The Mulligan Concept: NAGS, SNAGS and Mobilizations With Movement
The Mulligan Concept: NAGS, SNAGS and Mobilizations With Movement
Ed Wilson
81
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S APRIL 2 0 01
Wilson
82
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S APRIL 2 0 01
The Mulligan concept
83
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S APRIL 2 0 01
Wilson
84
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S APRIL 2 0 01
The Mulligan concept
85
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S APRIL 2 0 01
Wilson
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.
86
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S APRIL 2 0 01
The Mulligan concept
87
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S APRIL 2 0 01
Wilson
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
88
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S APRIL 2 0 01
The Mulligan concept
89
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S APRIL 2 0 01