Manual Therapy (996) 1118-126 (©1996 Pearse Profesional Lid Peripheral mobilisations with movement Linda Exelby Physiotherapy Department, Lister Hospital, Stevenage, Herts, UK SUMMARY. ‘The use of mobilisations with movement (MWM) for peripheral joints has been developed by Mulligan, A mobilisation is applied parallel or at right angles to the restricted joint movement. Ifthe applied ‘mobilisation achieves immediate improvement in the functional movement and abolishes the pain the treat- ment involves sustaining the mobilisation while the patient performs the active movement repetitively. On reassessment of the joint function, the movement should remain improved without the mobilisation. Theories as to why these techniques provide rapid improvement in pain-free range are proposed, and the general prin- ciples of examination and treatment are outlined. Specific clinical examples demonstrate how MWM can be used in isolation or integrated with other manual approaches to improve the quality of joint intraarticular gliding, neurodynamics and the facilitation of correct muscle recruitment. INTRODUCTION when the presenting problem is pain on an isometric contraction of muscle around a joint, The treatment of ‘The use of Brian Mulligan’s treatment approach of com- choice would be a glide to the joint that allows a pain- dining passive mobilisations with active movement in free isometric contraction. The latter was found to be the management of musculoskeletal dysfunction has particularly useful in the treatment of tennis elbow ‘become widespread amongst manual physiotherapists when the contraction of the wrist extensor muscles was in recent years. These techniques were pioneered by painful (Mulligan 1995; Vicenzino & Wright 1995). “Mulligan in New Zealand in the 1970s, Mulligan incor- This aticle proposes possible reasons for the rapid porated Kaltenbom’s (1989) principles of passive increase in pain-free movement, outlines the principles of ‘mobilisation in this approach. The combination of an treatment and illustrates via clinical examples how MWMs active movement with simultaneous passive accessory can be successfully utilised in the peripheral joints. ‘mobilisations directed along the zygapophyseal joint planes was used initially in the cervical spine. The iech- niques, performed in the weightbearing position, were PROPOSED MECHANISMS later found to be equally effective when treating other areas of the spine, They are thought to achieve painless Mulligan (1995) proposed that a minor positional fault ‘movement by restoring the reduced accessory glide. of the joint may occur following an injury or strain, ‘Similar principles can be applied to the treatment of resulting in movement restrictions or pain. Lewit (1985) peripheral musculoskeletal disorders and are termed has shown that reduced joint mobility can often be a ‘mobilisations with movement’ (MWM) (Mulligan result of a ‘mechanical block” from inert structures 1993; Mulligan 1995). In essence, the limited painful within a joint. Joint afferent discharge and optimal mus- physiological movement is performed actively while cle recruitment are closely linked (Stokes & Young the therapist applies a sustained accessory glide at right 1984, Schaible & Grubb 1993). Joint movement can be angles or parallel to the joint. The aim is to restore a reduced as a result of reflex muscle splinting (Lewit restricted, painful movement to a pain-free and full 1985, Schaible & Grubb 1993, Tayloret al 1994) which range state. These principles apply not only to painful prevents further damage and reduces nociceptor dis- active joint movements but may be equally effective charge from the joint by holding it in the mid-range position, It is suggested that treatment directed at the ERE RRMA ‘Rt Wil ave an eet on muscle activity and vice ne |, Grad Dip Man Ther, . ‘versa. Experiments carried out by Thabe (1986), Taylor MACE, See Phaterpi Piengy Deparment Ler P1999) wo ey et al (1095) uno elecvotyog, Hospital, Coreys Mil Lane, Stevenage, Hers SG14AB, UK, ‘Correspondence and equests fr opin to: LE raphy demonstrated that joint mobilisation and manipu-Peripheral mobilsatons with movement 119 lation had a reffex effect on the activity of segmental ‘muscles Baxendale & Ferrell (1981) and Lundberg et al (1978) have shown that end-range passive movements, have a reflex inhibitory effect on the muscle acting over the joint. Gerrard and Matyas (1980) on the other hand, ‘were unable to demonstrate any changes in muscle actv- ity with gentle mobilisation techniques performed inthe resistance-ree part ofthe range. This seems to indicate that to affect muscle reflexly via joint afferents the ‘mobilisation technique must be performed into resis- tance, However, to achieve the desired effect on muscle the mobilisation must be performed into resistance with- ‘out excessive pain a this would lead to an adverse effect ‘on the segmental muscle (Cobb etal 1975). This can be demonstrated clinically when mobilisation performed tno strongly results in protective muscle spasm. -MWMSs provide a passive painfree end-range corree- tive joint glide with an active movement. The combina- tion of joint mobilisation with active movement may be responsible for the rapid return of painfree movement PRINCIPLES OF TREATMENT Human joint surfaces are not fully congruent and physi- ological movements occur as a combination of a rota tion and a glide (Williams 1995), The Kaltenborn and Mulligan concepts place particular emphasis on restora- tion of the glide component of joint movement to facli- late full pain-free range of movement. The various slides used with MWMSs can be determined by applying Kaltenbom’s conceptual model (1989): Convex/Coneave rate the direction of decreased joint gliding in a hypomobile joint, and thus appropriate treatment can be deduced by this rule. When the convex joint partner moves, the slide occurs in the opposite direction (Fig. 1), e.g. with shoulder abduction a longitudinal caudad glide of the humerus occurs. With movement of a concave joint partner the glide occurs in the same direction (Fig. 2), e.g. with knee flexion in non-weight-bearing, there is an anteroposterior glide of the tibia on the femur. vv ({ * MOBIL. FIX. Fig. When the convex joint partner moves the side occurs inthe ‘opposite direction. (Reproduced itn kind permission from Physiotherapy 1995; $1 12) 725-72.) Fix. + )\} MOBIL. » 4 Fig.2_When the concave joint partner moves the glide oceurs inthe same diestion. Reproduced with kind permission fom Physiotherapy 1998; 81(12): 726-729.) ‘Treatment plane rule A treatment plane passes through the joint and lies at a right angle to concave joint partner (Fig. 3). Treatment is always applied parallel to this treatment plane. Hinge joints often respond particularly well to this glide, and this may be a frst treatment choice (Mulligan 1995). In summary the mobilisation or glide can be applied to a joint in two ways: (1) At right angles to the joint movement, e-g. a medial or lateral glide on the tibia hen improving flexion and extension (Fig. 4). (2) The appropriate glide can be determined by applying the concave convex rule, e.g. an anteroposterior (AP) slide ‘on the tibia when improving knee flexion (Fig. 5). If applying the above principles does not provide sut- ficient improvement, a more recent development is to apply a sustained rotation to the moving joint partner. ‘The conjunct rotation normally accompanying the phys- iological active movement being treated may be the ini- tial choice of techniqui ‘When pain with movement occurs in the carpal or tarsal bone regions, this pain can often be eliminated by gliding one bone relative to another and combining this with the painful movement. With joint movements that involve adjacent long bones such as at the wrist (radius and ulna), the ankle (tibia and fibula), the metatarsals and metacarpals itis often necessary (0 glide one long bone relative tothe other to achieve pain-free movement. EXAMINATION ‘The clinical examination of the musculoskeletal dys- function aims to establish the diagnosis and determine the underlying causative factors of the patient's symp- toms so that ¢he appropriate treatment can be imple- ‘mented. It is essential to identify and analyse both the ‘movement that precipitated the injury and functional activities that continue to exacerbate the symptoms. A. knowledge of normal anatomy and biomechanics is essential so that abnormalities can be identified. Active and passive physiological movements and accessory glides are performed so that their contribution to the ‘movement dysfunction and symptoms can be analysed.120 Macust Therapy gtde Conve, ' ' ‘ ' Fig. 3A trcement plane passes rough the jon and les a 99 res toa concave joint parser. Repraduced with Kind permission rm Phyieherapy 1995:81( 12}: 120-729) For example, ifa patient has a painful limitation of wrist extexsion, the passive physiological and accessory com- ponents of radiocarpal and midcarpal extension should be assessed as well as the quality of the intercarpal accessory gliding. Taking the Kaltenborn (1989) con- cavelconvex concept into consideration, if the radio carpal joint is implicated the posteroanterior (PA) glide of the proximal row of the carpal bones may be restricted. The testing of intercarpal gliding will specifi Fig. Lateral ge on tibia wih etive flexion, (Reproduced with kind cally identify movement abnormalities between the proximal carpal bones and the adjacent radius or trian- ‘gular fibrocartlage complex. TREATMENT Once the aggravating movement has been identified, an appropriate glide is chosen. The decision (© use a weight-bearing (WB) or non.weight-bearing (NWB) restricted movement will depend on the severity, irri- lability and nature of the condition (Maitland 1991), For example MWMs would preferably be performed in NWB if a patient with tibiofemoral limitation of exten sion had a history of recent trauma, Attempting to improve the same movement in WB at this stage may further exacerbate the condition. Once the glide has been chosen it must be sustained throughout the physiological movement until the joint returns (ois original starting position. As the joint moves the therapist must sustain the pressure, being constantly ‘aware of minor alterations in the treatment plane. The ‘mobilisations performed are always into resistance but without pain, Immediate relief of pain and improvement in ange of movement are expected. If this is nt achieved the therapist may try a different glide or a rotation. ison from Pasiocherapy 1995; 81(12:Peripheral mobilisations with movement 124 Fig. S—Anteroposerior (AP) onthe tibia wit active flexion. (Reproducsd wis kind permission from Physiotherapy 1998; 81(12) 726-729.) If pain-free movement is not achieved when perform. ing a MWM a complex movement can be analysed into its various components and the MWM performed with ‘one of the restricted single plane movements. For exam: ple, if a patient has tibiofemoral pain when performing half squat, this movement involves a combination of flexion, adduction and medial rotation of the tibia. Medial rotation in flexion may be restricted and painful when tested in NWB. Performing a MWM at right angles or paralle to the joint line on uctive medial rota tion in flexion in this NWB position may achieve greater improvement in pain-free range than a MWM performed with the half squat. If pain relief is still not achieved then another manual treatment approach should be pursued. This clinical decision can be made instantly. Clinical experience suggests that while sustaining the pain-free glide, the movement should be repeated 10 times. After this set of MWMSs the joint function is reassessed (© see if the movement remains improved Without the passive mobilisation component. It may be necessary to repeat this set of 10 MWMs two to three times to ensure prolonged correction of tracking and sufficient ufferent input. However, the number of repeti tions is dependent on joint irritability. Taping can also be applied to help maintain joint position and increase proprioceptive awareness. Teaching the patient to per~ orm their own MWMs is also useful to prolong pain- free movement. Clinically, therapists using these tech- niques have often reported more instantaneous, dra matic results than those obtained when using repeated sory or physiological passive mobilisations alone. ‘The following examples will illustrate the clinical application of MWMSs to peripheral joints, Ankle injuries The talocrural joint is relatively congruent and the gliding is usually successfully applied in the sagital plane 10 improve plantar or dorsiflexion. The direction ofthe glide is determined using the concave/convex concept. An acute ankle sprain with limitation of dorsiflexion may be treated in NWB with the patient lying on the treatment table with the ankle joint placed level with the end of the bed. A pillow paced under the knee will take the gastroe- nnemius off stretch, A sustained AP glide fo the talus is applied by the therapist while the patient actively dorsi- flexes the ankle, If the range of pain-free movement improves, the MWMS are repeated. Overpressure may be applied if pain-free end range is achieved (Fig. 6) Mulligan (1995) has found that applying a antero- posterior (AP) glide to the distal end of the fibula with active inversion often results in a dramatic improve-Manus Therapy ment of iaversion. This suggests that the dysfunction is more likely to be a joint surface problem rather than figamentous in nature. In this case the talocrural or inferior tibiofibular joints are implicated. Ifthe gliding of the talus relative to the mortise formed by the tibia and fibula does not result in pain-free inversion the inferior tibiofibular joint is implicated, There may be a history of previous inversion sprains and the patient may present to physiotherapy in the acute or chronic stage. Mulligan (1995) suggests that whea the foot is inverted beyond the expected range the fibula is \wrenched forward on the tibia with a positional fault occurring at the inferior tibio-fibular joint. In that case the anterior talofibular iigament may remain virtually undamaged. Taping applied to the fibula whilst the therapist holds the AP glide can complement the trea ment effects (Fig. 7), In the post-acute stage of ankle sprain the residual functional disability may be an inability for the patient to lower himself down stairs on the injured ankle, MWMs can be performed with this movement by apply ing a PA glide on the tibia and fibula and a counter AP glide on the talus applied with the therapist's web space ‘hile the patient lowers himself down a step. The use of | aabelt to glide the tibia and fibula will help the therapist perform a stronger PA glide. If pain relief is not achieved with this, MWMSs can be performed on the infe- rior tibiofibular join in an APIPA direction (Fig. 8), The normal movement of the fibula with dorsiflexion is a cephalad glide and lateral rotation. This movement can be facilitated by angling the AP on the fibula cormetly, It is important for the therapist to keep an open mind: the direction of the MWM on the tibia and fibula is that \Which enables the patient to achieve pain-free movement, Neural involvement in sprained ankles Restoration of more normal articular biomechanics can permit greater mobility of the adjacent neural tissue (Butler 1991). This can also be applied in the periphery using MWM when adverse neurodynamies is a compo- nent of the restricted movement. By using MWM$ the interface is moved actively relative to neural tissue in varying degrees of tension. The abave techniques often improve signs and symptoms more rapidly than passive Joint movement alone. The reasons for this are, as yet tunclezr, while theories hypothesizing why MWMs may have @ normalising effect on neurodynamics are dis- cussed by Wilson (1995, 1994), If, on assessment, inversion and plantarflexion are the symptomatic movements, and the symptoms are worsened by the addition of passive straight leg rais ig- 6 Anteroposterioe (AP) glide on the talus with tive dorsiflexion,ig. Corrective taping on fibula to maintain antsoposeior (AP) tie the differential diagnosis indicates abnormal superfi- ial peroneal nerve dynamics. Active inversion with & glide on the distal fibula ip this same position of ten- sion may result in the movement becoming symptom- free. The approach is to use the symptom-reducing lide as the treatment with the leg positioned in the same degree of siraight leg raise. Ifa glide performed con the fibula ir this position of tension can eliminate symptoms it is chosen as a treatment to be repeated with active inversion (Fig. 9). The head of the fibula is ‘a bony interface of the common peroneal nerve and a poteotial tension site (Butler 1991). A glide on the head of the fibula may also be considered as a treat- ment option since the injury may have altered the rela- tive position of the neck of the fibula to the common peroneal nerve. If there is no immediate change in symptoms it suggests that the nerve interface pathol- ogy may be soft tissue and more appropriate treatment must be given. Shoulder pathology ‘The integrity of the shoulder complex is reliant largely on its ligamentous and muscular components (Hawkins et al 1991), Incorrect movement patterns can result in alterations of a joint’s centre of rotation, which may cause cumulative microtrauma to the joint and its sur rounding structures (Grant 1994), Common movement Peripher! mobisations with movement 125, dysfunctions are frequently a result of incorrect scapula and rotator cuff musculature recruitment, a resulting downward facing glenoid cavity and anteriar or superior migration of the head of the humerus (Margery & Jones 1992; Jobe & Pink 1993) Mobilisations with movements integrate well with ‘muscle imbalance correction of taese movement abnor: malities. If the patient's problematic movement is abduction a corrective AP or longitudinal caudad glide fon the head of the humerus can be sustained while the patient actively ubducts the arm. The therapist's oppo- site hand fixates the seapula so that the glide of the humerus is relative to the scapula. It is important to ensure that the AP glide is applied at right angles to the plane of the glenohumeral joint. The resulting move: ‘ment must be pain-free. The patient can also be encour: aged to activate specific muscles. For example, once a patient has been taught to activate a weak trapezius in isolation the abduction MWM can be performed while encouraging correct recruitment of this muscle through the movement pattern (Fig. 10). Pain-free repetitions ensure sufficient corrective afferent input from the joint receptors and resulting reflex changes in muscle recruit ‘ment. A home programme of appropriate correct move- ‘ment patterns (Sahrman 1993) with the addition of tap ing will ensure prolonged and automatic pattern correction, ‘Similar glides can be applied if glenobumeral flexion is the symptomatic movement. A belt is usually used to slide the humeral head backward in the treatment plane, as the use of the therapist's hand over the anterior aspect of the head of the humerus will block the movement. A. counter pressure is applied to the scapula from behind, tis essential that the belt is maintained at right angles to the plane of the joint, The belt position on the therapist should be lower than the glenohumers! joint, this ensures that the belt does not elevate the humeral head ‘and impinge superior structures. The belt and therapist position must be altered so that when the glide is applied the flexion is facilitated (Fig. 11). CONCLUSION The above clinical examples serve to illustrate the flexi bility of this approach, which makes it highly suitable for integration into any therapist's favoured treatment regime, whatever their speciality. Mobilisation with movements enable the therapist to perform treatments in more dynamic, weight-bearing, Functional positions. As the aggravating movement is used, treatment is specific and the results are often dra matic (Mulligan 1995). A single case study design by Vicenzino and Wright (1995) using this approach demonstrated improvement in a patient with tennis elbow. As this concept becomes established it is hoped that further research will be undertaken to substantiate the claims of “immediate dramatic results’Ging iia and bale wit active end ange domi 1th ind permission fom Phys S112) 726-729,126 Manual Therapy ig. 11—Motilsaion with movement (MWA) with shoulder lexion REFERENCES. Baxendale R H, Forel W R 1981 The effet of knee join dishars ‘on transmission in Flexion pathways in dacerrate eats, Jour of Physiology 315: 231-242, ‘Buler D8 1997 Mobilisation of the Nervous Systm, Churchill Livingstone, Exinburgh 2, 185-210. Cobb OR: De Vis HE, Uiban RT, Loukens € A, Bige RI 197 Electrical sci in muscle pain. American Journal nf Physical Medicine 54: 80°87, Gerard B, Matyas T A 1980'Thecletromyographic evaluation ofan Smervershrl mobilisation veshnigue on cases preseating with cute pranpnal spasm the lamba spine a: Proceedings of te Second Manipulative Therapists Associaton of Austin Conference, Asai p 35-95 Grant 1994 Physical Therapy ofthe Cervical and Thorcie Spine, Sh ed, Churchill Livingstone, Edinburgh eh 16 39, Hawkins RJ, Mottads GH 1991 Controversy it anterior shoulder insability, Clnial Orhopaesics and Related Research 27 152-161 Joke FW, Pink M 1993 Clasification and weatment oF shoulder dysfunction inthe cverheud alte. Jour of Onhop and Sports Physical Therapy 18(2): 427-432, Kaltenborn FM 1989 Banal Mobiisstion the Extremity Soimeyth cl, Orthopaetie Physieal Therapy Products, USA. pll.20. LewitK'1985 The muscular ancl anicularfator in movement restriction, Manal Medicine 1: 83-85, Lundbeze A. Malmgren k, Schnberg ED 1978 Role of the joint feats ia motor conto exemple by elects om lex patsy fron afferents Journal of Physiology 288: 327-343 Main G D 1991 Periphoral Manipultion, 2nd ed. Buterworths, {Landon 923, Margery Mt Tones M 1992 China agnosis ard management of minor shoulder instability, Awan Journal of Physeteapy 384): 269-280 Mulligan B R 1999 Mobitisaions wih movement, Journal of Manual and Manipoltive Therapy TC) 134-156. Mulligan 1 R995 Manual Therapy Nags "Stag Bid. Pane View Services, New Zealand Murpiy'B A, Daison NJ Slack 1998 Sacra join "manipulation decreases the H-tflx. Elecuomyraphy and Clinical Neurophysiology 35: 87-94, Satvman § 1993 A Moscle Imbalance Approech to Muscoskeetl Disorders, Course Notes, Washington University, St Louin, Misco, USA Schaible#, Grubb B 1995 Afferent and spinal mechanisms joint in, Pain 55:5-54 ‘Sokes Mt, Young A 1984 The coniribution of refes inhibition to ‘anhrogchovs muscle weakness. Clinical Science 67:7 Taylor M,Sovinen T, Rheade P1994 Tho eet of Grade 4 dsvaction Tobilstion on patents with tmporomandiblrpin-sTunction ‘order Physiotherapy Tory and Practice We 123-136, Thabo 11986 EMG as ool to document diagnostic indings and etapeutic rests associated wih soma dysfunctions athe ‘per eervcal spinal joins nd saeroine joins, Mangal Medicine 2:83'58 Vieenzno , Wright A 199S Effects of a novel manipulative ‘physiotherapy technique on tennis elbow: a single ease ad. Manga Therapy 11) 30-38, Willams, fed) 1995 Gray's Anatomy, 38h ede, Chrcill Livingtone,Eainbura ch p 808-510. Wilson 1094 Beripheral joint mobilisation wih movement adits effects on adverge neu tension. Manipulative Physiotherapist 642) 38-40, Wilson E1995 Mobiisation with movement and adverse nour ‘wasion: an exploration of posse inks, Manipulive Physiotherapist 270) 4-46, PRP'Y oe