Manual therapy has been an essential part of healthcare for centuries, offering a hands-on approach to treating musculoskeletal conditions, reducing pain, and restoring optimal function. Among the various manual therapy techniques, the Mulligan Concept stands out as a quick, safe, and effective method, when indicated, and is currently used by manual therapists worldwide. It is distinctly different from some traditional forms of passive manual therapy that have been shown to be unreliable.
Understanding the Mulligan Concept
Developed by New Zealand physiotherapist Brian R. Mulligan, the Mulligan Concept is a manual therapy approach that includes mobilization with movement (MWM) and sustained natural apophyseal glides (SNAGs). Unlike many traditional manual therapy techniques, the Mulligan Concept involves active patient participation that is central to the treatment process. It aims to decrease or eliminate pain, increase functional mobility, and improve maladaptive movement patterns.
Potential Benefits of Including the Mulligan Concept in a Multi-Modal Treatment Plan
Modern views of manual therapy suggest that a multi-modal approach is key to success knowing that different individuals respond uniquely to various treatment interventions. Integrating a multi-modal approach that includes manual therapy, therapeutic exercise, patient education, and other techniques or modalities can provide a comprehensive and tailored treatment plan.
The Mulligan Concept fully embraces a multi-modal approach in the following ways:
- Immediate Pain Relief: Mulligan Concept manual therapy techniques such as MWMs can often provide immediate pain relief, even – when indicated - in chronic conditions. Often by applying minimal external forces, the therapist may change a painful movement into one without pain. This allows patients to experience reduced discomfort providing a pathway to uninhibited therapeutic exercise.
- Improved Functional Range of Motion: Restricted mobility is a common issue in musculoskeletal conditions presenting in the clinic. The Mulligan Concept's MWM approach promotes functional improvement by sustaining external forces similar to those applied in joint or soft tissue mobilization throughout the full ROM, with over-pressure applied at the end of the range, if pain-free.
- Enhanced Patient Participation: Reduction of fear-avoidance behaviors due to pain relief can lead to greater compliance and adherence to the treatment plan.
- Customization: The Mulligan Concept allows manual therapists to tailor treatment to each patient's specific needs and goals by directly addressing the client-specific impairment measure (CSIM). This personalized approach enhances patient outcomes and satisfaction with the treatment process.
The Science Behind Manual Therapy
Critics often question the efficacy of manual therapy due to the lack of concrete scientific evidence. This lack was present in the mid-1980s during the development of the concept. However, in the last 40-odd years numerous high-quality studies have confirmed the positive effects of the manual therapy techniques of the Mulligan Concept. Research published in peer-reviewed journals has consistently shown increases in range of motion, reduction of pain (and other symptoms), and improved functional outcomes in patients with various musculoskeletal conditions.
Interestingly, Mobilization with Movement is consistent with modern neuroscience theory. In their 2016 article in Physiotherapy Theory and Practice, Combining Manual Therapy with Pain Neuroscience Education in the Treatment of Chronic LBP: a narrative review of the literature. Puentedura and Flynn note: A narrative review of pain education suggests more benefit when manual therapy is coupled with exercise/activity.
While evidence-informed practice forms the foundation of modern medicine, it is crucial to balance it with patient beliefs and individual experiences. David Sackett, a pioneer in evidence-based medicine, emphasized integrating clinical experience with the best available external clinical evidence.
A Common Question Asked about the Mulligan Concept!
Must I accept Mulligan’s original hypothesis of positional faults to practice this form of manual therapy?
No! In line with a significant volume of modern research, MWM examination procedures and treatment techniques do not:
- Require palpation of the relative position of bony landmarks or relative movement of bones
- Rely on findings of pain provocation tests
- Require belief in any biomechanical theory, including the "positional fault" hypothesis
- Depend on establishing a diagnosis, a classification, or identification of a specific pathology or a “pain generator”
(Verbiage credit to Mark Oliver)
Mulligan Concept References
The 2022 edition of the reference list on www.bmulligan.com, the concept’s International website, currently contains 388 references pertaining to the Mulligan Concept. This number continues to grow year by year as more and more research about the concept is performed and published.
Mobilization with Movement: Validated – an example
As referenced in a previous post in this year’s blog, the APTA Clinical Practice Guideline (CPG) published in the December 2022 issue of the Journal of Orthopedic and Sports Physical Therapy (JOSPT) offers compelling evidence in favor of its efficacy. This CPG identifies Level I evidence and assigns a Grade B rating, indicating moderate evidence, for the use of manual therapy techniques and specifically the Mulligan Concept Mobilization with Movement in the treatment of lateral elbow tendinopathy.
Conclusion
So, back to the questions:
- Can manual therapy be beneficial?
- Should it be part of a comprehensive treatment plan?
There is definite evidence in favor of including manual therapy in a treatment plan, particularly the Mulligan Concept. By incorporating this efficient and effective technique into a multi-modal plan its numerous benefits can be harnessed to provide quality care and maximize patient outcomes.
So…manual therapy…
Should you use it? YES! (…says the evidence base, and many therapists and patients.)
Could you use it? YES! ( If you have been trained in manual therapy techniques such as the Mulligan Concept, and especially if you are a Certified Mulligan Practitioner (CMP)
Would you use it? OF COURSE!!
Don Reordan, PT, MS, OCS, MCTA, CIDN