2. Objectives
By the end of this class you are expected to;
Understand the basic concept of Maitland manipulation.
Identify basics of Maitland and Mulligan concepts.
Aware about Mackenzie exercise and their classification.
Differentiate between Mackenzie and Williams exercises.
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4. Introduction; manipulation
Manual therapy is the use of hands in a hands-on
technique with therapeutic intent and curative manner.
Manual therapy (massage, mobilization and manipulation)
may be used with the aim of increasing ROM there by
improving function.
Basically used with other techniques.
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5. Introduction; manipulation
Manipulation and mobilization are commonly used as a
treatments of pain and may be performed by physical
therapists & others.
Manipulation and mobilization are may have the same
meaning and interchangeable.
They are passive, skilled manual therapy technique
applied to joints and related soft tissues at varying speeds
and amplitudes using physiological and accessory motions
for a therapeutic purpose.
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6. Introduction; manipulation
From a small amplitude force at high velocity to a large
amplitude force at low velocity with a continuum of
intensities and speeds at which the technique applied.
Manipulation consists a localized force of high velocity
and low amplitude directed at specific spinal segments.
Mobilization use low-grade/velocity, small- or large-
amplitude passive movement techniques within the
patient’s ROM and control.
‘Manipulation or adjustment ' means the forceful
movement of joints or tissue to restore joint function.
• t or manipulation' means the forceful movement o
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7. History of manipulation
• Hippocrates, Father of Medicine
– 460-355 B.C.
– Wrote “On Setting Joints by
Leverage”
– Spinal Traction
– Reduction of dislocated shoulders
– Traditional bone setting flourished
in Europe during the period of
1600-early 1900’s
– No formal training
– Techniques passed down within
families
– Clicking sounds thought to be due to
moving bones back into place
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8. History of manipulation
Freddy Kaltenborn
– The Spine, …Mobilization 1961
– First to relate manipulation to arthro-kinematics
Geoffrey Maitland
– “Vertebral Manipulation”, 1964
– Treats “reproducible signs”
– Oscillatory techniques(Grades I-V)
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9. The Maitland Concept
There are several different main stream approaches to
manual therapy.
The Maitland Concept of Manipulative Physiotherapy
emphasizes a specific way of thinking, continuous
evaluation and assessment of a patient.
It is the art of manipulative physiotherapy and a total
commitment to the patient.
(“know when, how and which techniques to perform, and
adapt these to the individual Patient”)
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10. Con...
The application of the Maitland concept can be on the
peripheral or spinal joints,
Both require technical explanation and differ in technical
terms and effects,
However the main theoretical approach is similar to both.
The concept is named after its pioneer Geoffrey Maitland
who was seen as a pioneer of musculoskeletal PT.
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11. Con….
Key Terms
Accessory Movement - Accessory or joint play
movements are joint movements which cannot be
performed by the individual.
These include roll, spin and slide which accompany
physiological movements of a joint.
The accessory movements are examined passively to
assess range and symptom response in the open pack
position of a joint.
Understanding this and their dysfunction is essential to
applying the Maitland concept clinically.
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12. Con….
Physiological Movement - The movements which can be
achieved actively and analyzed for quality of responses.
Injuring Movement - Making the pain/symptoms 'come
on' by moving the joint in a particular direction during
the clinical assessment.
Overpressure - Each joint has a passive range of
movement which exceeds its available active range.
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13. Con….
The Maitland concept is a fantastic tool for approaching
an initial assessment.
It can be used to form a logical and deduced hypothesis
about the nature of the origins of the movement disorder
or pain.
Subjective assessment
Objective assessment
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14. Con….
Principles of Technique
1.The Direction - of the mobilization needs to be clinically
reasoned by the therapist and needs to be appropriate for the
diagnosis made.
Not all directions will be effective for any dysfunction.
Depends on Concave Convex Rule comes into use.
Different directions
A-P (Antero-posterior) or P-A (Poster-oanterior) and Joint
Distraction, Medial Glide and Lateral Glide
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15. Con….
• Grading scales
Grade I – small amplitude
movement at the beginning of the
available range of movement
Grade II – large amplitude
movement at within the available
range of movement
Grade III – large amplitude
movement that reaches the end
range of movement
Grade IV – small amplitude
movement at the very end range of
movement
Grade V - A high velocity
movement performed into the
spines resistance.
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16. Con….
3. Purpose
Lower grades (I + II) are used to reduce pain and
irritability.
Higher grades (III + IV) are used to stretch the joint
capsule and passive tissues and increase range of
movement.
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17. Mulligan Concept
Description
The concept of Mobilizations with movement (MWM) of
the extremities and sustained natural apophyseal glides
(SNAG) of the spine were first coined by Brian R.
Mulligan
Terms
NAGS- Natural Apophyseal Glides.
SNAGS - Sustained Natural Apophyseal Glides.
MWMS- Mobilization with Movements
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18. Con…
MWM is the concurrent application of sustained accessory
mobilization applied by a therapist and an active
physiological movement to end range applied by the
patient.
Mulligan proposed that injuries or sprains might result in a
minor "positional fault" to a joint causing restrictions in
physiological movement.
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19. Con…
Basic principles
During MWMs" as an assessment,
the therapist should look for PILL response to use the same
as a Treatment .
→P- Pain free.
→ I- Instant result
→LL- Long Lasting.
If there is No PILL response, that technique should not be
advocated.
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20. Con…
The second principle is CROCKS
→C- Contra-indications (No PILL response is a
contraindication)
→R - Repetitions (Only three reps on the day one)
→O- Over pressure
→C- Communications
→K - Knowledge (of treatment planes and pathologies)
→S- Sustain the mobilization throughout the movement.
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21. Con…
Techniques
1- SNAGs stand for Sustained Natural Apophyseal Glides.
Can be applied to all the spinal joints, the rib cage and the
sacroiliac joint.
The therapist applies the appropriate accessory
zygapophyseal glide while the patient performs the
symptomatic movement.
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22. Con…
2- NAGs stand for 'Natural Apophyseal Glides”.
For cervical and upper thoracic spine.
It consists of oscillatory mobilizations instead of sustained
glide like SNAGs, and it can be applied to the facet joints
between 2nd cervical and 3rd thoracic vertebrae.
NAGs are mid range to end range facet joint mobilizations
applied antero-superiorly along the treatment planes of the
joint selected.
Useful for grossly restricted spinal movement.
NAGs for the treatment of choice in highly irritable
conditions.
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23. CON…
3- MWM
Once the aggravating movement has been identified, an
appropriate glide is chosen.
Depends upon the severity, irritability and nature of the
condition to use WB or NWB.
Mobilizations performed are always into resistance but
without pain
Immediate relief of pain and improvement in ROM are
expected. 23
25. CON…
What is the McKenzie Method?
The McKenzie method (also known as MDT -Mechanical
Diagnosis and Therapy) is a comprehensive method of care
primarily used in PT.
A method developed in 1981 by Robin McKenzie, a PTist
from New Zealand.
Philosophy of active patient involvement and education for
back, neck and extremity issues.
A basic philosophy of McKenzie's theory is that the reverse
force can probably abolish the pain and restore function.
Is a classification system and a classification-based
treatment for patients with low back pain.
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27. CON…
1- Assessment
Consists taking a patient history and performing a
physical exam.
Both are used to consider the degree of impairment as
well as identify any red flags.
Can eliminate the need for expensive and/or invasive
procedures
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28. CON…
2- Treatment
Prescribes a series of individualized exercises.
The emphasis is on active patient involvement, which
minimizes the number of visits to the clinic.
Most patients can successfully treat themselves when
provided the necessary knowledge and tools.
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30. CON…
3- Prevention
Teach/learning how to treat the current problem by
patients them selves.
Gain hands-on knowledge on how to minimize the risk of
recurrence and to rapidly deal with recurrence if it occurs.
The likelihood of problems persisting can more likely be
prevented through self-maintenance.
Education of the patient is considered ‘mission critical’in
order to realize sustained pain relief.
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31. CON…
McKenzie Therapy Classifications
Three Classifications:
A- Postural Syndrome: is due to prolonged
positions/postures (affect muscles, tendons, or joint surfaces).
Pain may be local and reproducible when end range
positions.
B- Dysfunction Syndrome: Implies some sort of adaptive
shortening, scarring or adherence of connective tissue
causing discomfort.
It may be intermittent or chronic, but its hallmark is a
consistent movement loss and pain at the end ROM.
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32. CON…
When the patient moves away from end range their pain is
decreased.
C- Derangement Syndrome: is the most common.
Certain movements and particular movement patterns can
cause more sensitivity.
Such as a flexion or extension, the symptoms (low back
pain) become either more central (just in the low back) or
less intense.
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34. Williams Flexion Exercises
Williams flexion exercises — also called Williams
lumbar flexion exercises, Lumbar flexion exercises or
simply Williams exercises.
Are a set of related physical exercises intended to
enhance lumbar flexion.
Avoid lumbar extension,
Strengthen the abdominal and gluteal musculature in an
effort to manage low back pain non-surgically.
Devised in 1937 by Dr. Paul C. Williams, a Dallas
orthopedic surgeon.
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35. CON…
The basic cause of all pain is the stress induced on the inter-
vertebral disc by poor posture.
The goals of these exercises are to open the intravertebral
foramina and stretch the back extensors, hip flexors, and facets.
7-exercoses:-
1. Pelvic tilt exercises
2. partial sit-ups
3. Single/bilateral knee-to-chest
4. Hamstring stretching
5. Standing lunges
6. Seated trunk flexion
7. Full squats. 35
