S T E P B Y S T E P G U I D E T O D E L I V E R M A N U A L T H E R A P Y

B A S E D O N M U L L I G A N C O N C E P T

More than 1500 illustrations More than 1500 illustrations (including common mistakes done by therapists)(including common mistakes done by therapists)

SINCE 1992

R

Red Dot- denotes

STABILIZATION

Blue line- denotes

TREATMENT PLANE

Green Arrow- denotes

DIRECTION OF THE GLIDE

Red Arrow- denotes

DIRECTION OF STABILIZATION

Thumb down - denotes

WRONG HAND PLACEMENT/

THERAPIST POSITION

Thumb up - denotes

CORRECT HAND PLACEMENT/

THERAPIST POSITION

White line- denotes

MOVEMENT PLANE

Pointed finger - denotes

ATTENTION TO BE GIVEN

This book has been written for physiotherapists who practice manual therapy, and for those clinicians who are keen ongetting an insight into the Mulligan Concept. From its introduction and especially in the recent past, Mulligan Concepthas gained a lot of popularity because of its instantaneous and effective results.

The Mulligan Concept is one of the preferred concepts in the field of manual therapy. It is often the first choice oftreatment among clinicians because this concept allows the patients to perform the offending movements in afunctional position, that too in a pain-free way, hence, making the outcome very rewarding.

The thought process behind this book has been to elaborate the Mulligan Concept in a step by step manner to ensureeasy understanding and comprehension of all the techniques used in the concept. Its systematic approach to teachingthe principles behind the concept makes it particularly valuable to the physical therapist practicing Mulligan Concept.

This book features descriptions of all the techniques in the Mulligan Concept with a detailed set of illustrations in asequential manner. Emphasis has been laid on the patient's position, therapist's position, hand and belt placementincluding method of delivery of treatment with proper communication and reasoning throughout this book. Theaccurate application of the techniques is necessary to obtain optimal results; and the book emphasizes on this throughdemonstration of precautions to be taken. In this book, a free-flow of language is used to ensure that the user is able toactually feel the practical essence and easily understands the details.

Most of the Illustrations are provided with the following signs and symbols to enhance the reading experience and forbetter understanding of the Concept.

This book contains 288 pages covering the following topics

CHAPTER 1: CERVICAL SPINE

CHAPTER 2: THORACIC SPINE

CHAPTER 3: LUMBAR SPINE

CHAPTER 4: SACRO-ILIAC JOINT

CHAPTER 5: HIP JOINT

1.1. Natural Apophyseal Glides (NAGs)

1.2. Reverse NAGs

1.3. Sustained Natural Apophyseal Glides (SNAGs)

1.4. Functional SNAGs/Cervical MWMs

1.5. Fist Traction

1.6. Segmental Traction for Cervical Spine

1.7. Forearm Traction for Cervical Spine

1.8. Assessment of Cervicogenic Headache

1.9. Headache SNAGs with Headache

1.10. Reverse Headache SNAGs with Headache

1.11. Headache SNAGs withoutHeadache

1.12. Vertigo SNAGs

1.13. Self-SNAGs

2.1. Segmental Traction for Thoracic Spine

2.2. Sustained Natural Apophyseal Glides (SNAGs)

2.3. Self-SNAGs for Thoracic and Lumbar Spine

2.4. MWMs for Intercostal Joints/Space

2.5. MWMs for Costochondral / Costovertebral Joints

st2.6. MWM for 1 Rib

3.1. Segmental Traction for Lumbar Spine

3.2. Sustained Natural Apophyseal Glides (SNAGs)

3.3. Bent Leg Raise (BLR) Technique

3.4. Two Leg Rotation Technique/GateTechnique

4.1. Anterior Innominate Dysfunction (Postero-Medial MWM)

4.2. Posterior Innominate Dysfunction(Antero-Lateral MWM)

4.3. MWMs for Up-Slip/Down-Slip Dysfunction

4.4. MWMs for Anterior Tilt Dysfunction

4.5. MWMs for Posterior Tilt Dysfunction

4.6. MWMs for Nutation/Counter-NutationDysfunction

5.1. MWM for Hip Flexion (Non-WeightBearing)

5.2. MWM for Hip Internal/External Rotation (Non-Weight Bearing)

5.3. MWM for Hip Extension (Non-WeightBearing)

5.4. MWM for Positive Faber Test

5.5. MWM for Hip Abduction (WeightBearing)

5.6 MWM for Hip Extension (WeightBearing)

5.7. MWM for Hip Flexion (Weight Bearing)

5.8. MWM for Hip Internal/ External Rotation (Weight Bearing)

5.9. MWM for Hip Abduction (Tight Adductors)

5.10. MWM for Hip Extension (Tight Quadriceps)

5.11. Traction SLR

5.12. Compression SLR

6.1. Medial MWM for Knee Extension

6.2. Medial MWM for Knee Extension with Belt

6.3. Medial MWM for Knee Flexion

6.4. Medial MWM for Knee Flexion with Belt

6.5. Lateral MWM for Knee Extension

6.6. Lateral MWM for Knee Extension with Belt

6.7. Lateral MWM for Knee Flexion

6.8. Lateral MWM for Knee Flexion with Belt

6.9. Rotational MWM (Medial)

6.10. Rotational MWM (Lateral)

6.11. Squeeze Technique

6.12. MWM for Terminal Knee Flexion

6.13. MWM for Superior Tibio-Fibular Joint

7.1. Ankle Rocking

7.2. MWM for Tarso-Metatarsal

7.3. MWM for Metatarsal

7.4. MWM for Foot (Toes)

7.5. MWM for Ankle Sprain

7.6. MWM for Plantar Flexion

7.7. MWM for Dorsiflexion

7.8. MWM for Ankle Dorsiflexion in Weight Bearing (with Hand)

7.9. MWM for Ankle Dorsiflexion in Weight Bearing with Belt

8.1. MWM for Shoulder Distraction

8.2. MWM for Shoulder Internal/ External Rotation (Belt)

8.3. MWM for Shoulder Flexion (Belt)

8.4. MWM with Traction

8.5. MWM for Terminal Internal Rotation

8.6. Postero-Lateral MWM for Shoulder Pain

o8.7. Postero-Lateral MWM for Flexion (30

oto 120 ) with Belt

8.8. Acromio-clavicular Joint Assessment

8.9. MWM for Acromio-clavicular Joint

8.10. MWM for Sterno-clavicular Joint

8.11. Postero-Lateral MWM forFlexion o

(beyond 120 ) with Belt

8.12. MWM for Internal/External Rotation (Gross Restriction)

8.13. Shoulder Girdle MWM (4-point Correction in Sitting)

8.14. Shoulder Girdle MWM (Lion Position)

9.1. Medial and Lateral MWM for Extension

9.2. Medial and Lateral MWM for Flexion

9.3. Lateral MWM for Elbow Flexion/Extension (with Belt)

9.4. Medial MWM for Elbow Flexion/Extension (with Belt)

9.5. Self-MWM (Elbow)

9.6. MWM for Tennis Elbow (Lateral Glide)

9.7. MWM for Tennis Elbow (with Belt)

9.8. Self-MWM for Tennis Elbow

CHAPTER 6: KNEE JOINT

CHAPTER 7: ANKLE AND FOOT COMPLEX

CHAPTER 8: SHOULDER JOINT

CHAPTER 9: ELBOW AND FOREARM

9.9. MWM for Distal Radio-ulnar Joint

9.10. MWM for Proximal Radio-ulnar Joint

10.1. MWM for PIP, DIP and MCP Joints

10.2. MWM for Metacarpals

10.3. MWM for Intercarpal Joints

10.4. MWM for Wrist Joint (Lateral/Medial/Rotation)

10.5. MWM for Wrist Joint (Anterior/Posterior)

10.6. MWM for Wrist Joint (Weight Bearing)

11.1. Scapula

11.2. Lumbar Spine

11.3. Wrist Joint

11.4. PIP/DIP Joint

11.5. Tennis Elbow

11.6. Knee Joint (Osteoarthritis)

11.7. Sacro-Iliac Joint

11.8. Shoulder Joint

11.9. Ankle Sprain

11.10. Retrocalcaneal Bursitis/Tendo-AchillesStrain

11.11. Plantar Fasciitis

11.12. Tarso-Metatarsal Joint

11.13. Miscellaneous Taping Techniques

12.1. Hip Joint

12.2. Shoulder Joint

12.3. De Quervain's Tenosynovitis

12.4. Small Joints (Inter tarsals, Inter carpals and finger joints)

12.5. Golfer's Elbow

12.6. Tennis Elbow

12.7. Sesamoid Bone and Great Toe

13.1. Spinal Mobilization with Arm Movement (SMWAM)

13.2. Neural Tissue Mobilization (Neurodynamic Test Position)

13.3. SMWAM (Radial Nerve)

13.4. SMWAM (Median Nerve)

13.5. SMWAM (Ulnar Nerve)

13.6. Neurodynamic SNAGs (Radial Nerve)

13.7. Neurodynamic SNAGs (Median Nerve)

13.8. Neurodynamic SNAGs (Ulnar Nerve)

13.9. Spinal Mobilization with Leg Movement (SMWLM)

13.10. SMWLM (Femoral Nerve) 2 Therapists' Technique

13.11.SMWLM 3 Therapists' Technique

13.12. SMWLM (Sciatic Nerve) Single Therapist Technique

13.13. SMWLM (Femoral Nerve) Single Therapist Technique

13.14.Neurodynamic SNAGs (Sciatic Nerve)

13.15. Neurodynamic SNAGs (Femoral Nerve)

13.16.Neurodynamic SNAGs (Saphenous Nerve)

CHAPTER 10: WRIST AND HAND

CHAPTER 11: TAPING

CHAPTER 12: PAIN RELEASING PHENOMENON (PRPs)

CHAPTER 13: NEURODYNAMICS

SUGGESTED READINGS

GLOSSARY

INDEX

Illus. 1.1.1 : Cervical Spine

NAGs

•

•

NAGs are small amplitude, multiple, rhythmic,

mid to end range gentle oscillatory glides

which can be applied to the cervical spine

from C to C .2 7

These are the mildest form of manual therapy.

Illus. 1.1.2 : Cervical Spine and its Treatment Plane

•

•

These are small gentle glides and should

always be pain-free for the patients. If these

are painful in spite of applying correctly, then

all other means would be painful.

Gross restriction in cervical range of motion.

Indications

1.1 Natural Apophyseal Glides (NAGs)

CERVICAL SPINE1

•

•

•

•

•

These can be used in the case of elderly

patients having severe spondylitic changes.

To relieve post-manipulative soreness.

To check irritability of the cervical spine.

Sitting upright at the edge of a chair without

armrest (Illus.1.1.3)

Head of the patient should be held in neutral

position (neck may be kept in slightly flexed

position in order to have better palpation, if

pain-free).

Patient Position

Therapist Position

Hand Placement

•

•

•

•

Walk stance- standing antero- lateral to the

patient with weight evenly distributed on

both the feet (Illus.1.1.3).

Therapist's groin is in contact with the antero-

lateral surface of the patient's shoulder.

Therapist cradles the patient's head from his

hand, forearm and antero- lateral side of the

torso.

Therapist grasps the patient's base of the head

Illus. 1.1.3 : Position of the Therapist and the Patient for Central NAGs

Illus. 1.1.4 : Hand Placement of Therapist on Spine for Central and Unilateral NAGs

MANUAL OF MULLIGAN CONCEPT 5R

and all vertebrae above the level of

mobilization with his index, middle and ring

fingers of one hand (except little finger which

is to be used for mobilization).

Middle phalanx of little finger of the same

hand is placed under the spinous process, i.e.,

hooking the spinous process to the desired

level (vertebra to be mobilized).

Small gap should be maintained between little

and ring finger (Illus.1.1.4).

•

•

•

•

•

Lateral border of thenar eminence of the other

hand is placed obliquely under the little finger

in order to push it towards the eye ball of the

patient (as per treatment plane).

Mobilizing hand should be in mid-prone

position with the wrist in slight ulnar

deviation.

The glide is given by pushing the middle

phalanx of little finger of stabilizing hand with

the thenar eminence of mobilizing hand

antero-cranially (towards the eyeball of

patient) along the treatment plane

(Illus.1.1.2, 1.1.4, 1.1.6).

Mobilization

Illus.1.1.5 : Position of the Therapist and the Patient for Central NAGs with Mild Traction

•

•

•

•

Unilateral NAGs for cervical facet joints are

given antero- cranially towards the opposite

eyeball (Illus.1.1.4).

2-3 oscillations are performed per second.

Glides are performed rhythmically through

mid to end range after taking up the slack.

Traction to the cervical segments can also be

provided using the above technique.

Variations

•

•

•

The therapist applies traction to the cervical

spine by gaining his height and shifting the

weight from his front foot to the back foot

and then the glide can be performed at the

desired level (Illus.1.1.5).

In the case of patients with an exaggerated

cervical lordosis, the therapist can perform

the above glide after the patient is instructed

to do chin retraction.

For unilateral NAGs, little finger is placed on

the facet joint of the affected side by moving it

little laterally from the spinous process

(Illus.1.1.6).

6 CHAPTER 1 \ CERVICAL SPINE

Precautions To Be Taken

Reasoning

•

•

•

•

•

•

Do not block airway of the patient.

Any rotation, side-flexion of the neck should

be avoided (Illus.1.1.7).

Female therapist is advised to use a pillow or a

thick towel between the patient's head and

her breast. Patient's trunk should be properly

stabilized (Illus.1.1.8).

Therapist should use brachioradialis for giving

the glide and not the pronators of the

mobilizing forearm (Illus.1.1.5).

Inferior facet of the superior vertebra glides

cranially on the superior facet of the inferior

vertebra (to treat C segment, facet joint /4-5

spinous process of C is mobilized).4

Mobilization induced movement helps to

provide nutrition to the facet joints and disc.

Illus. 1.1.6 : Hand Placement of Therapist for Central and Unilateral NAGs

•

•

•

•

It might correct the positional fault between

affected facets.

It might release an entrapped meniscoid

between facet joints, if any.

It might stimulate mechanoreceptors and

proprioceptors in and around the joints.

It helps to release muscles around the joints.

Illus. 1.1.7 : Common Mistakes done by the Therapist during NAGs

Illus. 1.1.8 : Use of Pillow/Towel during NAGs

MANUAL OF MULLIGAN CONCEPT 7R

Dr. Deepak Kumar, MSPT, FIAP, CMP, PhD, MCTA

Dr. Deepak Kumar graduated from National Institute (1993) &

completed his PG in Sports Physiotherapy (2000) and Doctorate in Mulligan

Concept (2012). He has also been to Curtin University, Australia, to get his

super specialization in Manipulative Physiotherapy (2002). He was

awarded with distinguished service award by Indian Association of

Physiotherapists in 2006 and the prestigious fellowship award from Indian

Association of Physiotherapists in 2010. He is a clinical teacher and

examiner to various Universities in India.

He is one of the certified Mulligan Concept Teachers. He is also a

certified McConnell Concept Teacher for Asia region. Trained more than

10,000 students during the last 11 years from various reputed institutes of

Asia. Made 12 inventions in manual therapy, electrotherapy & exercise

therapy. Guided 53 research projects and still growing. Presented 34

research papers in various state/ national & international conferences like

IFOMT and WCPT, bagged 9 best papers and six 1st runner up awards.

Published 4 papers in reputed journals. The new techniques on Mulligan

Concept have been acknowledged by Brian Mulligan and mentioned in his th th

5 & 6 edn. book.

Dr. Deepak Kumar has an excellent background in teaching,

research, & clinical management skills to run Manual Therapy courses.

Treated more than 80,000 patients during the last 20 years (together with

the team). Administrating more than 60 professionals & support staff as

Director of Capri Institute of Manual Therapy. Organized more than

hundreds of CME / workshops / conferences including International

Conference on Manual Therapy in 2005, 2006, 2013 & 2014.

ISBN 13: 978-81-930073-9-6

S T E P B Y S T E P G U I D E T O D E L I V E R M A N U A L T H E R A P Y

B A S E D O N M U L L I G A N C O N C E P T

Capri Institute of Manual TherapyNew Delhi, INDIAwww.capri4physio.com

SINCE 1992

R