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textbook of techniques
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Wayne Hing
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Toby Hall
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Darren Rivett
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Bill Vicenzino
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Brian Mulligan
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This publication has been carefully reviewed and checked to ensure that the content is as accurate and current
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as possible at time of publication. We would recommend, however, that the reader verify any procedures,
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National Library of Australia Cataloguing-in-Publication Data
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9780729541596
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National Library of Australia Cataloguing-in-Publication entry
The Mulligan concept of manual therapy : textbook of techniques / Wayne Hing, Toby Hall, Darren Rivett,
Bill Vicenzino, Brian Mulligan.
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9780729541596 (paperback)
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615.82
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In 2011, I had the privilege to write a foreword for Our concepts have come a long way from 1985
a new textbook on my concepts authored by Bill when, by chance, I had an unexpected instant
Vicenzino, Wayne Hing, Darren Rivett and Toby pain-free success with a traumatised finger using
Hall. This was a timely, excellent publication enti- what are now known as Mobilisations With
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tled Mobilisation With Movement: The Art and the Movement. The patient, who was a young woman
Science. in her early twenties, presented with a swollen
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My own manual on my concepts, now in its 6th interphalangeal joint which was painful and would
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edition, badly needed to be updated to include not flex. I tractioned the joint several times which
more detail and an improved format. This task has accomplished nothing. I then applied joint (glide)
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been undertaken and led by Wayne Hing, with all translations in the recommended biomechanically
the above authors again being involved. It has appropriate direction for flexion. Like the trac-
taken over two years to complete this task. These tions, these glides were also ineffective and painful.
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erudite authors also had the wisdom to involve I then tried a medial translation accessory move-
many of my Mulligan Concept international ment which was unacceptable to the patient
teachers. They have contributed by writing much
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because of pain. Without much enthusiasm I then
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of the text, each being allocated different regions gently tried a lateral translation which prompted
of the body and different techniques. I must here the patient to say it does not hurt. Something
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particularly acknowledge and thank my colleagues prompted me to sustain this translation and ask
Mark Oliver and Frank Gargano for the new tech- her if she could flex her finger. To my astonish-
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niques and material they have contributed. ment and her delight the finger flexed without
I believe that the contents in this book, in its pain! She then said something like You have fixed
new format, are priceless. All who deal with mus- me. Of course!, I replied. She still had a small loss
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culoskeletal conditions and practise manual of flexion range due to some residual swelling but
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described within this book are only to be used myself? The only explanation I could come up
when they produce no pain on application and with for my chance success was that as a result of
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because they should be immediately effective if her trauma there was a minute positional fault of
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indicated. I know of no other manual therapy pro- the joint preventing flexion movement. When this
cedures for the entire body, which follow these positional fault was corrected it enabled a full
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guidelines. What is really special about them is recovery to take place. It was a simple hypothesis
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that it only takes about two minutes to decide if and because of this I began to look differently at
they are indicated. Not to be able to use our con- all joints that I treated and experimented to see if
cepts may be denying patients their best treatment I could achieve similar results by repositioning
option. I now have many hours of video showing other joint surfaces. I began having unbelievable
the efficacy of our concepts, personally treating successes in the clinic. A miracle a day I called
patients on stage in many cities in America before them. Louis Pasteur once said that chance only
my peers. The hundreds who have witnessed these favours the prepared mind. When I, by chance,
occasions are left in no doubt as to the efficacy of had my first miracle with the young woman and
these techniques because of the regular positive her painfully limited interphalangeal joint, I did
and instant pain-free outcomes. indeed have a prepared mind.
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Today the concepts that have grown from this plane you will never be able to successfully manip-
chance finding have come a long way and guide- ulate or effectively apply the Mulligan concepts.
lines are now in place for their successful clinical I must stress that the techniques contained with
use; these are fully described within this textbook. this book are not set in stone. They are all based
To optimally succeed with our concepts, you need on repositioning joint surfaces, or muscles and
advanced clinical reasoning and excellent han- their tendons, to see if one can achieve pain-free
dling skills. The detailed descriptions in this book resolution of a musculoskeletal problem. The
will help you immensely in both these aspects. techniques described in the book are those we in
Ideally of course, the reader should attend the the Mulligan Concept Teachers Association have
courses that are available around the world by clinically found to be effective. If any clinicians
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accredited Mulligan Concept teachers. Teachers applying them, who have the requisite knowledge
and courses are listed at www.bmulligan.com and handling skills, can improve upon these tech-
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While on the topic of teachers, I always niques then this would be most welcome. It is
acknowledge and thank my mentor Freddy
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hoped they would share their significant worth-
Kaltenborn. Freddy came many times from Europe while improvements with other clinicians and
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to teach in faraway New Zealand. He taught me teachers.
how to manipulate every joint in the spine and to I feel very humble to have the support of such
mobilise the extremity joints. His able teachings scholars as Wayne, Toby, Bill and Darren, and
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gave me excellent handling skills. He also increased thank them and Elsevier sincerely for this won-
my knowledge and the importance he placed on derful publication.
the clinical significance of treatment planes led me
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to successfully develop Mobilisations With Move- Brian Mulligan
ment. If you do not know each joints treatment
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This book entitled The Mulligan Concept of reasoning underlying the application of the Mul-
manual therapy: textbook of techniques presents ligan Concept, including consideration of the evi-
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over 160 Mulligan Concept techniques and dence base. The case studies followed the
includes therapist techniques as well as home application of the Mulligan concept from the first
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exercises and taping techniques. The book is session to discharge, showing how the techniques
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aimed at being a comprehensive and easy to follow were selected, applied and progressed over the
resource for the novice and experienced clinician, treatment program. However, the purpose of that
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as well as researchers. The book has been written first book was not to provide a detailed descrip-
for the clinician, teacher and student interested in tion of all the techniques under the Mulligan
furthering their familiarity to the wide array of Concept umbrella, which is the scope of this
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techniques under the Mulligan Concept umbrella. current book as it continues the work of the pre-
Mulligan Concept techniques are effective and ceding landmark Mulligans Manual Therapy:
safe when applied in accordance with easy to
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NAGS, SNAGS and MWMs book.
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follow guidelines and clearly identified underlying There was a real need for a comprehensive pre-
principles. sentation of the wide array of techniques under
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When Brian Mulligan first described Mobilisa- the umbrella of the Mulligan Concept. These
tion with Movements (MWM) in 1984 he shared techniques include MWM and other Mulligan
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his techniques through his original book entitled techniques such as pain release phenomenon
Manual Therapy: Nags, SNAGs and MWMs of (PRP). Each technique has been described in a
which there have been six editions over the past consistent and logical format fully explaining the
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30 years. This book has been written to expand on indications, application and modifications for
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and fully describe in a standardised format all the each technique. In addition, we have detailed the
techniques mentioned in Brian Mulligans afore- current available evidence for each technique and
mentioned original texts, as well as include new provided Clinical Reasoning Gems, the aim of
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techniques that were not included in those earlier which is to illustrate pertinent information regard-
landmark editions. This book is also intended as ing clinical reasoning relating to techniques pre-
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Mobilisation with Movement: the art and the The book is divided into 14 regional chapters,
science which was published in 2011. covering the whole body, and encompassing the
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Our first book presented the science underpin- whole range of musculoskeletal disorders that
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ning MWM and also described aspects of the art present to clinical practice, including apparent
inherent in its successful implementation. In that non-joint disorders such as lateral epicondylalgia.
book the basic principles of MWMs were out- The first chapters focus on MWM, exercise and
lined, potential mechanisms underpinning the taping techniques for the upper quadrant that
successful application of MWMs were canvassed, include the cervical spine through to the thorax.
and in depth aspects of its clinical application These chapters include cervicogenic headache and
were critiqued including guidelines on dosage and cervicogenic dizziness, the temporomandibular
troubleshooting. Over half of the first text pre- joint, shoulder complex, elbow, forearm, wrist and
sented the application of MWM in a series of case hand. The subsequent chapters cover the lower
reports. These case studies focused on the clinical quadrant, including the lumbar spine, sacroiliac
]PPP
joint, hip, knee, ankle and foot. The final chapter with an explanation of the rationale underlying
covers commonly used PRPs, which are distinct the system of annotations.
to MWM, but can be very helpful in the right
clinical presentation, usually after the condition Professor Wayne Hing
being treated have proven resistant to other Mul- Auckland, New Zealand, 2014
ligan Concept techniques. Adjunct Associate Professor Toby Hall
The techniques in this text are drawn from Perth, Australia, 2014
those presented on the Mulligan concept courses Professor Bill Vicenzino
taught worldwide and as such form the curricu- Brisbane, Australia, 2014
lum of the different levels of those Mulligan Professor Darren A. Rivett
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Concept courses. Also presented is a dictionary of Newcastle, Australia, 2014
annotations for the techniques described, along
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(IV\[[OLH\[OVYZ
Wayne Hing, PhD Brian Mulligan, FNZSP (Hon.) Dip MT
Professor, Bond University, QLD, Australia Lecturer, Author, President MCTA
Toby Hall, PhD, MSc, Post Grad Dip Manip Bill Vicenzino, PhD, MSc, Grad Dip Sports
Ther Phty, BPhty
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Adjunct Associate Professor, School of Chair in Sports Physiotherapy, University of
Physiotherapy and Curtin Health Innovation Queensland: School of Health and Rehabilitation
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Research, Curtin University, Perth, WA, Sciences: Physiotherapy, QLD, Australia
Australia
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Snr Teaching Fellow, The University of Western
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Australia, Perth, WA, Australia
Fellow of the Australian College of
Physiotherapists
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Darren A Rivett, BAppSc(Phty),
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GradDipManipTher, MAppSc(ManipPhty), PhD,
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MAICD, APAM, MMCTA(Hon)
Professor of Physiotherapy and Head of the
School of Health Sciences, The University of
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Headache is both a symptom and a disorder in its own right, hence classification of headache is impor-
tant to ensure that correct treatment is administered (Dodick, 2010). The International Headache Society
(IHS) has broadly classified headache as primary, where there is no other causative factor, or secondary
where the headache occurs in close temporal relationship to another disorder to which it is attributed
(Classification Committee of the International Headache Society, 2004). Cervicogenic headache (CGH)
is one form of secondary headache, which arises from disorder of the cervical spine.
Current medical teaching indicates that each form of headache has a different pathological basis, the
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majority of which do not have a musculoskeletal cause (Dodick, 2010). Hence, it is critical that the
individual presenting for treatment has their type of headache correctly identified. This is particularly
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important for manual therapists considering physical intervention for headache, where such interven-
tion is unlikely to be effective for disorders other than those affecting the musculoskeletal system (Hall,
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2011).
Mechanisms underlying CGH are those of convergence of afferent input from the upper three cervical
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segments with input from trigeminal afferents in the trigeminocervical nucleus (Bogduk & Govind,
2009). Hence input from sensory afferents in the cervical spine may be mistakenly perceived as pain in
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the head (Bogduk & Govind, 2009). Classification of headache disorders based on patient reported
symptoms and history is problematic due to the overlap of features between CGH and migraine and
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other headache forms. Headache classification is therefore based on physical examination. The cervical
flexion-rotation test (FRT) has been found to be a useful test to discriminate CGH from migraine or
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mixed headache forms (Hall, Briffa, Hopper & Robinson, 2010a). The positive cut-off point is 3233
(Hall, Briffa, Hopper & Robinson, 2010b; Hall, Briffa & Hopper, 2010; Ogince, Hall, Robinson &
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Blackmore, 2007). An MRI study revealed that a positive test primarily indicates limitation of movement
at the C1/2 level (Takasaki et al., 2010). The degree of limitation on this test has been shown to correlate
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with the severity, frequency, and duration of headache symptoms (Hall et al., 2010b), as well as being
independent of other physiological and lifestyle factors (Smith, Hall & Robinson, 2007). Consequently
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the test has utility regardless of the age, gender or lifestyle of the person tested. Further study is required
to identify the FRTs sensitivity to change as an outcome measure.
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In the presence of a positive FRT, a C1/2 self-SNAG can be applied as a treatment technique to attempt
to restore normal range of motion and reduce symptoms. However, if a patient presents to the clinic
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experiencing a CGH at the time of consultation and has a positive FRT, then a trial of Headache SNAG,
Reverse Headache SNAG, or upper cervical traction should be administered first. On subsequent visits,
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if symptoms are reduced but the FRT remains positive, then a C1/2 self-SNAG should be considered at
that point.
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The application of a self-SNAG to people with chronic CGH and a positive FRT was shown to be
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superior to a placebo treatment in a randomised clinical trial (Hall et al., 2007). Hall et al. (2007) showed
that when compared to the placebo the self-SNAG improved range recorded during the FRT by 10
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(95% CI: 4.7 to 15.3) immediately after application and that at 12 months the treated group were 22
(13 to 31) points superior on the headache severity index (baseline headache severity index approxi-
mately 54/100).
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also improve outcomes, as may the prescription of a self-fist traction as a home programme technique if the patient
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It may be possible to teach the patients partner, or another family member, to perform the traction technique.
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