Believe Me, Just WatchRaise Your Expectations for ... · PDF file• Positive outcomes (NRS, PVAS, PPT, PFG, ROM, strength, ... tissue derangement, referred pain ... medial, lateral,

Athletic Training Programs

Acute solution, Chronic relief: Don’t

Believe Me, Just Watch...Raise Your

Expectations for Immediate Clinical

Results Robinetta Hudson, MAT, ATC

Amy Richmond, MS, ATC

Belinda Sanchez, MS, ATC

Valerie Stevenson, MS, ATC

Russell Baker, DAT, ATC

James May, DAT, ATC

Diane Stankevitz, ATC


• Background & Foundational Principles

• Theories of Efficacy

• Overview of the Current Literature

• Principles of Treatment

• Application Guidelines

• Patient Outcomes

• Clinical Pearls

• Questions

• Learning Lab

Overview


Mulligan Concept

• Background

– Manual therapy technique

– Developed by physiotherapist Brian Mulligan

– Addresses his joint ‘positional fault’ hypothesis

– A sustained passive accessory joint mobilization WITH

an active or functional movement (Vicenzino, et al, 2011)


Foundational Principles

• The Mulligan Concept was influenced by James Cyriax, Fredrick Kaltenborne,

Geoffrey Maitland, and Robin McKenzie (Hing, et al, 2015)

• Cyriax

– passive joint mobilization

• Kaltenborn

– appreciation of joint mechanics

• Maitland

– proper treatment application produces a change in pain

• McKenzie

– patient self-management and repeated movement


Theories of Efficacy• A Neurophysiological Component

– The general nature of manual therapy contributing to hypoalgesia and stimulation of the

sympathetic nervous system (large A beta fibers) resulting in a decrease of symptoms

(Paungmali,Vicenzino & Smith, 2003; Paungmali, O’Leary, Souvlis & Vicenzino, 2003).

– A change in bone position may produce a non-opioid mechanical hypoalgesia by instantaneously

triggering processes within the CNS

• A Psychological Component

– All interventions are influenced by non-physical factors such as existing beliefs on injury, tissue

damage and pain from both the patient and the clinician (Vincenzino, et. al, 2011)

– Patient willingness to please ie. placebo effect

• A Positional Fault

– Injury results in a positional fault - minor bony incongruity - at a joint

– A minor bony incongruity resolved with his sustained glide and the patient active movement thus

eliminating the source of a patient’s presenting problem (Mulligan, 1993)


Support for Positional Fault Theory• Hubbard et al. (2006) - fibular positioning in CAI cases

– lateral fluoroscopy images distal tibia-fibula (30 CAI and 30 uninjured cases; n=60)

– findings: significantly increased anterior displacement of fibula in CAI cases

• Kavanagh (1999) - positional fault in acute and chronic sprained ankles

– potentiometer used to measure force of displacement during AP glide of fibula (2 CAI w/o hx

sprain, 6 acute sprains, 17 normal; n=25 with bilateral measures on each)

– findings: 2 acute sprains produced significantly increased movement during AP glide of fibula; no

difference from normal ankles in all remaining sprain and CAI cases

• Hsieh et al. (2002) - case report using MRI to evaluate MCP positional fault

– positional fault found at MCP on MRI (compared to uninvolved) and tx with MWM

– post-tx MRI performed 1 week post discharge

– findings: original positional fault returned; pain and limited ROM did not return


Analysis of the Literature• Efficacy-based literature

– Lateral Epicondylitis

• RCT ( Paungmali et al., 2003; Vicenzino et al., 2001)

• Cohort Studies (Paungmali et al., 2003; Abbott et al., 2001)

• Improvement on all measured outcomes: PVAS, PPT, TPT, Grip Strength, PFGS

– Dorsi-Flexion post LAS

• Randomized cross-over trials (Reid et al., 2007; Vicenzino et al., 2006; Collins et

al., 2004)

• Improvement on all measured outcomes: ROM goniometry and/or WBLT, FAAM

• Gilbreath et al. (2014) reported no improvement in DF - unknown if pre-tx

asymmetries existed

– Case Studies & Case Series

• Positive outcomes (NRS, PVAS, PPT, PFG, ROM, strength, function) have been

reported in MWM of:

– De Quervain’s, MCP sprain, lateral epicondylitis, shoulder pain &

impingement, neck/thorax/lumbar mobility, knee OA, ankle


Analysis of the Literature• Mechanism-based literature (biomechanics and neurophysiology)

– Changes in heart rate, BP, skin conductance, skin temperature, cutaneous blood

flux were reported immediately post application of lateral epicondylitis MWM

(Paungmali et al., 2003)

– Changes in skin conductance were reported bilaterally during and post tx

application of sidelying SMWLM - tx side produced the most change (Tsirakis

& Perry, 2015)

• similar supraspinal mechanisms of pain reduction found in joint

mobilization literature


Treatment Indications• MWMs can be used to treat:

– Joint pain with motion or weight bearing

– Loss of joint ROM

– Any conditions and/or symptoms associated with joint restriction

• sub-acute sprains, tissue derangement, referred pain, headaches, vertigo,

breathing restrictions (Mulligan, 2010)

– Mulligan discovered MWMs through finger dislocation

– Will treat pain associated with loss of ROM, but may not treat

chemical and thermal pain (Collins, Teys, Vicenzino, 2004)

• Must assess for fractures, comorbidities, and underlying conditions prior

to application


Principles of Treatment

• PILL (Mulligan, 2010)

– Pain-free

– Immediate effect

– Long

– Lasting

• Client Specific Impairment Measure (CSIM) ( Hing, et al., 2015)


Principles of Treatment

• CROCKS (Mulligan, 2010)

– Contraindications

– Repetitions

– Over-pressure

– Communication and cooperation

– Knowledge

– Sustain, skill, sense, and subtle


Application Guidelines• Other rules for Applying MWMs

– Test application during evaluation

• Indicated when an accessory glide eliminates pain

– Must follow PILL and CROCKS rules

• adjust hand position if soft tissue damage is present

– Accessory Glide

• extremities

– distraction, medial, lateral, internal rotation, external rotation, or any combination

• spine

– in the direction of the facet joints

– Begin with limited repetitions on the first treatment

• 3x10 reps in the extremities

• 1x3 reps in the spine

• Patients may have side effects following treatment

(NES Seminars; Mulligan, 2010)


Application Guidelines

• Mulligan has some specific MWMs

• Some techniques have specific glides and movements that must be

applied

• MWMs can still be used to treat joints or conditions without these

techniques

• Taping techniques can reinforce the MWM

• Tape the joint in the direction of the pain-free glide and allow the patient

to leave the clinic

– will reinforce the PILL effect



Patient Outcomes


Lateral Ankle Sprain MWM

• Case series analysis

• Five adolescent patients14-18 years (mean = 15.8± 1.64)

• Grade II acute lateral ankle sprains

• Average of 4.4 treatments over 9 days (intake to discharge)

• Discharge criteria consisted of: a PSFS of nine or higher, NRS current pain

of 1 or less, and a DPA scale score of 23 or less

• All treatments began within 72hrs after injury




LAS MWM Cont.Discussion Points

• All patients presented with a grade II ankle sprain

• The results of this case series indicate that a single treatment of MWM for a LAS led to an

immediate reduction of pain and an increase in function in all patients

• Patients were assessed and treated based on arthrokinematic changes

• Mobilisations with Movement (MWMs) used in acute stage

Conclusion

• The patients in this case series reported immediate decreases in pain and immediate

increases in functional activity while maintaining positive patient reported outcomes for 4

weeks post discharge


MC “Squeeze” Technique

• A multi site randomized sham-controlled study

• To assess the effects of the Mulligan Concept (MC) “Squeeze” technique compared to a sham

technique in participants presenting with a clinically diagnosed meniscal tear

• Twenty three participants (n=23), recruited as a sample of convenience in a physically active

and sedentary population, ranging from 14-62 (age = 24.91 ± 12.09)

• A maximum of 6 treatments were applied within a 14-day period for each treatment

• Patients were assessed using the Numeric Pain Rating Scale (NRS), Patient Specific

Functional Scale (PSFS), the Disablement in the Physically Active (DPA) scale and the Knee

Injury Osteoarthritis Outcome Score (KOOS)


Outcomes

MC ‘Squeeze” Group

M (±SD)

Sham Group

M (±SD)

p Effect Size PowerIntake

Final

Treatment Intake

Final

Treatment

NRS (Avg) 2.64 (±.89) 0.44 (±.44) 3.67 (±2.50) 2.42 (±1.96) .206 .075 .238

PSFS 3.67 (±1.72) 9.50 (±1.85) 6.45 (±1.57) 7.00 (±2.07) .000* .666* 1.00*

‡DPA 23.92 (±10.05) 9.00 (±8.12) 24.91 (±11.96) 18.55 (±14.05) .013* .272* .739

‡KOOS5 65.50 (±12.26) 79.32 (±15.22) 60.76 ±18.32) 69.84 (±13.69) .162 .095 .282

Note: MC = Mulligan Concept; NRS = Numeric Rating Scale for pain; Avg = average; PSFS = Patient Specific

Functional Scale; DPA = Disablement in the Physically Active Scale; KOOS5 = Knee injury and Osteoarthritis

Outcome Score (composite score)

‡ANCOVA with baseline scores extracted as covariates

*Notes statistical significance, large effect size, and high power


Sign/Symptoms

MC ‘Squeeze” Group (n=12)Sham Group

(n=11)

Intake Final Treatment Intake Final Treatment

n (%) n (%) n (%) n (%)

History of Popping/Clicking 10 (83.33) 2 (16.67) 9 (81.82) 9 (81.81)

JLT 12 (100) 4 (33.33) 11 (100) 8 (72.73)

Pain in TKE 6 (50) 0 (0) 6 (54.55) 6 (54.55)

Pain in TKF 11 (91.17) 0 (0) 10 (90.90) 6 (54.55)

Positive McMurray’s Test 11 (91.17) 2 (16.67) 10 (90.90) 8 (72.73)

Positive Thessaly’s Test 10 (83.33) 0 (0) 11 (100) 6 (54.55)

Positive Apley’s Test 5 (41.67) 0 (0) 2 (18.18) 2 (18.18)

Edema 0 (0) 0 (0) 1 (9.09) 1 (9.09)

NWB/PWB 3 (25) 0 (0) 1 (9.09) 0 (0)

Note: MC = Mulligan Concept; JLT = joint line tenderness; TKE = terminal knee extension; NWB = non weight-bearing; PWB =

partial weight-bearing


Discussion• Both groups reported positive effects

• MC ‘Squeeze” group’s positive effects were more superior

–All 12 participants in the MC group met discharge criteria within the 14-day, 6 treatment restriction

–Only 4 sham participants (n = 11) met discharge criteria within the same time frame.

–100% of the MC “Squeeze” group reported NRS scores of 1 or less at the completion of the study

–Only 36% of the sham group reported 1≥ on the NRS

–Improvements in function were significantly better in the MC group (PSFS)

–MDC after the first treatment and overall

–Important for not only athletic competition, but overall health and well-being

–Participants’ perception of their disability was also improved significantly more in the MC group

–100% of MC participants reported DPA scores <23 compared to 55% of sham


Conclusion•The results in this study indicate the MC “Squeeze” technique

had a positive effect on patient function over a period of 14

days that was, in general, clinically and statistically superior to

the sham treatment.

•While pain improvements were similar, the MC “Squeeze”

technique contributed to greater improvements in function and

psychosocial well-being as a result

•The MC “Squeeze” technique is an effective conservative

treatment option for the treatment of meniscal tears


Clinical Pearls

• Minimal force is necessary to apply the accessory glide

• Can be done in the position where the pain and/or restriction occurs

– laying, sitting, standing

• Overpressure at end range is necessary to restore normal joint motion

• Can use a strap, towel, or padding for assistance

• There are self-application techniques for patients to use at home

• Taping reinforces the PILL effect

• Specific application techniques



Acknowledgements

• NATA

• The University of Idaho • DAT Program

• College of Graduate Studies

• Idaho IDeA Network of Biomedical Research Excellence


References• Abbott, J. H., Patla, C. E., & Jensen, R. H. (2001). The initial effects of an elbow mobilization with movement technique on grip

strength in subjects with lateral epicondylalgia. Manual Therapy, 6(3), 163–169. http://doi.org/10.1054/math.2001.0408

• Amro, A., Diener, I., Bdair, W. O., Hameda, I. M., Shalabi, A. I., & Ilyyan, D. I. (2010). The effects of Mulligan mobilisation with

movement and taping techniques on pain, grip strength, and function in patients with lateral epicondylitis. Hong Kong Physiotherapy

Journal, 28(1), 19–23. http://doi.org/10.1016/j.hkpj.2010.11.004

• Collins, N., Teys, P., & Vicenzino, B. (2004). The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion

and pain in subacute ankle sprains. Manual Therapy, 9(2), 77–82. http://doi.org/10.1016/S1356-689X(03)00101-2

• Gilbreath, J. P., Gaven, S. L., Van Lunen, B. L., & Hoch, M. C. (2014). The effects of mobilization with movement on dorsiflexion

range of motion, dynamic balance, and self-reported function in individuals with chronic ankle instability. Manual Therapy, 19(2),

152–157. http://doi.org/10.1016/j.math.2013.10.001

• Hing, W., Bigelow, R., & Bremmer, T. (2009). Mulligan’s mobilization with movement: A systematic review. The Journal of Manual

& Manipulative Therapy, 17(2), 39–66.

• Hing, W., Hall, T., Rivett, D., Vincenzino, B. & Mulligan, B. (2015). The Mulligan Concept of manual therapy. Textbook of

techniques. Australia: Elsevier

• Hoch, M. C., & Mckeon, P. O. (2010). The effectiveness of mobilization with movement at improving dorsiflexion after ankle sprain.

Journal of Sport Rehabilitation, 19(2), 226–232.

http://doi.org/10.1016/S1356-689X(03)00101-2

http://doi.org/10.1016/j.math.2013.10.001


References• Hsieh, C.-Y., Vicenzino, B., Yang, C.-H., Hu, M.-H., & Yang, C. (2002). Mulligan’s mobilization with movement for the thumb: A

single case report using magnetic resonance imaging to evaluate the positional fault hypothesis. Manual Therapy, 7(1), 44–49.

http://doi.org/10.1054/math.2001.0434

• Hubbard, T. J., Hertel, J., & Sherbondy, P. (2006). Fibular position in individuals with self-reported chronic ankle instability. Journal of

Orthopedic & Sports Physical Therapy, 36(1), 3–9.

• Kavanagh, J. (1999). Original article Is there a positional fault at the inferior tibiofibular joint in patients with acute or chronic ankle

sprains compared to normals ? Manual Therapy, 4(1), 19–24.

• Kim, L. J., Choi, H., & Moon, D. (2012). Improvement of pain and functional activities in patients with lateral epicondylitis of the

elbow by mobilization with movement : A randomized, placebo-controlled pilot study. Journal of Physical Therapy Science, 24(9),

787–790.

• Marrón-Gómez, D., Rodríguez-Fernández, Á. L., & Martín-Urrialde, J. a. (2015). The effect of two mobilization techniques on

dorsiflexion in people with chronic ankle instability. Physical Therapy in Sport, 16(1), 10–15. http://doi.org/10.1016/j.ptsp.2014.02.001

• Mulligan, B. (1993). Manual Therapy Rounds: Mobilisations with Movement (MWM’s). The Journal of Manual & Manipulative

Therapy, 1(4), 154-156.

• Mulligan, B. R., (2010). Manual therapy NAGS, SNAGS, MWMs etc. (6th ed.). Wellington, New Zealand: Plan View Services Ltd.

http://doi.org/10.1054/math.2001.0434

http://doi.org/10.1016/j.ptsp.2014.02.001


References• Pagorek, S. (2009). Effect of manual mobilization with movement on pain and strength in adults with chronic lateral epicondylitis.

Journal of Sport Rehabilitation, 18(3), 448–457.

• Paungmali, A., Vicenzino, B. & Smith, M. (2003). Hypoalgesia induced by elbow manipulation in

lateral epicondylalgia does not exhibit tolerance. The Journal of Pain, 4(8), 448-454.

doi: 10.1067/S1526-5900(03)00731-4

• Paungmali, A., O’Leary, S., Souvlis, T. & Vicenzino, B. (2003). Hypoalgesic and Sympathoexcitatory effects of mobilization with

movement for lateral epicondylalgia. Physical Therapy, 83, 374-383. Retrived from: http://ptjournal.apta.org on Novemenber 27, 2014.

• Teys, P., Bisset, L., Collins, N., Coombes, B., & Vicenzino, B. (2013). One-week time course of the effects of Mulligan’s mobilisation

with movement and taping in painful shoulders. Manual Therapy, 18(5), 372–377. http://doi.org/10.1016/j.math.2013.01.001

• Teys, P., Bisset, L., & Vicenzino, B. (2008). The initial effects of a Mulligan’s mobilization with movement technique on range of

movement and pressure pain threshold in pain-limited shoulders. Manual Therapy, 13(1), 37–42.


• Tsirakis, V., & Perry, J. (2015). The effects of a modified spinal mobilisation with leg movement (SMWLM) technique on sympathetic

outflow to the lower limbs. Manual Therapy, 20(1), 103–108. http://doi.org/10.1016/j.math.2014.07.002

http://ptjournal.apta.org




References• Mulligan, B., Miller. J, Claassen R. (2005). Mulligan Practitioner (CD-ROM). Digital Concepts. Canadian distributor: Canzed

Seminars

• Vincenzino, B., Hing, W., Rivett, D. & Hall, T. (2011). Mobilisation with Movement: The art and science. Australia: Elsevier

• Vicenzino, B., Branjerdporn, M., Teys, P., & Jordan, K. (2006). Initial changes in posterior talar glide and dorsiflexion of the ankle

after mobilization With movement in individuals with recurrent ankle sprain. Journal of Orthopaedic & Sports Physical Therapy,

36(6), 464–471. http://doi.org/10.2519/jospt.2006.2265

• Vicenzino, B., Paungmali, A., Buratowski, S., & Wright, A. (2001). Specific manipulative therapy treatment for chronic lateral

epicondylalgia produces uniquely characteristic hypoalgesia. Manual Therapy, 6(4), 205–212. http://doi.org/10.1054/math.2001.0411

• Vicenzino, B., Paungmali, A., & Teys, P. (2007). Mulligan’s mobilization-with-movement, positional faults and pain relief: Current

concepts from a critical review of literature. Manual Therapy, 12(2), 98–108. http://doi.org/10.1016/j.math.2006.07.012

http://doi.org/10.2519/jospt.2006.2265

http://doi.org/10.1054/math.2001.0411


Thank You


Learning Lab


Tibio-Fibular IR Flexion – FWB

• Indications: limited or painful knee flexion

•Position: Pt FWB; clinician kneels lateral to Pt

•Hand Placement: grasp fibular head and tibial tuberosity with heel of hand and fingers

•MWM: IR tib-fib while patient performs the painful motion (e.g., DL squat)


Tibio-Fibular IR Flexion – Self MWM

• Indications: PILL effect on Tib-Fib IR MWM

•Position: Pt places foot of involved knee anterior onto chair (can start with leg in IR)

•Hand Placement: grasp fibular head and tibial tuberosity with heel of hand and fingers

•MWM: IR tib-fib while moving involved knee further into flexion


Tibio-Fibular IR - Taping

• Indications: PILL effect on tib-fib IR MWM

• Position: Pt FWB with leg/foot of involved knee into IR. Flexes knee slightly

• Taping: fix tape laterally, posterior to fibular head. Spiral in a superior and anterior direction (stay low on patellar tendon),cross medial joint line, posterior thigh, and finish laterally on thigh

• Reinforce the glide: can use anterior hand to provide tib-fib IR while applying tape. Apply 2nd strip of tape if needed


Tibio-Fibular Medial Glide Flexion – FWB

• Indications: limited or painful knee flexion

•Position: Pt FWB; clinician kneels lateral to Pt

•Hand Placement: grasp medial distal femur and lateral proximal fibula & tibia

•MWM: stabilize femur and apply a medial tib-fib glide while Pt performs painful motion (e.g., DL squat)


Tibio-Fibular Medial Glide – Self MWM

• Indications: PILL effect on tib-fib Medial Glide

•Position: Pt places foot of involved knee anterior onto chair

•Hand Placement: grasp medial distal femur and lateral proximal fibula & tibia

•MWM: stabilize femur and apply a medial tib-fib glide while moving involved knee further into flexion


Meniscus “Squeeze” Technique - NWB

• Indications: limited ROM, joint-line (JL) pain

• Position: Pt supine; clinician lateral to patient side of JLT

• Hand Placement: place medial border of 1st thumb at point of JLT; use pad of 2nd thumb to apply reinforcement to 1st

• Tx: apply a centrally-oriented “squeezing” force at the JL while the patient performs the painful motion (e.g., knee flexion or extension). If treating extension, release the “squeeze” as JL closes at the end ROM

**The treatment will be uncomfortable at the site of JLT


“Squeeze” Technique Overpressure

Variations in Full Knee Flexion

• Note: flexion “Squeeze” can be performed in NWB, PWB, and FWB while Extension “Squeeze”

only performed in supine


Lateral Ankle Sprain (LAS) MWM – Distal

Tibiofibular Joint• Indications: limited or painful

inversion after LAS

• Position: Pt long-seated, ankle off edge of table; clinician anteromedialto involved ankle

• Hand Placement: thenar eminance on anterior distal 2-3 cm of lateral melleolus

• MWM: glide the fibula dorso-cranial, while the patient performs ankle inversion. Apply a pain free overpressure at the end range


LAS MWM Variations

Patient uses strap to

apply passive over-

pressure at end range

Clinician uses padding

to minimize pain &

improve grip

Modified thenar grip

to avoid lateral

malleolus


LAS MWM - Taping

• Indications: PILL effect on LAS MWM

• Position: Pt long-seated, ankle off edge of table; clinician anteromedial to involved ankle

• Taping: fix tape laterally, just distal to lateral malleolus. Spiral in a superior posterior direction, cross the Achilles tendon posteriorly, finish anteriorly on the tibia

• Reinforce the glide: can use free hand to provide fibular glide while applying tape. Apply 2nd strip of tape if needed


Turf Toe MWM - Extension

• Indications: limited or painful great toe extension

• Position: Pt long-seated, ankle off edge of table; clinician lateral to involved foot

• Hand Placement: medial and lateral aspect, just proximal and distal to MTP joint line

• MWM: glide the metatarsal medially, laterally, or rotate, while the patient performs great toe extension


Turf Toe MWM - Taping

• Indications: PILL effect on LAS MWM

• Position: Pt long-seated, ankle off edge of table; clinician anteromedialto involved ankle

• Taping: fix tape laterally, just distal to lateral malleolus. Spiral in a superior posterior direction, cross the Achilles tendon posteriorly, finish anteriorly on the tibia

• Reinforce the glide: can use free hand to provide fibular glide while applying tape. Apply 2nd strip of tape if needed

Documents

Believe Me, Just WatchRaise Your Expectations for ... · PDF file• Positive outcomes (NRS, PVAS, PPT, PFG, ROM, strength, ... tissue derangement, referred pain ... medial, lateral,