Bill Vicenzino Wayne Hing Darren Rivett Toby HallEdinburgh   London   New York   Philadelphia   St Louis   Toronto
Churchill Livingstone                      is an imprint of Elsevier                      Elsevier Australia. ACN 001 002 ...
CONTENTSForeword by Brian Mulligan                     vii     Chapter 10 Temporomandibular joint dysfunction:Foreword by ...
FOREWORD BY BRIAN MULLIGANThe need for an appropriate textbook on my concepts             O stands for overpressure. Basic...
FOREWORD BYPROFESSOR GWENDOLEN JULLThe term Mobilisation with Movement, or MWM, is              constructed and presented ...
Foreword  As mentioned, the MWM approach has generated               approach will grow and thrive for the bene¿t of futur...
PREFACEWe aimed to make this book a comprehensive and                The book is essentially in ¿ve parts. The ¿rst partun...
AUTHORSBill Vicenzino PhD, MSc, BPhty, Grad Dip Sports Phty    Darren Rivett PhD, MAppSc (ManipPhty),Professor of Sports P...
ReviewersPam Teys MPhty (Sports Phty), BPhty, Grad Cert           CH YangHigher Ed                                        ...
ACKNOWLEDGMENTS  To my wife Dorothy and children Michelle, Louise        Christine and Douglas, wife Liz, son Sam and daug...
Mobilisation withMovement: itsapplication
Chapter 1IntroductionDarren Rivett, Bill Vicenzino, Wayne Hing and Toby HallIn the history of manual therapy revolutionary...
1 • Introduction                                                            similarly developing their interests in manual...
MOBILISATION WITH MOVEMENT: THE ART AND THE SCIENCEjoint in both Àexion and extension. Further repeti-           Mulligan ...
1 • IntroductionMulligan Practitioner (CMP) competency examina-                may follow the convex–concave rule of joint...
MOBILISATION WITH MOVEMENT: THE ART AND THE SCIENCEapplied, although rather than provoking or localising         systemati...
1 • Introduction     practitioners informing patients of expected             relation to MWM recognises the unique clinic...
MOBILISATION WITH MOVEMENT: THE ART AND THE SCIENCEinterpretations and trivial technical issues. The history    do so with...
Mobilisation with Movement: The Art and the Science by Vicenzino, Hing, Rivett and Hall
Mobilisation with Movement: The Art and the Science by Vicenzino, Hing, Rivett and Hall
Mobilisation with Movement: The Art and the Science by Vicenzino, Hing, Rivett and Hall
Mobilisation with Movement: The Art and the Science by Vicenzino, Hing, Rivett and Hall
Mobilisation with Movement: The Art and the Science by Vicenzino, Hing, Rivett and Hall
Mobilisation with Movement: The Art and the Science by Vicenzino, Hing, Rivett and Hall
Mobilisation with Movement: The Art and the Science by Vicenzino, Hing, Rivett and Hall
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Mobilisation with Movement: The Art and the Science by Vicenzino, Hing, Rivett and Hall


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The Mulligan technique is an extremely popular technique for manual therapists who are keen to learn more of the techniques and the evidence base behind them. This book presents a one stop source of Brian Mulligan’s Mobilisation With Movement (MWM) management approach for musculoskeletal pain, injury and disability that integrates evidence base into clinical practice. The material is presented in a way that is accessible both to the student practitioner and advanced practitioner of musculoskeletal healthcare.

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Transcript of "Mobilisation with Movement: The Art and the Science by Vicenzino, Hing, Rivett and Hall"

  1. 1. Bill Vicenzino Wayne Hing Darren Rivett Toby HallEdinburgh London New York Philadelphia St Louis Toronto
  2. 2. Churchill Livingstone 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© 2011 Elsevier AustraliaThis publication is copyright. Except as expressly provided in the Copyright Act 1968and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publicationmay be reproduced, stored in any retrieval system or transmitted by any means (includingelectronic, mechanical, microcopying, photocopying, recording or otherwise) without priorwritten permission from the publisher.Every attempt has been made to trace and acknowledge copyright, but in some cases thismay not have been possible. The publisher apologises for any accidental infringementand would welcome any information to redress the situation.This publication has been carefully reviewed and checked to ensure that the content is asaccurate and current as possible at time of publication. We would recommend, however, thatthe reader verify any procedures, treatments, drug dosages or legal content described in thisbook. Neither the author, the contributors, nor the publisher assume any liability for injuryand/or damage to persons or property arising from any error in or omission from this publication.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, etcOther Authors/Contributors: Vicenzino, Bill.Dewey Number: 615.82______________________________________________________________________________Publisher: Melinda McEvoyDevelopmental Editors: Sam McCulloch and Rebecca CornellPublishing Services Manager: Helena KlijnProject Coordinator: Geraldine MintoEdited and indexed by Forsyth Publishing ServicesProofread by Gabrielle ChallisCover and internal design by Lisa PetroffPhotography by Porfyri PhotographyIllustrated by Lorenzo Lucia of Galaxy StudiosTypeset by TNQ Books and Journals Pvt. Ltd.Printed by China Translation & Printing Services Ltd
  3. 3. CONTENTSForeword by Brian Mulligan vii Chapter 10 Temporomandibular joint dysfunction:Foreword by Professor G Jull ix an open and shut case 123Preface xi Chapter 11 Golfer’s back: resolution ofAuthors xiii chronic thoracic spine pain 134Contributors xiii Chapter 12 Mobilisation with Movement in theReviewers xiv management of swimmer’s shoulder 143Acknowledgments xv Chapter 13 A recalcitrant case of aircraftSECTION ONE MOBILISATION WITH MOVEMENT: engineer’s elbow 152 ITS APPLICATION 1 Chapter 14 A chronic case of thumb pain and Chapter 1 Introduction 2 disability with MRI identi¿ed 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 169SECTION TWO EFFICACY 25 Chapter 16 Restoration of trunk extension Chapter 3 A systematic review of the 23 years after iatrogenic injury 179 ef¿cacy of MWM 26 Chapter 17 Hockey hip, a case of chronic dysfunction 192SECTION THREE MECHANISMS AND Chapter 18 Thigh pain: a diagnostic EFFECTS 65 dilemma 199 Chapter 4 Mulligan’s positional fault Chapter 19 Two single case studies of lateral hypothesis: de¿nitions, 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 de¿cits and likely impact of Mobilisation with Movement 93SECTION FOUR CASE STUDIES 101 Preface to case studies 102 Chapter 8 A headache that’s more than just a pain in the neck 103 Chapter 9 A diagnostic dilemma of dizziness 114
  4. 4. FOREWORD BY BRIAN MULLIGANThe need for an appropriate textbook on my concepts O stands for overpressure. Basically, the mobilisationhas 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, enablesand 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. Whilereasoning and reÀection is within these pages making painless, maximum movement must be gained and thisthis volume an excellent reference for the researcher, can only be attained by applying overpressure. Withteacher and clinician, and it will become a worthy stan- longstanding restrictions the movement gained on daydard 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 scienti¿c back- C stands for communication and cooperation. Youing, has been the fact that MWMs are only to be used as must explain in detail to the patient what you are abouta treatment when, on assessment, they have a ‘PILL’ to do. They must know to tell you immediately if thereeffect. The acronym stands for pain-free, instant result is any discomfort. Without their feedback you will notand long lasting. succeed. Pain-free refers to both the mobilisation and move- K stands for knowledge. Manual therapists mustment 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 criticalis an immediate pain-free improvement in function. that they know all joint con¿gurations 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 repositioningment 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 withson for this, after three visits you can say that MWMs sensitive painful structures are important. You need aare 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 spongement 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 structuresappropriate 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 senseing 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 anyapy 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 feelhas 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 theinjuries, on day one, it is wise because of irritability individual contributors for the immense time and effortto apply the techniques three to six times. With the that has gone into its creation. I cannot thank themspine we have ‘the rule of three’. On day one only use enough.MWMs three times. This is because some patients fol- Brian Mulligan 2010lowing any form of manual therapy get a latent reac-tion to their treatment. This is minimised by the ruleof three. Even when they get this reaction it is of shortduration and when it settles they are still much betterand further treatment can be given. vii
  5. 5. FOREWORD BYPROFESSOR GWENDOLEN JULLThe term Mobilisation with Movement, or MWM, is constructed and presented novel paradigms whichin common usage in the vocabulary of manual ther- stand to advance the understanding and applications ofapy practitioners worldwide. MWM is a method of MWM. To advance the ¿eld, they have developed amanual 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 theyskeletal disorders. The term is also synonymous with have named the Client Speci¿c Impairment MeasureNew Zealand physiotherapist Brian Mulligan, a gifted (CSIM) which acts as a key and central feature of theand innovative clinician and manual therapist who has approach to patient assessment and management. Thisdeveloped the approach over several decades, with the model is well conceived, comprehensive and standsassistance of his patients. Brian Mulligan has made a to guide the clinician’s clinical reasoning in patientmajor contribution to the ¿eld of manual therapy. He assessment and management. Importantly, use of suchhas generously shared his knowledge, clinical exper- a model can guide design of future research rangingtise 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 uncriticallyhe has trained others to teach the approach. Brian Mul- a management approach and ‘spread the doctrine’. Whatligan 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 andcians and patients alike. their determination to advance the ¿eld. The available The therapeutic approach to MWM has undoubt- evidence of bene¿t of MWM has been presented inedly gained the attention of clinicians because of its an unbiased way using the rigorous methodology of aeffectiveness in the management of patients with mus- systematic review. While some preliminary evidenceculoskeletal pain and movement disorders. There has of bene¿t is emerging, the need for further high qual-been some research investigating its ef¿cacy and the ity trials is noted. In relation to mechanisms of actionhypotheses for its mechanisms of effect. However, to to explain the effects of MWM, the historical positionaldate the MWM approach has had its seminal basis in fault hypothesis of MWM is critically reviewed. Whileclinical observation of responsiveness to the clinically appreciating the available evidence, the authors forgereasoned application of passive movement/position- ahead and present a new model for consideration of theing in combination with active movement. While the mechanisms of action of MWM to advance the ¿eld bothprimacy 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 biomechanicalcies alike for delivery of practice which is also research one, to one which also incorporates the neurosciencesinformed 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 dif¿cult in a theoretical construct, such asingly 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 text’s 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. Thecal researchers and teachers, well versed in the MWM authors have successfully addressed this challenge byapproach. They have all been involved in research into providing several well crafted chapters of patient casesthe ef¿cacy and effectiveness of MWM and thus have presented by leading clinicians in the ¿eld, as well asa strong and authoritative clinical and research base to the authors themselves. What is of enormous valueexplore both the art and science of Brian Mulligan’s in these chapters for clinicians is the inclusion of theapproach. 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 widetested and advanced. The authors are to be congratu- application of the principles and practice of the MWMlated on the scholarship evident in this text. They have approach in the musculoskeletal ¿eld. ix
  6. 6. Foreword As mentioned, the MWM approach has generated approach will grow and thrive for the bene¿t of futureconsiderable interest and enthusiasm in the ¿eld of patients and manual therapists. The authors are to bemanual therapy. From a clinical standpoint, it has, over congratulated on the eloquent way they have broughtthe past two or more decades, provided an advance to the art and science of MWM together in this text withthe art of manual therapy and assisted many patients due scienti¿c and clinical rigour. It will be appreciatedwith painful musculoskeletal disorders. However, as is by clinicians and researchers alike.commonly encountered, the clinical art of MWM is to Gwendolen Jull MPhty, PhD, FACPdate well in advance of its science and evidence base, Professor of Physiotherapywhich is essentially at the beginning of its journey. This The University of Queenslandtext provides a vital basis on which the science can be Australiadeveloped further to ensure that the Mulligan MWMx
  7. 7. PREFACEWe aimed to make this book a comprehensive and The book is essentially in ¿ve parts. The ¿rst partunique exposition of the state of the scienti¿c evidence introduces the concept of MWM and its principles offor a relatively new form of manual therapy, Mobilisa- application. Part two provides a systematic review oftion with Movement (MWM). When Brian Mulligan the evidence for its ef¿cacy. 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 anreports. In the intervening period the empirical evi- evaluation of Mulligan’s positional fault hypothesis.dence has steadily grown to now include randomised Part four is comprised of twelve case reports in whichcontrolled trials and systematic reviews. Moreover, the the authors and other expert case contributors describebiological understanding of MWM has evolved from the application (with underpinning clinical reasoning)Mulligan’s self-admitted simplistic ‘positional fault of MWM for a wide range of musculoskeletal disor-hypothesis’ to the testing of scienti¿c hypotheses in ders of varying complexity. The reader will get mostsophisticated 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 incorporatepresent the evidence for all forms of MWM (including discussion and commentary integrating the scienti¿csustained natural apophyseal glides of the spine) from evidence with the clinical guidelines in the context ofthe past quarter of a century in one volume. the patient’s unique presentation. The book concludes In addition to the science underpinning MWM, this with the ¿fth part; a troubleshooting section that aimstext also describes ‘the art’ inherent in its success- to guide practitioners in optimising their application offul implementation. Basic principles are outlined and MWM.more advanced aspects of its clinical application are This book has been written for the clinician, teacherdeveloped and critiqued, including guidelines on dos- and post-graduate student interested in furthering theirage and troubleshooting. Most importantly, the practi- understanding and skill in MWM, and indeed manualcal art of MWM is illustrated in a series of case studies therapy more broadly. It builds on but does not replacein which real life clinical presentations elucidate the Mulligan’s texts as it is not intended to be a catalogueclinical 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 bene¿t them invide detailed descriptions of selected techniques and their studies of manual therapy and evidence-basedhome exercises. These cases help bridge the divide that management of musculoskeletal disorders.typically separates the science and the art of various Professor Bill Vicenzinoapproaches in manual therapy. Brisbane, Australia, 2010 Although the primary focus of the book is MWM, Associate Professor Wayne Hingmuch of its content is applicable to manual therapy Auckland, New Zealand, 2010in general. In particular, the chapters describing the Professor Darren Rivettcurrent understanding of potential mechanisms of Newcastle, Australia, 2010action provide a summary of the contemporary theo- Dr Toby Hallries explaining the clinical bene¿ts of manual therapy. Perth, Australia, 2010Similarly, the case reports stand alone as a resource tofoster the development of skills in clinical reasoningas they relate to the management of musculoskeletaldisorders. xi
  8. 8. AUTHORSBill Vicenzino PhD, MSc, BPhty, Grad Dip Sports Phty Darren Rivett PhD, MAppSc (ManipPhty),Professor of Sports Physiotherapy, BAppSc(Phty), Grad Dip Manip TherHead 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 NewcastleWayne Hing PhD, MSc(Hons), ADP(OMT), DipMT,DipPhys, FNZCP Toby Hall PhD, MSc, Post Grad Dip Manip, FACPAssociate 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 ConceptsCONTRIBUTORSLeanne Bisset PhD, MPhty (Sports Phty), MPhty Tracey O’Brien MPhty (Sports Phty), BPhty(Musculoskeletal Phty), BPhty Former executive member SMA Qld Board ofAPA Titled Sports Physiotherapist Directors (2000–2007), Associate lecturer inAPA Titled Musculoskeletal Physiotherapist Physiotherapy at the University of QueenslandSenior Lecturer, Grif¿th University Mark Oliver MScStephen Edmonston PhD, A/Prof. Private PractitionerDirector, Postgraduate Coursework Programs, Schoolof Physiotherapy, Curtin University of Technology Sue Reid MMedSc (Phty), Grad Dip Manip Phty, BAppSc (Phty), BPharmPaul Hodges PhD, MedDr (Neurosci), BPhty (Hons) Faculty of Health Science, The University ofProfessor and NHMRC Principal Research Fellow Newcastle, CallaghanDirector, NHMRC Centre of Clinical ResearchExcellence in Spinal Pain, Injury and Health Kim Robinson BSc, FACPUniversity of Queensland Specialist Musculoskeletal Physiotherapist Adjunct Senior Teaching Fellow, Curtin UniversityC Hsieh MS, PT, DC, CA Senior Teaching Fellow, The University of WesternPrivate practice, Owner of John Hsieh Australia Director Manual ConceptsM HuAssociate Professor, School and Graduate Institute of Michele Sterling PhD, MPhty, BPhty, Grad DipPhysical 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 ProgramSpinal Physiotherapy Specialist/Physiotherapy (CONROD)Researcher, Primary Care Musculoskeletal Research Senior Lecturer, Division of Physiotherapy, SchoolCentre, Primary Care Sciences, Keele University of Health and Rehabilitation Sciences, University of QueenslandBrian Mulligan FNZSP (Hon), Diploma M.TRegistered Physical TherapistDeveloper of the concept of Mobilisation withMovement xiii
  9. 9. ReviewersPam Teys MPhty (Sports Phty), BPhty, Grad Cert CH YangHigher Ed Department of Physical Therapy,School of Physiotherapy, Bond University Tzu-Chi University, Hualien, Taiwan, Republic of ChinaC YangPresident, Calvin Yang MD Medical ImagingREVIEWERSDr Nikki Petty Ken NierePrincipal Lecturer, Programme Leader Professional Senior Lecturer, School of Physiotherapy, LaTrobeDoctorate in Health and Social Care University, Melbourne, AustraliaClinical Research Centre for Health Professions,School of Health ProfessionsUniversity of Brighton, UKDr Alison RushtonSenior Lecturer in Physiotherapy, School of Health andPopulation SciencesCollege of Medical and Dental Sciences, University ofBirmingham, UKxiv
  10. 10. ACKNOWLEDGMENTS To my wife Dorothy and children Michelle, Louise Christine and Douglas, wife Liz, son Sam and daughterand Selina. Amy for putting up with me during the writing process. As testament to my father Romeo’s belief in the ben- The support of all my family truly means more to mee¿ts 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 theparents and family who have always been there and techniques for the DVD and for performing many ofsupported me through my journeys. Special mention them. He continues to be an inspiration for the correctto 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 techniquesMulligan 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 theous 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, Katrinator 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 providedNotable are Bob Elvey, Kim Robinson, Brian Mulligan by Dr Natalie Collins in the conduct of the systematicand Kate Sheehy, but there are many others. Thanks review and quality analyses in Chapter you all. Special thanks go to my family: my parents xv
  11. 11. Mobilisation withMovement: itsapplication
  12. 12. Chapter 1IntroductionDarren Rivett, Bill Vicenzino, Wayne Hing and Toby HallIn the history of manual therapy revolutionary changes years studies testing this hypothesis using cutting-edgein clinical practice have appeared from time to time. imaging and other research tools. It is timely that thisThe 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 integratednal 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 basisskills in clinical observation, palpation and reasoning, and empirical proof. A substantial part of this text willopened 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 explainsional boundaries. Indeed, their names have over the effects of MWM reported by practitioners andtime become synonymous with manual therapy itself. increasingly observed in empirical quantitative trialsAlmost without exception, these outliers of manual of its ef¿cacy. The remaining axis of convention, albeittherapy exhibited self-deprecation and a continual the weakest type of evidence, is clearly supported bydrive 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 professionalual therapy practitioners, with his unique ‘Mobilisa- texts (Petty, for example[2]), and the growing numbertion with Movement’ (MWM) concept signi¿cantly of Mulligan courses run annually across 25 countriesimpacting on manual therapy practice worldwide over (see for current courses), as wellthe 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 isMWM, 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 topotential underpinning mechanisms and evidence base appreciate the history of the individual who initiatedfor Mulligan’s 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 describedwhich can be used for differing clinical scenarios, and BRIAN MULLIGANa steady increase in the quantity and quality of support- The following historical recount is based on an inter-ing research. Indeed, from Mulligan’s early descriptive view with Brian reports and videotaped patient treatments from Brian Mulligan began his career as a physiothera-his clinic in New Zealand, scienti¿c investigation pist after a chance conversation with a work colleagueinto 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 Newbeing 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-ligan’s relatively simple ‘positional fault’ hypothesis pletely changed the course of Mulligan’s life and set inas to the possible mechanistic basis for the clinically place a chain of events that had major implications forobserved effects of his techniques, there are in recent manual therapy.2
  13. 13. 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 signi¿cance 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 alsoFigure 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 manualDunedin. This was the same era that two other well therapy and was keen to learn about peripheral jointknown physiotherapists also graduated in Dunedin, mobilisation. In 1970 Mulligan was New Zealand’sRobin McKenzie and Stanley Paris. Mulligan’s ¿rst representative at the World Confederation for Physicaljob 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 jointhospital system into private practice. His ¿rst private mobilisation course. It was the ¿rst time he had beenpractice work was a two-week private clinic locum exposed to mobilisation techniques for the extremityposition for Robin McKenzie. At that time there were joints. Shortly after his return to New Zealand he wasonly ¿ve private physiotherapy practices in Welling- asked to teach the new skills he had learnt to the localton. Mulligan enjoyed the experience immensely, and private practitioners’ group. He ran his ¿rst weekenddecided that this type of physiotherapy practice would course on Kaltenborn mobilisation techniques in his career path in the future. Accordingly, he started Shortly afterwards, in 1972, he was asked to teach ahis 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, whichety of Physiotherapists (NZSP). He joined the NZSP completely changed his whole approach to manualafter 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 theiron the presidency soon after. He attended as many condition. The patient presented with a grossly swollenmeetings as he could in those early years to increase his ¿nger with painfully limited Àexion and extension fol-clinical knowledge and to develop his skills in practice, lowing a sporting injury. Mulligan used contemporarybeing 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 jointlems at that time. glide mobilisations. Nothing appeared to signi¿cantly In the late 1950s, Jennifer Hickling from London improve the patient’s condition.gave seminars in New Zealand on Dr James Cyriax’s Mulligan again attempted a medial glide techniqueapproach to orthopaedic medicine, which included but the patient reported this as being painful. He thenspinal manipulation (high velocity thrust) and passive applied a lateral glide, which the patient stated did notjoint 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 Àex the injured ¿ngerling’s knowledge and expertise. Mulligan’s interest while he sustained the pain-free lateral glide (Figurein manual therapy was greatly stimulated by these 1.2). The technique was immediately successful andseminars. About this time, Paris and McKenzie were restored the full range of pain-free movement to the 3
  14. 14. MOBILISATION WITH MOVEMENT: THE ART AND THE SCIENCEjoint in both Àexion and extension. Further repeti- Mulligan wrote his ¿rst textbook on his concepttions rendered the patient symptom-free after only one of manual therapy in 1989.[4] Every few years a newtreatment 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 ishad completely reduced following this single applica- in its sixth edition[5] and has sold more than 75 000tion of MWM. For Mulligan, this was a Louis Pasteur copies worldwide. It has also been translated into 10moment: ‘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 infrom this single observation of a recalcitrant clini- 2003 based on self-treatment techniques entitled Selfcal problem. Mulligan thought a great deal about this treatments for the back, neck and limbs, and is currentlypatient, and soon realised the whole concept of posi- in its second edition. Techniques from the Mulligantional faults and MWM. He was keen to apply the Concept are also now described in CDROM and DVDsame idea to all his patients with ¿nger joint problems, products (see for a description ofand 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 focusof 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 bene¿ts of the concept.oped in the spine at the same time. Mulligan realised In 1990 Mulligan lectured at Curtin University ofthat the effects of MWM in the peripheral joints were Technology in Perth, Western Australia. Three UKsimilar to the effects of SNAGs in the spine. All these physiotherapists, Toby Hall, Linda Exelby and Sarahtechniques essentially involved sustained accessory Counsel were attending postgraduate courses at thejoint glides together with physiological movement. university at the time and were impressed by theHe rationalised that the techniques somehow restore approach Mulligan presented. These three physiother-a positional fault which arose from either trauma or apists took Mulligan’s techniques back to the UK andmuscle imbalance. started teaching them to their colleagues. Such inter- Momentum gathered quickly from this early incep- est was generated that this eventually led to invitationstion of MWM. Mulligan was very excited by his for Mulligan to teach in the UK and Europe and to thediscovery and knew he had to share it with other development of the international Mulligan Conceptphysiotherapists. 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 teachingtherapy special interest group of the NZSP known as group was set up to standardise the teaching of thethe 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 coursesof techniques from different concepts, including those for physiotherapists all over the world. In addition, dueof 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 asMulligan Concept course was held in 1986. competent Mulligan Concept practitioners, Certi¿ed A BFigure 1.2 (a) Manual application of a lateral glide MWM for a loss of flexion of the proximal inter-phalangealjoint of the index finger(b) Application of a lateral glide MWM for a loss of hip flexion using a treatment belt4
  15. 15. 1 • IntroductionMulligan Practitioner (CMP) competency examina- may follow the convex–concave rule of joints[6] but intions were established. To date, there are over 300 cli- some cases in the opposite direction to the mechanismnicians worldwide who have gained this certi¿cation. of injury movement. Sometimes a little trial and error In recognition of his signi¿cant contribution to man- is needed to ¿nd the right direction. One distinctionual therapy and the physiotherapy profession, Mulli- with SNAGs, which are effectively the ‘MWM of thegan 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 ifship 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 orbership 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 applicationary 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 standardPhysiotherapy Profession (2007). The impact that the manual therapy physical examination to evaluate itsMulligan Concept has had on clinical practice was potential as an intervention. A seamless integrationhighlighted when Mulligan was named one of ‘The can be undertaken after examining the active/func-Seven Most InÀuential 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 readilyAmerican 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 moveThe fundamental components of the MWM techniques (without having to change position), and frequentlyare still as they were when in 1984 Mulligan ¿rst observed the treatment and its reassessment can be applied inimmediate 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 thegeal joint and asked the patient to actively Àex that joint. technique immediately if no positive change is evidentFurthermore, 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 physicalThis was especially impressive because the ¿nger joint examination and for treatment are essentially the samehad 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 morepain-free and long lasting response has become the key comprehensively in Chapter 2. Generally, mobilisationprinciple guiding MWM application today. techniques, including MWM have been conceptualised MWM can be de¿ned as the application of a sus- as being indicated for mechanically induced joint paintained passive accessory force to a joint while the and joint stiffness limiting ROM. However, MWM haspatient actively performs a task that was previously also been proposed by Mulligan to effect what appearidenti¿ed as being problematic. A critical aspect of to be soft tissue conditions, such as lateral epicondylal-MWM is the identi¿cation of a task that the patient gia of the elbow and lateral ankle ligament sprain, andhas dif¿culty 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 mechanismsmost frequently a movement or a muscle contraction by which MWM may exert its effects are considered inperformed to the onset of pain, or to the end of avail- Chapters 4, 5, 6 and range of motion (ROM) or maximum muscle con- While innovative and original in nature, the MWMtraction. In this text, we will refer to this as the Client concept has parallels to other ‘traditional’ mainstreamSpeci¿c Impairment Measure (CSIM, see Chapter 2 for approaches to manual therapy that would facilitatemore 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 inand 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 onally 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 notis the one that effects the greatest improvement in the surprising given that Mulligan was heavily inÀuencedCSIM. It is somewhat surprising that a lateral glide is early in his career by both these practitioners throughthe 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 isthen other directions may be tested. Alternate glides used as an indication that the correct technique is being 5
  16. 16. MOBILISATION WITH MOVEMENT: THE ART AND THE SCIENCEapplied, although rather than provoking or localising systematic review of such trials, where this is limitedpain 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 levelstion in MWM as there are in the Maitland approach and of evidence), whether it be a case report or from thesome 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 theone (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 cliniciansity to the combined movement approach described by apply the external research evidence for MWM withinBrian Edwards[11] in which pain-free joint positioning a clinical reasoning framework and without losing theis used to enable end-range passive mobilisation. The uniqueness and individuality of the patient. The patientother 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 owngiven by McKenzie as to how he chanced upon the beliefs, understandings, expectations and experiencestherapeutic 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, theworld appear to share an ability to creatively clinically patient is required to actively engage in their treatmentreason or think outside the box. and management, as opposed to just passively receiv- ing the ‘laying on of hands’ implicit in many traditionalMWM 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 mustdetermined 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 torequires the clinician to routinely follow several basic perform an active movement or functional task thatrules (e.g. the treatment plane rule, convex–concave is problematic and for which treatment was soughtrule) and therefore is at odds with the development of (e.g. a painful or limited movement). Third, manyskilled 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 anreasoning. 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 adapteddevelopment of the practitioner’s 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 ofreasoning the above elements of MWM necessitate that the patient understands the principles of MWM and isJones 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. Theassociated clinical reasoning processes. Their model importance of collaboration and patient cooperationis consistent with the patient-centred approach to evi- to the success of MWM is highlighted in an acronymdence-based medicine advocated by Sackett et al.[13, 14] favoured by Mulligan (personal communication,Evidence-based medicine has been de¿ned by Sack- 2009) in his teaching – CROCKS:ett et al (p.71)[14] as ‘the conscientious, explicit, and ▪ Contraindications to manual therapy as for anyjudicious use of current best evidence in making deci- manual therapy techniquessions about the care of individual patients’. These ▪ Repetitions of the technique are required, but withauthors further stress that evidence-based medicine is care on initial application and in acute injuries foran integration of the practitioner’s clinical expertise which three to six repetitions are recommendedwith both the best external clinical research evidence ▪ Overpressure to ensure optimal ongoing improve-and the patient’s preferences in making decisions mentsabout their care. While for treatment the ‘gold stan- ▪ Communication and cooperation is essentialdard’ for evidence is the randomised clinical trial or a for safe and effective MWM application with6
  17. 17. 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 re¿ne 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 identi¿ed 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 individual’s life experiences) response in their ‘worst’ movement or activity. — that is important in clinical reasoning, but how these Moreover, such a powerful response has signi¿cant 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 hypothetico–deductive processes in manual therapy the technique’s 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 technique’s 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 patient’s ill- tion of MWM on the basis of the patient’s initial and ness or pain experience is inÀuenced by their own changing responses. Metacognitive skills are higher life experiences and immediate contextual circum- order thinking skills of self-monitoring and reÀec- stances, and therefore their clinical presentation can- tive appraisal of one’s 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 identi¿ed 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 inÀexibil- which has a signi¿cant 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 7
  18. 18. MOBILISATION WITH MOVEMENT: THE ART AND THE SCIENCEinterpretations and trivial technical issues. The history do so with an open but healthily sceptical mind. Theof manual therapy is replete with examples where a case studies comprising the bulk of the chapters willfar-sighted pioneer has been feted like a guru by his provide the novice reader with the con¿dence to takefollowers, who with the fervour of religious zealots the concept of MWM into their clinic, and the experi-then proceed to construct a framework that stiÀes cre- enced clinician with the opportunity to develop theirativity and the further evolution of the protagonist’s clinical reasoning skill by comparing their reasoning toapproach,[17] and which misdirects future practitioners that of other Mulligan Concept practitioners.and advocates of the approach away from the origina-tor’s 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-Basedsive and contemporary discourse on Mulligan’s 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. Cyriax’s Illustrated Manual of Orthopaedicevidence base for MWM into clinical practice, with Medicine (2nd edn). Oxford: Butterworth-Heinemannan 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 ef¿cacy, 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.ligan’s ‘positional fault’ hypothesis, as well as other 7 Mulligan B. Manual Therapy - ‘NAGS’, ‘SNAGS’,impairments/de¿cits in the pain, sensory, sensorimo- ‘MWMS’ etc. (5th edn). Wellington: Plane View Servicestor 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 Mechanicalseries of case studies (Chapters 8 to 19) that demon- Diagnosis and Therapy (2nd edn). New Zealand: Spinalstrate how the former considerations can be utilised Publications the clinical reasoning process. The latter will also 9 Maitland GD, Hengeveld E, Banks K, English K.demonstrate the framework within which the practitio- Maitland’s Vertebral Manipulation (6th edn). Oxford:ner is able to design and implement customised MWM Butterworth-Heinemann 2001. 10 Boyling J, Jull G. Grieve’s Modern Manual Therapy:techniques for the individual patient, as illustrated The Vertebral Column (3rd edn). Edinburgh: Churchillby some prominent Mulligan Concept practitioners. Livingstone 2004.By presenting these cases within a clinical reasoning 11 Edwards B. Manual of Combined Movements: Theirframework 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: Churchillual patient’s 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 forticularly those for which evidence is supportive, will Manual Therapists. Edinburgh: Butterworth-Heinemannbe described in detail and depicted. In the event that 2004:3–24. 13 Sackett D, Straus S, Richardson W, Rosenberg W,a practitioner confronts issues in putting into practice Haynes R. Evidence-based Medicine: How to Practicethe MWM techniques, we have included a technique and Teach EBM (2nd edn). Edinburgh: Churchilltroubleshooting section (Chapter 20), which is geared Livingstone 2000.towards practitioners self-reÀecting 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 issolutions to these issues. and what it isn’t. BMJ. 1996;312:71–2. This book will be of bene¿t for students of manual 15 Gifford L. Pain, the tissues and the nervous system: atherapy and for the various health professionals work- conceptual model. Physiotherapy 1998;84:27– clinically in this ¿eld, and it should provide a valu- 16 Miller P. Pattern Recognition is a Clinical Reasoningable 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). Manualbook, the reader should strive to ¿rst understand the Therapy 1999;4:125–6.principles and evidence underpinning MWM, and to8