A school of manual therapy, a therapy which provides Instant result with long lasting effect. treating almost all causes.

1. Mulligan’s Mobilization
Radhika Chintamani

2. Contents
• About the Founder
• Definitions
• Basic Concepts
• Mechanism of Action
• Principles of treatment
• Principles of Application of Treatment
• Equipment
• Techniques
• SNAGs
• NAGs
• Peripheral MWM

3. Contents
– Spinal Mobilization with limb movement
– Other Techniques
• Indications
• Contraindications
• Recent Advances
• References

4. About the Founder
Brian R. Mulligan.
• Brian R. Mulligan qualified as a physiotherapist in 1954
and gained his Diploma in Manipulative Therapy in 1974.
• In 1996, he was made an Honorary Fellow of The New
Zealand Society of Physiotherapists for his contributions
to physiotherapy.
• In 1998, he was made the life member of The New
Zealand College of Physiotherapy.

5. About the Founder
• Mulligan has been the author for various articles
pertaining to the concept that have appeared in New
Zealand Journal of Physiotherapy and international
journals as well.
• He has authored two books:
– Manual therapy NAGs, SNAGs, MWMs etc., for
Physiotherapists.(2003)
– Self-treatment for the back, neck and limbs for the
public.

6. Definitions
• Mobilization with Movement (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. Passive end of the
range overpressure or stretching is then delivered
without any pain as a barrier.
• The concept of MWM of the extremities and sustained
natural apophyseal glides of the spine was first coined by
B. Mulligan.
– Kisner C., Colby LA. Therapeutic exercise: foundations and techniques. FA Davis, 2012.

7. Important Acronyms
• Mobilization With Movement (MWM)
• Natural Apophyseal Glides (NAGs)
• Sustained Natural Apophyseal Glides (SNAGs)
• Spinal Mobilization With Limb Movements (SMWLMs)
• Spinal Mobilization With Arm Movements (SMWAMs)
• Pain Release Phenomenon (PRPs)

8. Basic Concepts
• Convex concave motion rule
• Treatment plane

9. Convex Motion Rule
When the convex joint
partner moves, the
glide occurs in the
opposite direction.
Concave Motion Rule
When the concave joint
partner moves, the
glide occurs in the same
direction.

10. Treatment plane:
A treatment plane passes through the joint and lies at a right
angle to a concave joint partner.
Treatment is always applied parallel to this treatment plane.

11. Mechanism of Action/ Paradigms of Practice
• Biomechanical Effects: (evidence- based)
– Straightens the spine
– Unlocking the lock joints
– Shifts an IVD fragment & reduces annular distortion
– Increases the proprioceptive feedback
– Stretching, tearing or rupturing adhesions that limit
joint or muscle range
– Remove blockage or interference of blood flow, nerve
compression, sympathetic chain and cerebrospinal
fluid circulation

12. Mechanism of Action/ Paradigms of practice
• Positional Faults Hypothesis:
– Mulligan proposed that injuries or sprains resulted in
minor positional fault to the joint causing restrictions in
physiological movements. The technique overcomes
joint “tracking problems” or positional faults (joints with
subtle biomechanical changes).
– These abnormalities provoke pain, stiffness or weakness
in the joint. The therapist works to re-align the joints.
• Response:
– Transient change in bone position
– Increase ROM

13. Mechanism of Action/ Paradigms of practice
• Neuro-physiological Effects: (evidence- based)
– Corrects abnormal reflexes and organ dysfunction
– Stretches contracted muscles causing relaxation
– Modulates peripheral nociceptors
– Activates gating mechanism, neurotransmitters.
– Associated changes in sympathetic and motor system.
• Theory of extinction and habituation:
– Pain is considered as a form of aversive memory. Here,
exposure to painful movement in the absence of any overt
danger, is fundamental and is used in the EXTINCTION of the
aversive memories.

14. Mechanism of Action/ Paradigms of practice
– Progressive mobilization desensitizes the nervous
system through HABITUATION. The mechanism
involves a progressive decline in the ability of the pre-
synaptic nerve terminal to transmit impulses.
• Response:
– Initial endogenous non-opoid hypo-algesia by
excitation of the sympatho-excitation through
movement.

15. Principles of Treatment
1. A passive accessory joint mobilization is applied
following the principles of Kaltenborn. This accessory
glide must itself be pain free.
2. During assessment the therapist will identify one or
more comparable signs as described by Maitland. These
signs may be;
a) A loss of joint movement ,
b) Pain associated with movement, OR
c) Pain associated with specific movement.

16. Principles of Treatment
3. The therapist must continuously monitor the patients
reaction to ensure no pain is recreated. The therapist
must investigate various combinations of parallel or
perpendicular glides to find the correct treatment plane
and grade of accessory movement.
4. While sustaining the accessory glide, the patient is
requested to perform the comparable sign. The
comparable sign should now be significantly improved.

17. Principles of Treatment
5. Failure to improve the comparable sign would indicate
that the therapist has not found the correct treatment
plane, grade of mobilization, spinal segment or that the
technique is not indicated.
6. The previously restricted and/or painful motion or
activity is repeated by the patient while the therapist
continues to maintain the appropriate accessory glide.

18. Principles of Application of Treatment.
• The PILL Principle:
While applying MWMs as an assessment, the therapist
should look for PILL response to use the same as a
treatment technique.
– P - pain free
– I- instant result
– LL – long lasting
If there is No PILL response, the technique should not be
advocated.

19. Principles of Application of Treatment.
• The CROCKS Principle:
– C- Contra-indications ( No PILL response)
– R- Repetitions
– O- Overpressure
– C- Communications
– K- Knowledge (of treatment planes & pathologies)
– S- Sustain the mobilization throughout the movement.

20. Equipments
• Plinth / couch
• Mulligan belt
• Mulligan pads
• Tape

21. Techniques
• The Mulligan’s mobilizations are categorised into :
– The Spinal Mobilizations
• Cervical and Upper Thoracic Spines: NAGs, Reverse
NAGs, SNAGs, self SNAGs, SMWLMs.
• Thoracic Spine
• Lumbar Spine: SNAGs, self SNAGs
• Sacroiliac Joints
• The Rib Cage
• Other spinal therapies: manipulation, self treatment,

22. Techniques
– The Extremities
• MWMs
• Compression treatments
• Pain Release Phenomenon
• Other extremity therapies
• Grips:
– ‘vee’ finger grip positioning for upper thoracic and
cervical spine.
– B Mulligan. Manual therapy NAGS, SNAGS, MWMS, etc. Plane View Press, Wellington, 2012, 6th
edition.
– Wilson E. The Mulliga concept: NAGs SNAGs and MWM. Journal of body work and movement therapies (2001)
5(2): 81-89.

23. Techniques- NAGs
• These are used for cervical and upper thoracic spine.
• It consists of oscillatory mobilizations instead of sustained
glide and it can be applied to facet joints between 2nd cervical
to 3rd thoracic vertebrae.
• NAGs are mid to end range facet joint mobilizations applied
antero-superiorly along the treatment planes of the joint
selected.
• Graded according to the tolerance of the patient and is useful
for grossly restricted spinal movement.

24. Techniques- NAGs
• NAGs can be used for treatment of choice in highly
irritable conditions after application of manual traction.

25. Techniques- Reverse NAGs
• These are used for the upper thoracic spine and shows
some benefits in the lower cervical spine.
• They replicate passively the head retraction motion.
• So, in case of NAGs the superior facet glides up the
inferior. In reverse NAGs, the inferior facet glides up on
the superior.

26. Techniques- SNAGs
• SNAGs can be applied to all spinal joints, the rib cage and
the sacroiliac joint.
• The technique is performed when the therapist applies
the appropriate accessory zygapophyseal glide while the
patient is asked to do the physiological symptomatic
movement resulting in a full pain free movement.
• Although SNAGs are performed in weight bearing
positions they can be adapted for use in non weight
bearing positions.

27. Techniques- SNAGs
• They should not be used when the symptoms are
multilevel and if the conditions are highly irritable.

28. Techniques- SNAGs
Criteria for SNAGs Treatment Approach
1. They are all done in weight bearing postures.
2. They are mobilizations with active movements followed by
passive overpressure.
3. The follow the treatment plane rule.
4. The mobilization component is sustained.
5. They are applied to most spinal joints.
6. When indicated they are painless.
7. They are carried out at end range.
8. They require thorough knowledge to allow straight forward
procedure for each movement loss.
9. No time is wasted as the treatment regime is decided within a
couple of minutes.

29. Techniques- Self SNAGs
• Self SNAGs are a useful home routine . It is the only
manual technique used by the patient who presents for
treatment.
• The technique should be demonstrated
on an articulated spine or on an
assistant.
• Should ideally be taught on the first
day of treatment as the patient will get
it right this way.

30. Techniques- Self SNAGs Errors
• Common errors that the patients do:
1. They may forget the placement of their hands.
2. They place the bulky towel on the spinous process instead of
using just the edge.
3. They tend to pull the towel forwards and not in the superior
direction of the facet plane.
4. They forget to maintain the glide for the full duration of the
movement.

31. Techniques- MWMs
• SNAGs and MWMs are similar in that they both address
the problems of pain and restriction, both bring about
change at the time of delivery , both are painless when
indicated and both are sustained mobilizations with
movement.

32. Techniques- MWMs
• There is very little difference between SNAGs & MWMs as
SNAGs are facet mobilizations which are normally both in
the plane and the direction of the active movement
whereas in the extremities, the mobilisation plane to
correct the positional fault is in the direction different to
the movement of the glide.

33. Techniques- SMWAMs
• The spinal mobility allows the movement at the
peripheral joints. The mobilization combines the
extremity joint mobilizations with the extremity joint
movements.
• So, when the shoulder girdle is moved, the spinal
movement also takes place because of the muscle
attachments from the scapula to the cervical and upper
thoracic spine.

34. Techniques- SMWLMs
• SMWLMs allows for the transverse pressure is applied to
the side of the relevant spinous process as the patient
concurrently moves the limb through the previously
restricted range of movement.
• The assumption is that restriction of movement is of spinal
origin which may not imply neural compromise since spinal
movement must occur when a limb moves beyond a certain
point.
• Self-SMWLMs & self-SMWAMs can be taught to the patient.

35. Techniques- PRPs
• If a combination of movements & compression causes
pain, then the combination is repeated for 20 second to
see if the pain disappears during the time, the pressure
on the articular surface should remain constant.
• If pain increases, STOP immediately. Apply less or no
pressure and then , repeat it for 20 seconds. If the pain
disappears, then repeat the technique with the same
amount of pressure.

36. Techniques- PRPs
• PRP can be given in chronic conditions when the initial
repair has already taken place. There are 4 types of PRPs:
Compression, Traction, Stretch and Contraction.

37. Techniques-Taping
• Taping provides protection and support to the injured
part whilst allowing optimal movement which is pain-
free.
• A zinc oxide tape can be used which is adhesive, slightly
porous and non-elastic in nature.
• The benefits of using tape can be enhance circulation,
control over swelling, prevents worsening of injury and
re-injury.
• It allows the body to be conditioned and strengthened
which is lost due to inactivity.

38. Techniques-Taping
• The principles of application are:
– Maintain the correction of positional fault allowing the
patient to perform the restricted movement in a pain-
free way.
– Tape should be applied in such a way that the
therapeutic glide is maintained.
– Always reinforce the tape by applying it in exactly the
same manner.

39. Techniques- Neurodynamic MWM
• The neural tissues may get adhered to the surrounding structures,
resulting in lack of sliding, gliding and stretching to the nerve.
• Due to transverse glide the vertebral body rotates towards the
same side, resulting in opening of the foramina on the affected
side.
• Adding arm movements with the opened foramina will result in
mobilization of the neural tissues.
• The pain reduces with an increase in spinal and limb movements.

40. MWM Prescription Parameters
• Repetitions / Sets: ten repetitions for three sets.
• Frequency: three to six sessions a week or as frequent as a session
every two hourly or once in five days.
• Amount of force: although it is an important variable in Mulligan's
concept, only one study gave methods of applying force by using a
hand held dynamometer where 66% showed maximal gains of the
effects.
• Rest periods: this ranges from 30 second to 2 hours between the
sets.
– Hing W., Bigelow R., Bremner T. Mulligan’s mobilisation with movement: a review of the tenets and prescription of
MWMs. New Zealand Journal of Physiotherapy (2008): 36(3):144-164.

41. Indications
• Green Flags;
– Pain of a non-inflammatory nature
– Acute pain from injury
– Loss of motion due to arthritic conditions
– Post surgical conditions
– Headaches due to neck problem
– Dizziness associated with neck problem
– TMJ pain & movement restrictions
– Acute or Chronic Ankle sprains
– Tennis elbow

42. Indications
• Green Flags;
– Sacroilitis
– Frozen Shoulder
– Any Neuromusculosketal pain and stiffness
• Any neurological and musculoskeletal condition can be
treatment, as long as the therapist follows the basic rule
of not causing pain.

43. Contraindications
• Relative Contraindications: ( Yellow Flags)
– Joint Hypermobility
– Pregnancy
– Osteopenia
• Absolute Contraindications: (Red Flags)
– Bone Weakness ( Tumour, Osteoporosis, Metabolic
Bone Disease)
– Vascular (Anticoagulant Therapy, Aortic Aneurysm)
– Neurological Deficits (multilevel PIVD, Cervical
Myelopathy)
– Psychological Disorders.

44. Evidence Based Practice
• A randomized placebo-controlled trial was done to evaluate
the short effects of MWM in Non specific Low back pain
which was checked for the outcomes such as kinematic
variables (range of motion, speed), pain, kinesiophobia and
functional disability. 32 participants were allotted into 2
groups. The intervention was given for 3 sets for 6 sessions.
• The outcomes used were Visual Analog Scale, Tampa Scale
of Kinesiophobia, Oswestry Disability Index and the
Kinematic Analysis for Range of motion and Speed on an
optoelectronic device (Elite-BTS) with reflective markers(9).

45. • The study suggested substantial improvements favouring lumbar
SNAGs as compared with the placebo for KA-R, pain at rest and
during trunk flexion as well as for functional disability in contrast
to no difference in KA-S and kinesiophobia.
– Hidalgo, B; Pitance, L ; Hall, T ; Detrembleur, C; Nielens, H Short-Term Effects of Mulligan Mobilization With
Movement on Pain, Disability, and Kinematic Spinal Movements in Patients With Nonspecific Low Back Pain: A
Randomized Placebo-Controlled Trial. Journal of Manipulative and Physiological Therapeutics, (2015)Vol. 38,
no.6, p. 365-374

46. • The aim of the study was to see the effect of McKenzie
Extension Exercise Programme versus Mulligan’s
Sustained Natural Apophyseal Glides for Chronic
Mechanical Low Back Pain. It was a Randomized Clinical
Trial. The outcome measures used were Visual Analog
Scale, Oswestry Disability Index and Lumbar ROM which
were measured at baseline and after 4 weeks of
intervention.
• Results showed that McKenzie EEP showed a better
reduction of pain while Mulligan’s SNAGs showed better
improvement in lumbar range of motion.

47. • Both the groups showed no difference in terms of functional
disability. Since, a total of only 37 participants were collected, a
larger sample size is required to be able to generalize these
findings to the population, although the results were quite
favourable.
• Waqqar S., Shakil-ur-Rehman S., Ahamed S. McKenzie Treatment versus Mulligan Sustained Natural Apophyseal Glides for Chronic
Mechanical Low Back Pain. Pak J Med Sci. (2016): 32(2): 476-479.

48. • In a cross-over study, to check the short term effects of
MWM technique and MWM with taping on painful
shoulders of 25 participants. The participants were
allotted to 2 groups. Here, the outcome measures taken
were ROM, pain pressure threshold and current pain
severity (PVAS) which were measured at pre-, post-, at 30
mins and at 24 hrs.
• So, after a week of the wash-out period, the participants
were crossed over and the procedure was repeated.

49. • The intervention showed no particular significance in PPT but
showed improvement in VAS and ROM at the 1 week follow-up.
• Also, the MWM with taping provided a sustained improvement
in ROM and decreased pain to one week follow-up which was
superior to MWM.
– Teys P, Bisset L, Collins N, Coombs B, Vincenzo B. One week time course of effect of mulligan MWM and taping in Painful
Shoulder. Manual Therapy 2013: 18 (5); 372-377.

50. • Although there is literature to support the use of MWM in
Lateral Ankle Sprain, there is no literature that is directed
at the pain free mobilization application and no study
exists on the use of a modified versions of the MWM
technique.
• This patient was a 23 year old female basketball player.
She had pain on palpation and so, could not be given
MWM the traditional way. The therapist then applied the
MWM 2” away from the ankle and the patient was asked
to walk around and showed resolution of pain.

51. • This was then followed by tape. The outcome measures
NPRS, Disablement of Physical Activity (DPA).
• the follow-up was taken after the single session of the 16th
day. During that time, the patient participated in 2
tournaments with taping in MWM and experienced only
mild discomfort.
• This shows that MWM techniques are modifiable and can
be modified to the individuals needs and necessities. Also,
MWM taping helps to maintain proper trakking of the
joints and prevent any abnormal joint play that may
return.
– Mau H, Baker RT. A modified Mobilization with Movement to treat lateral ankle sprain. Int. J. Sports Phys Ther
2014:9(4);540-548.

52. Summary
• Always treat the patient in weight bearing positions,
performing the movement in a pain-free way.
• Movement must be pain-free.
• Always check the resultant vector/ angle of pull/ parallel
position of the treatment belt to the floor/ angle and position
of the forearm.
• Always sustain the glide till the starting position is achieved.
• Always work in the available range.
• Always apply the overpressure at the end of the range.
• Be parallel to the treatment plane.
• The position / handgrip / belt must not block the patient’s
movement.

53. Summary
• Grip must be firm but painless.
• Hand / belt placement must be always close to treatment
plane / joint line. Ensure proper translation and avoid
rotation
• There should be proper communication between the
therapist and the patient during the session of mobilization.
• Always explain what the treatment is and what the patients
requires to do.
• Do not over treat the patient
• Re-assess and compare with earlier assessment
• Teach self-treatment whenever possible.

54. References
• Vincenzo B., Paungmali A., Teys P. Mulligan’s mobilization with movement,
positional faults and pain relief: Current concepts from a critical review of
literature. Manual Therapy (2007): 12; 98-108.
• Hing W., Bigelow R., Bremner T. Mulligan’s mobilisation with movement: a review
of the tenets and prescription of MWMs. New Zealand Journal of Physiotherapy
(2008): 36(3):144-164.
• B Mulligan. Manual therapy NAGS, SNAGS, MWMS, etc. Plane View Press,
Wellington, 2012, 6th edition.
• Kisner C., Colby LA. Therapeutic exercise: foundations and techniques. FA Davis,
2012.
• Deepak Kumar, Brian Mulligan. Manual of Mulligan Concept: A step by step guide
to deliver manual therapy based on mulligan concept. Capri Institute of Manual
Therapy. First Ed.(2014).
• Wilson E. The Mulligan concept: NAGs SNAGs and MWM. Journal of body work
and movement therapies (2001) 5(2): 81-89.

55. Thank
You.