CLINICAL METHODS

The Mulligan concept: NAGS,

SNAGS and mobilizations
with movement
. . . . . . . . .

Ed Wilson

Introduction techniques must not reproduce

the symptoms that the patient
Developed in the 1980s by Brian
is complaining of. Indeed
Mulligan, a New Zealand based
these symptoms (pain,
physiotherapist, NAGS, SNAGS
weakness, stiffness) must be
and mobilizations with movement
eliminated or the technique is
(MWMs) are essentially articular
abandoned as unsuitable and
techniques with neuro-muscular
other methods are substituted
consequences. They share some ideas
for it.
and methods with Kaltenborns seat
The amount of force used to
belt techniques (Kaltenborn 1980)
glide a joint tends to be minimal,
and with the Positional Release
although they can be quite
concept (Jones 1981).
vigorous if so indicated if
NAGS (natural apophyseal
being used to treat stiffness
glides) are essentially accessory
rather than pain, for example.
movements, gliding one spinal facet
(b) In NAGS and SNAGS the
upon its neighbour, and are
accessory treatment force is
performed on a passive patient
applied along the facet planes of
(Fig. 1). SNAGS (sustained natural
the spinal joints, therefore the
apophyseal glides) are similar
direction is different for a C1/2
accessory glides performed on a
problem compared to that of a
Ed Wilson BA MCSP patient who is simultaneously
T1/2 problem (Fig. 3). With
Member of the Mulligan Concept Teachers actively moving through the
Association peripheral joints the direction of
previously painful or restricted
force will depend upon the type
Correspondence to: E. Wilson range of movement (Fig. 2). MWMs
of joint being treated. If it is a
Highthorn Physiotherapy Clinic, apply the principle of accessory glide
132 Lawrence Street, hinge-type joint, i.e. basically it
plus active movement too, but they
York, YO10 3EB, UK articulates in the sagittal plane
are applied to peripheral joints.
Received June 2000 and is a bone end-to-end
The central tenets of Mulligans
Revised July 2000 articulation, like the knee, then
concept are:
Accepted August 2000 the force is applied at right
...........................................
Journal of Bodywork and Movement Therapies (2001)
(a) all techniques are carried out angles to the movement taking
5(2), 81^89 within a painfree framework. place (Fig. 4).
# 2001 Harcourt Publishers Ltd
doi:10.1054/jbmt.2000.0191, available online at
Some palpation or pressure If the joint is of the parallel
http://www.idealibrary.com on pain is permitted, but the type, i.e. the bones are long

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 Wilson

Fig. 3 Facet planes upper cervical spine.

shape of the articular surfaces,

the thickness of the cartilage, the
orientation of the fibres of
ligaments and capsule, the
direction of pull of muscles and
tendons, facilitate free but
Fig. 1 Cervical NAGS. controlled movement while
simultaneously minimizing the
compressive forces generated by
that movement. Normal
proprioceptive feedback
bones and articulate in a side- however, as anomalies
maintains this balance.
by-side manner, like the inter- frequently occur, so the
Alteration in any or all of the
metacarpal joints, then the force therapist should be prepared to
above factors would alter the
applied will alter that parallel experiment a little to find the
joint position or tracking during
relationship during movement optimum effective degree of
movement and would provoke
(Fig. 5). force and its direction.
symptoms of pain, stiffness or
With MWMs, the direction of (c) The techniques have been
weakness in the patient. It is
application of the force can be developed to overcome joint
common sense then that a
predicted to a large extent by the tracking problems or
therapist would attempt to re-
shape of the articular surfaces, positional faults, i.e. joints with
align the joint surfaces in the
and/or by knowledge of the subtle biomechanical changes.
least provocative way.
forces acting upon the joint. Normal joints have been
This is not 100% accurate, designed in such a way that the How does the therapist know
that they have correctly re-
aligned the joints biomechanics?
Simply by eliminating the
patients symptoms. Hence
Mulligans (1985) insistence on
the techniques being painfree,
because only if they are can we
be sure that all is well with the
joint. Frequently remarkably

Fig. 2 Cervical SNAGS. Fig. 4 Hinge-type joint.

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 The Mulligan concept

correcting articular relationships. can be found at the end of this

Indeed, techniques involving both article.
accessory and active movements are
likely to exacerbate symptoms
MWMs
rather than relieve them. Hence if
Mulligan cannot achieve normal The patient presents with a history
movement rapidly with his which indicates that manual therapy
techniques he abandons them in would be an appropriate response.
Fig. 5 Joints with bones in parallel planes.
favour of other treatment Particularly they complain of
modalities. symptoms only on movement or
Mild resting aches may well activity. There are little or no resting
be an indicator of disturbed symptoms: no indicators of serious
little force (and hence subtle
proprioception being misinterpreted pathology. For example, any
movement at the joints
by an agitated central nervous reported weakness should suggest
surfaces) is required to achieve
system, and being made worse by muscle inhibition rather than
this painfree status. Indeed, in
active movement. This would be neurological deficit, although one
some instances the patient is
entirely suitable for Mulligans can mimic the other of course.
unaware that treatment is
approach. The first element of treatment
occurring at all!
So, symptoms of pain, stiffness or now commences: it is explained to
To summarize this section, we weakness on movement are the the patient that their symptoms are
see that Mulligan has developed primary indicators for these benign and are due to mal-tracking
methods of correcting joint techniques. Otherwise, the of the joint, and that treatment will
biomechanics during active appropriateness of the techniques consist of gently correcting that
movement in the case of SNAGS for a particular patients must be tracking as they perform the
and MWMs which rely on the judged on what Maitland (Maitland movement through the range
patient to report freedom from 1986) calls the SIN factor, i.e. previously provocative of their
symptoms as the indicator of their severity, irritability and nature of symptoms. This simple explanation,
successful application. Manual the presenting condition. In this using lay terminology allays their
therapists who are experienced in respect Mulligans techniques are fears and recruits the downward
their use quickly learn not to persist the same as all other manual therapy inhibitory modulation systems
with that particular form of approaches, as indeed they are in which can be extremely helpful in
treatment if the symptom-free regard to contraindications. reducing symptoms (Shacklock
response is not almost immediate. However, the relative gentleness 1999).
Learning to admit that one is not and the insistence on the application Next it is emphasized just how
being effective is a difficult lesson to of the techniques within a important it is to report accurately
learn for most therapists, but it is symptom-free framework make on the symptoms as treatment
one which Mulligans ideas force them safer than many other manual proceeds. They must not experience
one to accept. therapy approaches. Indeed NAGS, their symptoms, and if they do they
for example, can be used where must report it at once so that
more vigorous, manual therapy appropriate changes can be made to
Indications for use techniques have exacerbated the the treatment. Knowing that they
As the previous section suggests, problem. are in the hands of a therapist who is
The techniques have been designed not about to hurt them is also very
to overcome movement problems by reassuring for most patients.
subtly altering joint biomechanics in With the painfree concept
Methodological principles
a precise way. They are not aimed at established and agreed, the speed at
resting pain unless it is relatively The methodological principles for which the patient is to perform the
minor but is made significantly MWMs and SNAGS are essentially given movement is negotiated, along
worse by movement. Substantial similar so they will be outlined first. with a signal for when to commence
resting pain usually indicates an A detailed description of techniques the movement. This ensures that the
underlying pathology or active for individual joints is not treatment technique and the active
inflammatory process which may be appropriate here. They can be movement are truly simultaneous.
causing the tracking problem but found in Mulligans book and his In the case of an MWM for a
will not be relieved by merely videos. The address of the stockist hinge-type joint, the elbow for

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example, the technique would be to

fix or stabilize the proximal bone
the humerus with one hand whilst
gliding the forearm laterally with the
other as the patient carries out active
flexion or extension (Fig. 6). The
therapists hands must be positioned
just above and just below the joint
line to avoid the technique becoming
a collateral ligament stress test, or to
avoid compressing the radial head
against the capitulum. It must also
be remembered that the direction of
the accessory technique must follow
the joint line, which in the case of
the elbow is oblique, slanting
cephalad towards the lateral side. Fig. 6 Lateral glide of forearm on humerus.
With the glide applied as the
patient performs the previously
symptomatic movement their
feedback is critical. If the symptoms 2. Painfree over-pressure at the end Again, basically, we are altering
are worsened then the glide is of range. the relationship of one bone to its
patently in the wrong direction, or 3. Teach the patient how to neighbour as the patient carries out
the problem is unsuitable for MWM replicate the technique for an active movement. Obviously we
at that particular time. (If reversing painfree repetitions at home. can no longer effectively stabilize as
the direction of the accessory glide 4. If appropriate, tape the joint in we did in MWMs, nor can we strap
also exacerbates the problem then the desired position and the joint into position, but in other
the likelihood is that the technique encourage home exercise again respects SNAGS and MWMs can be
should be abandoned.) (Fig. 7). considered as being the same.
If, however, by the application of It should be pointed out, however,
SNAGS
the symptoms on movement are that Mulligan recommends only
improved but not eradicated this The methodological principles for three repetitions of the successful
suggests that the technique is SNAGS are similar to MWMs and snag in the cervical spine. It is a
correctly chosen but requires fine are performed in the manner notoriously unpredictable area and
tuning. An alteration in the amount mentioned above. this advice should be heeded.
of pressure used and/or a subtle
alteration in the angle of that
pressure should render the
movement painless. When it does so
we then perform perhaps 10
repetitions of the now asymptomatic
movement, maintaining exactly the
amount and direction of glide
pressure.
Following the painfree repetitions
the movement is then tested without
the glide being applied. In a
remarkable number of cases the
movement remains asymptomatic. If
it does not then there are several
options available to the therapist.

1. More repetitions of glide with

active movement. Fig. 7 Strapping for lateral glide at the wrist.

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 The Mulligan concept

Other factors to be born in mind

are:

1. The structural osseous anatomy

of the spine. It was pointed out
earlier that the accessory force of
a snag is applied along the facet
plane to facilitate glide
and to avoid joint surface
compression. These planes differ
from area to area and the
therapist must be well informed
regarding the angle of facet
planes in the particular region to
be treated.
2. The facet planes change their
Fig. 8 Lumbar SNAGS in sitting.
orientation to each other in
different phases and directions of
movement. The therapists
accessory force must follow this
throughout the movement and
back. For example, in cervical
rotation the upper cervical facets
travel much further than those in
the lower cervical region.
Therefore, if treating the upper
cervical spine with SNAGS the
therapist must adopt a starting
stance which permits the
comfortable rotation of their
arm, trunk and hips in order that
the facet plane can be followed as
it moves.
3. With lumbar SNAGS (Fig. 8)
Mulligan recommends treatment
in sitting if the patients
symptoms can be reproduced in
sitting. If they are only manifest
in standing then they must be
treated in standing.
4. It is of course possible to perform
SNAGS either centrally by
exerting pressure on the spinous
process, or unilaterally by
exerting pressure on the articular
pillar.
5. As with MWMs, self SNAGS can
be taught to the patient (Fig. 9).
6. To finally eradicate symptoms
the therapist may elect to use
over-pressure of the movement.
However, care must be taken
especially with the upper cervical
spine. Staying within the painfree Fig. 9 Self SNAGS into extension lumbar spine.

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framework minimizes risk of cervical spine are implicated then C2 (Fig.10), i.e. it involves
course. NAGS are preferable. It is not neither the oscillatory glides of
advisable to snag multiple levels in the NAG nor the active
one treatment session. movement of the SNAG. The
If, however, the patient sustained pressure on C2 is
NAGS
experiences only a catch of pain frequently minimal, so much so
As mentioned earlier, NAGS differ during one part of the movement, that patients often do not
from SNAGS and MWMs in that thus implying a singular joint experience it at all. However,
they are applied to a passive patient, problem, then SNAGS would be such light pressure for maybe 20
i.e. the patient does not perform a preferred. Similarly, if symptoms seconds is all it may take to
concurrent movement. The necessity were manifest only at the end of eliminate even the worst
to respect the facet plane orientation range then SNAGS would be headache of spinal origin.
remains paramount however (Fig.1). suitable. (b) Spinal mobilization with limb
Depending upon the patients movement. Here a transverse
presentation, NAGS are carried out pressure is applied to the side of
in mid to end range. Essentially they
Brief miscellany the relevant spinous process as
are oscillatory accessory glides done There are many other techniques the patient concurrently moves
in a posterior anterior direction, and developed by Mulligan but lack of the limb through the previously
are used to treat movement space here prohibits description. restricted range of movement
problems originating from C2T3. However, of particular merit (Fig. 11). The assumption here is
They can be applied centrally or clinically are the headache technique that the restriction of movement
unilaterally with the patients and the spinal mobilization is of spinal origin of course. This
cervical spine in neutral or with limb movement does not necessarily imply
positioned in the direction of techniques. neural compromise since spinal
movement limitation. When movement must occur when a
performed they must not reproduce (a) Headache. Done with a current limb moves beyond a certain
the patients symptoms. headache in order that the point. Thus the technique
If description, observation and efficacy of the treatment is addresses a spinal structural/
palpation reveal that the problem confirmed, this technique mechanical restriction, but this
joint is C5/C6 then the NAG would involves a sustained alteration in may have neural implications
be applied to C5 at a rate of 23 per the relative positions of C1 and too.
second for a few seconds, then
the patients movement would be
re-assessed. Improvement in
symptoms would indicate another
brief set of NAGS, and so on. Often
it requires several sets to achieve
symptom free status.
If, however, the chosen NAG
makes the symptoms worse then it is
worth considering reversing the
treatment plan, i.e. instead of gliding
C5 above C6, now glide C6 under
C5 and correct the error.
When does one prefer NAGS to
SNAGS for cervical movement
dysfunction? Essentially it depends
upon the patients presentation, upon
their SIN factors and the findings on
assessment. NAGS are much less
likely to provoke latent pain than are
SNAGS, so NAGS would be the
treatment of choice for irritable
patients. Also if multiple joints of the Fig. 10 Headache technique.

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 The Mulligan concept

automatically alters biomechanical

joint function creates a tracking
problem in fact. Then the disturbed
proprioceptive output from the
malaligned joint itself contributes
abnormal stimuli to a central
nervous system already operating
at an enhanced level of excitability.
This will affect efferent output too,
and then the joint is contributing to
its own malfunction (Fig. 12).
Manual re-positioning of the joint
by the therapist now looks like a
good treatment approach. Correct
alignment of the joint would remove
the abnormal barrage, and gentle
Fig. 11 Spinal mobilization with arm movement. handling plus painfree initiation of
movement may well rapidly re-assert
a normal response from the central
nervous system. Thus we have the
Although not in Mulligans It sedates an agitated, facilitated process of mobilization induced
book there are techniques born nervous system, particularly the analgesia (Zusman 1985, 1994).
of his concept which can be dorsal horn, by bombarding it with Recruiting downward inhibitory
used to address apparent the painless normality it has always modulation by a non-emotive
pathoneurodynamics (Wilson 1994, been patterned to receive. Normal explanation, caring manner and
1996) or to enhance muscle tone afferent discharge provokes a gentle handling helps too, of course.
directly (Wilson 1997). reciprocal normal efferent discharge In chronic conditions the same
to the structures controlling joint overall process occurs but with the
movement. added complications which
Discussion Thus we are probably overcoming chronicity brings. Lateral
Two points inevitably arise when symptoms generated by neuro- epicondylagia (LA) is a good
discussing Mulligans concept and muscular imbalance. The techniques example for several reasons:
techniques with colleagues. will not be effective if applied to
chronically adaptively shortened
(a) How does it work so rapidly?
situations, or where serious (a) Cyriax (1983) regards it as a
(b) Why do the beneficial effects
pathology exists. They may alleviate soft-tissue problem and treats it
persist after perhaps only three
the symptoms of the latter accordingly with frictions,
of four repetitions of symptom
temporarily but they will manipulation and/or injection.
free movement when the
undoubtedly recur. (b) Maitland (1977) meanwhile
symptoms may have been
In acute conditions it may be that states that in cases of chronic
longstanding?
the response of the mechano- LA there is inevitably some joint
When treating patients Mulligans receptors to sudden over-stretch of dysfunction too. He goes on to
response to them is to say it gets the soft tissue lies at the root of the treat the joint dysfunction and
joint used to tracking properly. This problem. There is minimal trauma, reports that the soft-tissue
is usually a satisfactory answer for if any, but the receptors continue component recovers
lay people but it is only a partial their protective firing and evoke spontaneously.
answer. However, a full explanation muscle response in consequence. (c) For chronic LA, Mulligan
is possibly not available with current This over-reaction may be as a result states that joint repositioning is
investigative paradigms and of pain memory (Gifford 1998) or used to eliminate pain and
methods. An attempt at explanation perhaps merely an anomalous enhance grip strength (Vicenzino
should be made nevertheless. reaction (Di Giovanna 1991). 1995).
Perhaps Mulligans response can Whatever the reason for the (d) Positional release techniques
be phrased differently but maintain exaggerated response, the selective (Chaitow 1996) use painful soft-
the same essential meaning: alteration in muscle tone tissue monitors (trigger points)

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to project the abnormal discharge to

the soft tissue and to behave as if
that tissue is still damaged.
If a therapist gently re-positions
the joint into its correct alignment,
and normalize its proprioceptive
discharge, it may so quieten the
CNS that the soft-tissue pain would
seem to disappear as spontaneously
as Maitland, Mulligan and Chaitow
suggest. It would also release the
inhibition or hypertonicity of the
relevant musculature and increase
grip strength thereby (Vicenzino
1995). (There is no magic here: just
the application of a reasonably well
researched physiological process.
Attempting to justify manual
therapy interventions without
recourse to this process leaves a
large hole in clinical reasoning
paradigms.)
Fig. 12 Potential effects of initial soft tissue compromise.

Example
then re-position the joint until will add their excitatory discharge,
The reader is invited to try this
the soft-tissue pain disappears. ultimately contributing to its own
small experiment.
(e) LA is a common symptom of dysfunction through altered efferent
fibromyalgia, the aetiology of activity. Check your range of abduction at
which is shrouded in mystery However, whether or not the CNS the shoulder joint, being aware of
and controversy. will recognize that both soft-tissue the experience of free movement.
and joint are complaining of distress Now with the index and middle
All the above can be reconciled if is debatable as it is already highly fingers place on the anterior greater
we accept that in many cases soft- sensitized to the soft-tissue afferent tubercle (Fig. 13) gently glide the
tissue tenderness is a manifestation discharge before the joint afferents head of humerus posteriorly using
of an agitated central nervous arrive. The CNS readily confuses ounces of pressure. With this glide
system (Cohen 1995) and does knee pain and hip pathology, or in position perform abduction
not necessarily reflect a current experiences arm pain during a heart again. In most cases a tightening
soft-tissue lesion. attack, due to convergence of their or stiffening of the joint will be
We could argue as follows: respective axons into the dorsal horn experienced due to subtle alteration
Muscular or tendinous tissue of the receptor sites. It is therefore in joint biomechanics. This is what
common extensor group at the conceivable that these sites will the patient experiences, but with the
elbow suffers traumatic over-strain. confuse or misinterpret incoming addition of the altered
The mechano-receptors will behave signals from soft-tissue or joint. proprioception being analysed by an
as described above and exert their Later, because of the adaptive, excited CNS.
effect on the neuro-muscular system. protective response of the nervous
Shortly afterwards the damaged system the soft-tissue trauma site is
not disturbed and quickly heals.
Summary
tissue will leak inflammatory
exudate which will in turn cause However, the CNS remains in a Symptom free joint mobilization
chemo-receptor discharge into an state of heightened excitability added to muscular activity is the
already excited CNS, thus increasing because joint proprioception has core of Mulligans work. Well
its response. Joint biomechanics remained abnormal throughout the executed on an appropriate patient
its tracking will now be seriously healing process. Convergence as it can be rapidly and permanently
disturbed, and its proprioceptors discussed above could lead the CNS effective. It can be used alone or in

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Di Giovanna E 1991 An Osteopathic

Approach to Diagnosis and Treatment.
J. B. Lippinott, Philadelphia
Gifford L 1998 The central mechanisms.
In: Gifford L (ed). Topical Issues in Pain.
NOI press
Jones L 1964 Spontaneous release by
positioning. The D. O. 4
Jones L 1981 Strain and Counterstrain.
Academy of Applied Osteopathy,
Colorado Springs
Kaltenborn FM 1980 Mobilisation of the
Extremity Joints. Dlaff Norlis, Oslo
Maitland GD 1977 Peripheral Manipulation.
Butterworths
Maitland GD 1986 Vertebral Manipulation.
Butterworths
Mulligan BM 1985 Manual Therapy, Nags,
Snags, MWMs etc. Plane View Services
Shacklock MO 1999 Central pain
mechanisms: A new horizon in manual
therapy. Australian Journal of
Physiotherapy 45(2): 8592
Fig. 13 Self-treatment: posterior glide of head of humerus. Vicenzino B et al. 1995 Effects of a novel
manipulation physiotherapy technique
on tennis elbow. A single case study.
Manual Therapy 1(1): 3035
Wilson E 1994 Peripheral joint mobilization
with movement and its effects on adverse
conjunction with other therapeutic Books and videos on the neural tension. Manipulative
approaches. The techniques are a Mulligan Concept are available physiotherapist 26(2): 3539
useful addition to the repertoire of from: Houghtons, Rich Barton Wilson E 1995 Mobilisation with movement
any manual therapist but they are House, Chideock, Bridport, Dorset and adverse neural tension: an
exploration of possible links.
certainly not a panacea for all ills. DT6 6JW, UK. Manipulative Physiotherapist 27(1):
A careful and comprehensive 4046
assessment will determine which Wilson E 1997 Central facilitation for
patients are suitable and which are remote effects: treating both ends
REFERENCES of the system Manual Therapy 2(2):
not, and those that are suitable fall
Chaitow L 1996 Positional Release 165168
largely into the movement-induced Techniques. Churchill Livingstone, Zusman M 1985 Re-appraisal of a proposed
symptoms category. They are used Edinburgh neurophysiological mechanism for
to correct minor joint derangements Cohen ML 1995 The clinical challenge of the relief of joint pain with passive
which often display a secondary hyperalgesia. In: Shacklock, joint movements. Physiotherapy
disproportionate array of effects. MO (ed). Moving in on pain. Practice 1
Butterworth Heinemann Zusman M 1994 Manipulative Physiotherapy
That is the key to Mulligans Cyriax J 1983 Textbook of Orthopaedic and mechanical pain Manipulative
work. Medicine, 8th edition. Bailliere Tindall Physiotherapist 26(2)

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