• A therapist applies a sustained accessory glide to a joint while the patient actively performs a previously painful movement
• The glide corrects a "positional fault" - a minor malposition of joint surfaces following injury
• The movement must be pain-free during application; if pain occurs, the technique is wrong or contraindicated
• Immediate and lasting improvement is expected

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

• Cozen's test = resisted wrist extension with elbow extended → pain at lateral epicondyle confirms lateral epicondylitis (tennis elbow). (Already marked correct)

• Muscle Energy Technique (MET) uses the patient's own isometric contraction (post-isometric relaxation or reciprocal inhibition) to stretch and mobilise restricted tissues. (Already marked correct)

• ABPI = Highest ankle systolic BP ÷ Highest brachial systolic BP. Normal ≥ 0.9; <0.9 indicates peripheral arterial disease. (Already marked correct)

• Normal motor NCV in large myelinated fibers ranges from 40–70 m/s, with the standard reference being approximately 50–60 m/s. (Already marked correct)

• ASIA Impairment Scale C = Motor incomplete; motor function preserved below neurological level, but more than half of key muscles below the level have muscle grade < 3.
• AIS-D = more than half have grade ≥ 3. (Already marked correct)

• Phalen's test (wrist flexion for 60 seconds) → reproduces tingling/numbness in median nerve distribution → positive for carpal tunnel syndrome. (Already marked correct)

• In obstructive disease (asthma, COPD), FEV1 is disproportionately reduced → FEV1/FVC ratio < 0.70. In restrictive disease, both FEV1 and FVC fall proportionally, so ratio is preserved or increased. (Already marked correct)

• Increased HCO3 (primary) → raises pH (alkaline) = Metabolic alkalosis. (e.g., vomiting, diuretic use). (Already marked correct)

• Tremors = rhythmic, involuntary oscillatory movements from alternating contraction of agonist-antagonist muscle pairs. Dyssynergia = inability to perform coordinated movements; Titubation = head/trunk tremor; Asthenia = weakness. (Already marked correct)

• NCV is affected by:
  • Age - decreases with aging (reduced myelination)
  • Temperature - decreases ~2 m/s per 1°C fall in limb temperature
  • Limb variation - upper limb NCV is generally faster than lower limb (Already marked correct)

Summary Table

Case: 50-year-old female teacher - Right Shoulder Pain & Stiffness

i. PT Assessment (6 marks)

A. Subjective Assessment

• 50-year-old female, teacher (overhead occupation)
• Right shoulder pain + stiffness - 4 months duration
• Insidious onset, gradual progression
• Aggravated at night (inflammatory component) and overhead activities
• Functional limitations: combing hair (hand-behind-head), wearing clothes (internal rotation), lifting objects above shoulder level

• Known case of Diabetes Mellitus (major risk factor - insulin-dependent patients are nearly 5x more likely to develop frozen shoulder)

• Occupational impact: difficulty writing on board, overhead activities as a teacher
• ADL limitations: dressing, grooming, reaching overhead

• Rule out: cervical radiculopathy, malignancy, referred cardiac pain (left side), infection

B. Objective Assessment

• Posture: forward head posture, rounded shoulder, muscle wasting (supraspinatus/deltoid)
• Gait: arm held close to body, reduced arm swing

• Tenderness over anterior and inferior joint capsule
• Coracoid process tenderness
• No warmth/swelling (distinguishes from acute inflammation)

• Deltoid, supraspinatus, infraspinatus: reduced due to pain inhibition
• Scapular stabilisers: weakened secondary

• VAS/NPRS score (0-10) - at rest, on movement, at night
• Character: aching at rest, sharp on movement

• DASH score (Disabilities of Arm, Shoulder and Hand)
• SPADI (Shoulder Pain and Disability Index)
• PSFS (Patient Specific Functional Scale)

ii. Structural and Functional Impairments (5 marks)

Body Structure Impairments:

1. Thickened and contracted glenohumeral joint capsule - hallmark of adhesive capsulitis; joint volume reduced from normal ~30 mL to <10 mL
2. Fibrosis of the rotator interval - especially coracohumeral ligament and superior glenohumeral ligament
3. Axillary pouch obliteration - inferior capsule binds to itself
4. Reduced joint space on imaging
5. Possible rotator cuff involvement - secondary to disuse and restricted mobility

Body Function Impairments:

1. Severe restriction of active and passive ROM - capsular pattern (ER > Abd > IR)
2. Pain - insidious, present at rest and aggravated at night and with movement
3. Reduced muscle strength and endurance - disuse atrophy of deltoid and rotator cuff
4. Impaired neuromuscular control - altered scapulohumeral rhythm
5. Reduced proprioception - secondary to capsular mechanoreceptor involvement

iii. Contextual Factors (3 marks)

Environmental Factors:

Personal Factors:

Summary of Diagnosis:

This is a primary adhesive capsulitis (secondary to diabetes mellitus) presenting in the freezing-to-frozen phase, characterised by insidious painful stiffness, capsular pattern restriction of both active and passive ROM, and significant functional limitations in a middle-aged diabetic female teacher. The prognosis is guarded given the diabetic background, with a longer expected natural history of 12-24 months. Physiotherapy targeting pain relief, ROM restoration, and functional recovery is the primary management approach.