it
y(e.g.Anky
losi
ngSpondy
losi
s)

CONTRA- INDI CATI ONS

Osteopeni a
Hyper mobi l
ity
Pregnancy
Anti-coagul anttheapy
RED FLAGS:
Osteopor osis
Activei nfl
ammat i
on
I
nfect i
on
Tumour
Met abol i
cbonedi sease
My elopat hies
Neur ological deficit
s
Unst ablej oint/
fracturel
ine
Non- unitedf racture
Cl
ini
calr
easoni
ngandwor
kingmechani
sm
Pai
nmechani
sm canbedi
vi
dedi
ntocont
ri
but
ionsf
rom

1.Per
ipher
alMechani
sm(
Input
)

2.Cent
ralMechani
sm(
Processi
ng)

3.ResponseMechani
sm(
Out
put
)

ThePosi
ti
onalFaul
tTheor
y
I
tisthemi cr
omal-al
ignmentoft
het
woj
ointsur
faceswhi
chcannotbeseenon
r
adiologi
cali
nvest
igati
on.

1. Peri
pheralMechanism:Heref
actorst
hatmightcont
ribut
etoincreasednoci
cept
ive
si
gnal
ingtot
hecentr
alner
voussyst
em aret
akenintoconsi
derat
ion.

Mechanor ecept orsar epresentt hroughoutt hesomat osensor ysy stem, withi
naffer ent
nociceptive, tacti
leandpr opr ioceptiveneur ons.MWMsar eappl iedonl ywher easy mpt om of
painorst i
f f
nesscoi ncideswi thmov ementsuggest ingt hatmechanocept i
veinputi sl i
nked
tothepr esent i
ngsy mpt oms.I tfoll
owst hatal teri
ngt hismechanocept i
veinputwi l
l then
l
ikelyalterthesy mpt oms, atleastf orthedur ationthatt hei nputi sal ter
ed.Theappl icationof
aMul li
gant echniquemayal t erthef orceand/ordi r
ect ionoff orceexer tedt o
mechanor ecept ori nt heappl i
edr egionwhi chwi l
lsubsequent l
yal terthesui t
eof
mechanor ecept iveinputt ot heCNS.Mechanor eceptiv ei nputmaybenoci cepti
ve( pai n
facil
it
ating)ort actil
e/ propri
ocept ive(gener allypaini nhibi t
ing).Thus, anMWM mi ghtr educe
sympt om ei therbyr educingnoci ceptivesignal ingori ncr easingnon- nocicepti
vesignal i
ng.
Furthernot e, providedt hatsuf f
ici
entf orceisappl i
edt oal t
ermechanor ecept i
veinputa
changei nsy mpt omswi l
lli
kel yresultregardlessofwhet heraposi tionalfaultispresentor
corrected.Thus, theposi t
ional faulthypothesi si snotr equi redt oexpl aintheimmedi ate
effectofMWM.
2.Cent
ralmechani
sm:

A.Exti
ngui
shi
ngmov ement
-pai
nassociat
ion:
repeat
ingt
hemovementi
nrel
ati
velypai
n-
fr
eemanneraff
ordedbyappl
icat
ionoft
heMWM mayassistt
obreaktheassoci
ati
on
betweenmovementandpai
n.

I
thasbeensuggest
edthatMWM mi
ghtber
epeat
edi
nor
dert
ofaci
l
itat
epai
n-f
ree
movementmemor i
es.

MWM t ar
get
sthepat
ientspeci
fi
cphy
sical
taskassociat
edwithpai
n,andt
hati
tdoesi
n
apai
nlessmannerl
endsittobei
ngvi
ewedasal ear
ningstr
ategy

B.Placeboandr eassur ance:al thoughpl aceboi sunlikelyt

opl ayast rongr oleint heeff
ect
ofTREATMENTdur i
ngappl icationast hiscoul dnoteasi l
yexpl ai
nthedi rect
ion
specifi
cityoft heimpr ovementi npainandMOVEMENT- I
Tpr obablydoespl ayr ole
foll
owingi t
sappl icati
on.placeboi sanef fectthatappear stobedi r
ect l
ydependenton
thepositiveexpect ati
onoft reatmentbenef it.thispositi
veexpect ationcanbeder i
ved
from anumberofdomai nssuchasv er bal i
nformat ionnonv erbalcuesandv icari
ousor
experiment allear
ning.ifreassur ancei st hepot entaspectoft heplaceboef fectthen
therapi
stshoul dalsoconsi derhowt heycanbol sterthereassur i
ngef fectofMWM wi t
h
otherstrategiesforexampl er eassuringpat ient sthatongoingpai nt ypicall
yreflect
nervoussy stem sensi ti
vit
yr atherthant issuedamageandmov ementi ssaf eand
recoveryispossi ble

3.Out
put
(response)Mechani
sm

Changesinthepat
ter nofmuscl eacti
vat
ionareacommonr esponset
opainandinj
uryandare
thoughttoser
veapr otecti
vefuncti
onintheneart
erm.Faci
l
itati
onofant
agoni
standinhi
bit
ion
ofagonistar
egenerallyfound.

InacasewhereMWM applicat
ioni
mmediatelyr
educespai
nitcanbededucedt
hata
part
icul
arpat
ter
nisf
aci
l
itat
ingpain-
fr
eeagonistmovementandreduci
ngpai
n.
Joi
ntNut
ri
ti
on

Joi
ntcar
ti
lageget
snut
ri
ti
ont
hroughsy
nov
ial
flui
d,bymov
ementofsy
nov
ial
fol
ds.

Thesy
nov
ial
fol
dsmov
ewhent
hej
ointmov
es.

Tomov
ethej
ointmeanst
oper
for
m somer
angeofmot
ions.

Andtohaverangeofmot
iont
her
eshoul
dbej
ointpl
ay,
whi
chi
spr
ovi
dedori
mpr
ovedby
ManualTher
apy
Pr
inci
ples:
1.Al
way str
eatt
hepati
enti
nwei
ghtbear
ingposi
ti
onori
npai
nful
posi
ti
on,
per
for
ming
of
fendingmovementi
napai
n-f
reeway.

usuall
ypatientscompl ainsofpainwhi l
et hejointsarebeingloaded.e. g.inosteopor osisof
kneepat i
entcompl ainsofpainwhi lest anding, walki
ng, ascendi ngordescendi ngst airsand
notwhent heyar einlyingpositi
onsowhydoweneedt ot r
eatt hem inl y
ingrsupi ne
posit
ion?Insteadi fwet r
eatthem inwei ghtbear ingpositi
oni twoul dbemor ef uncti
onal
tr
eatmentandy oucanmakeouti nstant lywhet heryourgl i
dei swor kingornot .Andsi nce
youcandemonst ratethepat i
entthatt hemov ementwhi chwasear lierpainfulhasnow
becomepai n-freeaf termobili
zation,thepat i
entdev elopsconf idencei nyourt r
eat ment
i
mmedi at
ely.I
nwei ghtbear i
ngresul t
sar elongl asti
ngcompar edt ononwei ghtbear ing.In
casethejointisi nfl
amedort heSI N(sev er i
ty,i
rri
tabil
i
tyandnat ureofpai n)isv eryhighi t
wontbepr acticallypossibletotreatthepat ientinwei ghtbearing.Thenper formt hegl idei
n
PWBt henpr oceedt oFWB.I fit
sst i
llpainf ulthengof orNWBt henPWBandt henFWB

2. Mov
ementmustbepai
n-f
reei
fnott
henchanget
hepr
essur
e/hol
d/angl
e/l
evel
/si
de(
spi
ne)
.

Whenindi
catedthegl
idesarepai
nfr
ee.I
ftheydon’
twor
ktheyweren’
tindi
cat
ed.Therei
s
di
ff
erentt
reatmentpl
aneforever
yonesomakesureyoumodif
ythepositi
onaccordi
ngl
y.

3.Checktheresul
tantv
ector
/angl
eofpull
/par
all
elposi
ti
onoft
reat
mentbel
ttot
he
fl
oor/
angleandposit
ionofyourf
orear
m.

4.Don’
tfor
gett
osust
ainy
ourgl
i
de,
unt
ily
our
etur
ntot
hest
art
ingposi
ti
on.

Thev er
ydiff
erencebetweenmulli
ganandot herconcept sisthatt
hegl i
deissustai
ned
(i
nsteadofrepeatedosci
ll
ati
ons)whil
ethepat i
entperformst heoffendi
ng/rest
rict
ed
mov ement.I
ftheappropri
ategl
ideissust
ainedtherewi llbenopain.Ifther
ewillbenopai
n
thenpati
entwillbeabl
etomov etoanewr angeofmot ion.Thiswayy ou’l
lgetf
asterr
esul
ts.
Oncey oufi
ndt hecor
rectgl
idesustai
nitf
or6t o10r epitit
ions.

5.Don’
tdot
hemov
ementpassi
vel
yasi
tismost
lyact
ive.

6.Al
way
swor
kint
heav
ail
abl
eendr
ange.

I
tisunder
stoodthatify
ouarenoti
ntheendr
ange,
youwi
l
lnotgai
nnewr
angeof
moti
on,andit
’l
lbejustwast
eofti
me
7.Don’
tfor
gett
hepassi
veov
erpr
essur
eatt
heendofr
ange.I
twor
ksl
i
kecr
eam onmi
l
k.

It
seasytohur tothersbutnoty ouself
.Si mil
i
arl
ywheny ouar etreatingwi thpassiv
e
mov ement,chancesar ehighthaty oumayent erintopainfulzone[ P2]andsetupnew
i
nflammation, becauseofmi crotraumai nandaroundt hej oint.Butift hepati
ent
perfor
msithimsel f,chancesar elessofgoi ngbey ondP2nomat t
erhowst rong
commandy ougi ve.Thenaf terknowi ngtheendrangepassi veov erpressurecanbe
addedthattoi fpossibleshouldbeper formedbypat i
enthimsel f
.Ifnott henbyPTor
att
endantbuti nnosi tuationoverpressureshouldbepai nf
ul .Passi veov er
pressure
shouldbeaddedonl ywheny ouf i
nfanewP1orR1.I ftheP1i ssamet heny ouarenot
supposedtogi vepassi veov er
pressur e.Thi
smeansy ourglinei sineffecti
veandy ou
needtodosomemodi ficati
ons.

8. Beparal
l
eltot
het
reatmentpl
aneandper
pendicul
art
ot hemovementpl Maj
ane. ori
tyoft
he
ti
methegli
dei
sparal
l
eltothetr
eat
mentplaneandperpendi
cul
art
othemovementpl
ane.

9.Sy
nchr
oni
zepr
oper
lybet
weeny
ourhand/
for
ear
m/pel
vi
s/bodyandt
het
reat
mentpl
ane.

10.Yourposi
ti
on/handgr
ip/bel
tmustnotbl
ockt
hepat
ient
’smov
ement
.

11.Takecar
eoft
heamountofpr
essur
eappl
i
edont
hej
oint
s.

Ifj
oint
sandmuscl
esarerel
axed,
andi
fpat
ienti
srel
axedonl
yal
i
ttl
eamountoff
orcei
s
enoughtogl
i
dethejoi
nt

12.Af
teragoodst
abi
l
izat
iononl
y,y
ouhav
eagoodmobi
l
izat
ion.

13.Gr
ipmustbefir
m butpai
nless.Thereshoul
dbeanevendi
str
ibut
ionofy
ourhand/
bel
t
pr
essur
e.Checktheamountofpr essur
eandthear
eaofcont
act.

14.Hand/
beltpl
acementmustbealway
scl
oset
othet
reat
mentpl
ane/j
ointl
i
ne.Ensur
epr
oper
t
ransl
ati
onandavoi
drotat
ion.

15.Thereshouldbepropercommunicati
onbet
weenyouandy
ourpati
entduri
ngthe
mobili
zati
on.Alwaysexpl
ainwhatyouar
egoingt
odoandwhatthepati
enthastodo.
Check‘Thepain’or‘
Apain’
.

16.Checkforpainrel
i
eforincr
easedROM andcompar
ewi
tht
heear
li
erassessment
.Donot
overt
reatthepati
ent
(fol
lowtherul
eofthr
ee)

17.Youmustt
eachsel
ftr
eat
mentwhenev
erpossi
ble.

Wheny ouaret
reat
ingthepat
ienti
nthecli
nic,
youareapply
ingthegl
i
deonlyfor5to10
minut
esbutwhatabouttheother23hoursand50mi nut
esoftheday?I
fatallt
hepati
ent
doesnothi
ngthewholedaYthenchancesarehight
hathe’l
lcometothecl
ini
cthenextday
wit
hthesameROM