Mobilization with movement (MWM) Mulligan's concept

Mobilization With Movement: Principles of Application

Brian Mulligans concept of MWM is the natural continuance of progression in the development of manual therapy from active self-stretching exercises, to therapist-applied passive physiological movement, to passive accessory mobilization techniques.

MWM is the concurrent application of pain-free accessory mobilization with active and/or passive physiological movement. Passive end-range overpressure or stretching is then applied without pain as a barrier.

Principles of Application

These techniques are applicable when;

No Contraindications:

The techniques of mobilization should only be applied when no contraindication for manual therapy exist.

Full orthopedic examination:

A full orthopedic examination has been completed, and evaluation of the results indicates local musculoskeletal pathology.

Biomechanical analysis:

A special biomechanical analysis reveals localized loss of movement and/or pain associated with function.

Pain Free application:

There is no pain produced during or immediately after application of the technique, because pain is considered a barrier and indicates incorrect tecnique, direction, or that the method is unsuitable.

Clinical  application of MWM

Comparable Signs:

One or more comparable signs are identified during the examination. A comparable sign is a positive test sign that can be repeated after a therapeutic maneuver to determine the effectiveness of the maneuver.

For Example; 

A comparable sign may include loss of joint play movement, loss of ROM, or pain associated with movement during specific functional activities, such as lateral elbow pain with resisted wrist extension,

painful restriction of ankle dorsiflexion, or pain with overhead reaching.

Passive techniques:

A passive joint mobilization is applied using the principles of Kaltenborn. Utilizing the knowledge of joint anatomy and mechanics, a sense of tissue tension, and sound clinical reasoning, the therapist investigates the various combinations of parallel or perpendicular accessory glides to find the pain-free direction and grade of accessory movement. This may be a glide, spin, distraction, or combination of movements. This accessory movement must be pain-free.

Accessory glide with active comparable sign:

While the therapist sustains the pain-free accessory force, the patient is requested to perform the comparable sign. The comparable sign should now be significantly improved that is, there should be increased ROM, and the motion should be free of the original pain.

No pain:

The therapist must continuously monitor the patient's reaction to ensure no pain is produced. Failure to improve the comparable sign would indicate that the therapist has not found the correct direction of accessory movement, or that the technique is not indicated.

Repetitions:

The previously restricted and/or painful movement or activity is repeated 6 to 10 times by the patient while the therapist continues to maintain the appropriate accessory mobilization.

Further gains are expected with repetition during a treatment session, particularly when pain-free passive overpressure is applied to achieve end-range loading.

Patient Response and Progression

Pain as a guide:

Successful MWM techniques should render the comparable sign painless while significantly improving function during the application of the technique.

Self-Treatment:

Once patient response is determined, self-treatment is often possible using MWM principles with sports-type adhesive tape and/or the patient providing the mobilization component of the MWM concurrent with the active physiological movement.

Total Program:

Having restored articular function with MWM, the patient is progressed through the ensuing rehabilitation sequences of the recovery of muscular power, endurance, and neural control.

Sustained improvements are necessary to justify ongoing intervention. 

Theoretical Framework

Mulligan postulated a positional fault model to explain the results gained through his concept. Alternatively, inappropriate joint tracking mechanisms due to an altered instantaneous axis of rotation and neurophysiological response models have also been considered. For further detail of the application of the Mulligan concept as it applies to the spine and extremities, refer to manual therapy, NAGS, SNAGS, MWMS, etc.

Focus on Evidence

Early research on the MWM approach confirms its benefits; however, the mechanism by which it affects the musculoskeletal system, whether mechanical or physiological, has yet to be fully determined. A study by Paungmali and associates measured a significant reduction in pain, increased sympathetic nervous system response immediately following MWM for chronic lateral epicondylalgia compared with a placebo intervention, results that were similar to those in studies of spinal manipulation. They interpreted this to imply that there is a multisystem response to manipultion, whether the spine or the elbow is manipulated.