The Mulligan Concept - Principles

1. Theoretical Foundation - The "Positional Fault" Theory

2. Core Techniques

A. Mobilisation with Movement (MWM)

• Used for peripheral joints (shoulder, elbow, knee, ankle, wrist, etc.)
• The therapist applies a sustained accessory glide to the joint while the patient actively performs the previously painful or restricted movement
• Gentle overpressure may be added at the end range to further improve range of motion
• The technique is patient-driven - the patient's immediate pain response guides the therapist in selecting the correct glide direction and force

B. Sustained Natural Apophyseal Glides (SNAGs)

• Used for the spine (cervical, thoracic, lumbar)
• A sustained glide is applied to the spinous process or articular pillar while the patient performs an active spinal movement (e.g., flexion, rotation)
• Designed to restore pain-free spinal range of motion

C. Natural Apophyseal Glides (NAGs)

• Oscillatory central or unilateral posteroanterior glides applied to the cervical and upper thoracic spine
• Applied mid-range (unlike SNAGs which go through full range)
• Used for general spinal stiffness and pain

D. Mobilisation with Movement using a Belt/Strap

• A non-elastic belt (Mulligan belt) is used as an alternative to hand contact
• Allows the therapist to apply a sustained glide at the hip or pelvis
• Particularly useful for hip joint techniques and spinal techniques (Spinal Mobilisation with Leg Movement - SMWLM)

E. Self-Mobilisation Techniques

• Patients are taught to replicate the glide technique at home using their own hands, a towel, or a strap
• Extends the therapeutic effect between clinic visits

3. The CRIPS Rule (Guiding Principles)

4. Key Application Principles

• Pain-free is mandatory: If the movement remains painful, the therapist must change the direction, angle, or magnitude of the glide. Pain during a technique is an absolute contraindication to continuing.
• Active patient participation: Unlike passive manipulation, the patient actively performs the movement - the therapist never forces the joint passively through range.
• Functional reassessment: The outcome is tested immediately in a functional position or activity relevant to the patient's complaint.
• Direction specificity: The correct glide direction is found by trial and error - typically it is parallel to the joint treatment plane (Kaltenborn's concept) but may be cranial, caudal, medial, lateral, or rotatory.
• Force magnitude: The glide force must be sufficient to correct the positional fault but never provocative.

5. Proposed Mechanisms (Current Evidence)

• Mechanical: Correction of a subtle positional fault/joint maltracking
• Neurophysiological: Activation of mechanoreceptors causing hypoalgesia (pain gate mechanisms, activation of descending pain inhibitory pathways)
• Neurodynamic: Normalisation of neural tissue mechanics alongside joint mechanics
• Placebo/contextual: The therapeutic interaction and expectation of improvement

6. Indications

• Peripheral joint pain and restricted range of motion (tennis elbow, ankle sprains, knee pain, shoulder impingement)
• Cervicogenic headache
• Cervical, thoracic, and lumbar pain
• Post-fracture rehabilitation
• Sports injuries
• Chronic pain with movement restriction

7. Contraindications

• Active inflammatory arthritis (acute flare)
• Fractures, tumours, or infection at the treatment site
• Osteoporosis (relative contraindication - reduce force)
• Neurological compromise requiring urgent intervention
• Any technique that produces pain - must stop immediately

Summary