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Mulligan Concept of El
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textbook of techniques
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Wayne Hing Toby Hall Darren Rivett Bill Vicenzino Brian Mulligan
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is an imprint of Elsevier Elsevier Australia. ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
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Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. The publisher apologises for any accidental infringement and would welcome any information to redress the situation.
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This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher.
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This edition © 2015 Elsevier Australia
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9780729541596 National Library of Australia Cataloguing-in-Publication entry
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Hing, Wayne, author.
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National Library of Australia Cataloguing-in-Publication Data
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This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication.
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The Mulligan concept of manual therapy : textbook of techniques / Wayne Hing, Toby Hall, Darren Rivett, Bill Vicenzino, Brian Mulligan.
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Physical therapy—Handbooks, manuals, etc Movement therapy—Handbooks, manuals, etc. Manipulation (Therapeutics)—Handbooks, manuals, etc Hall, Toby, author. Rivett, Darren, author. Vicenzino, Bill, author. Mulligan, Brian, author.
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Content Strategist: Melinda McEvoy Content Development Specialists: Martina Vascotto Project Manager: Anitha Rajarathnam Edited by Forsyth Publishing Services Proofread by Fiona Van Dam Cover and internal design by Lisa Petroff Index by Robert Swanson Typeset by Toppan Best-set Printed by China Translation & Printing Services Ltd.
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Our concepts have come a long way from 1985 when, by chance, I had an unexpected instant pain-free success with a traumatised finger using what are now known as ‘Mobilisations With Movement’. The patient, who was a young woman in her early twenties, presented with a swollen interphalangeal t which was painful and would not flex. I tractioned the t several times which accomplished nothing. I then applied t (glide) translations in the recommended biomechanically appropriate direction for flexion. Like the tractions, these glides were also ineffective and painful. I then tried a medial translation accessory movement which was unacceptable to the patient because of pain. Without much enthusiasm I then gently tried a lateral translation which prompted the patient to say ‘it does not hurt’. Something prompted me to sustain this translation and ask her if she could flex her finger. To my astonishment and her delight the finger flexed without pain! She then said something like ‘You have fixed me’. ‘Of course!,’ I replied. She still had a small loss of flexion range due to some residual swelling but she departed my rooms with a smile. The young woman returned two days later and her finger had completely recovered. Why, I asked myself? The only explanation I could come up with for my chance success was that as a result of her trauma there was a minute positional fault of the t preventing flexion movement. When this positional fault was corrected it enabled a full recovery to take place. It was a simple hypothesis and because of this I began to look differently at all ts that I treated and experimented to see if I could achieve similar results by repositioning other t surfaces. I began having unbelievable successes in the clinic. A ‘miracle a day’ I called them. Louis Pasteur once said that chance only favours the prepared mind. When I, by chance, had my first miracle with the young woman and her painfully limited interphalangeal t, I did indeed have a prepared mind.
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In 2011, I had the privilege to write a foreword for a new textbook on my concepts authored by Bill Vicenzino, Wayne Hing, Darren Rivett and Toby Hall. This was a timely, excellent publication entitled Mobilisation With Movement: The Art and the Science. My own manual on my concepts, now in its 6th edition, badly needed to be updated to include more detail and an improved format. This task has been undertaken and led by Wayne Hing, with all the above authors again being involved. It has taken over two years to complete this task. These erudite authors also had the wisdom to involve many of my Mulligan Concept international teachers. They have contributed by writing much of the text, each being allocated different regions of the body and different techniques. I must here particularly acknowledge and thank my colleagues Mark Oliver and Frank Gargano for the new techniques and material they have contributed. I believe that the contents in this book, in its new format, are priceless. All who deal with musculoskeletal conditions and practise manual therapy should have a copy. What makes our concepts so special is that all the Mobilisation With Movement techniques described within this book are only to be used when they produce no pain on application and because they should be immediately effective if indicated. I know of no other manual therapy procedures for the entire body, which follow these guidelines. What is really special about them is that it only takes about two minutes to decide if they are indicated. Not to be able to use our concepts may be denying patients their best treatment option. I now have many hours of video showing the efficacy of our concepts, personally treating patients on stage in many cities in America before my peers. The hundreds who have witnessed these occasions are left in no doubt as to the efficacy of these techniques because of the regular positive and instant pain-free outcomes.
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plane you will never be able to successfully manipulate or effectively apply the Mulligan concepts. I must stress that the techniques contained with this book are not set in stone. They are all based on repositioning t surfaces, or muscles and their tendons, to see if one can achieve pain-free resolution of a musculoskeletal problem. The techniques described in the book are those we in the Mulligan Concept Teachers Association have clinically found to be effective. If any clinicians applying them, who have the requisite knowledge and handling skills, can improve upon these techniques then this would be most welcome. It is hoped they would share their significant worthwhile improvements with other clinicians and teachers. I feel very humble to have the of such scholars as Wayne, Toby, Bill and Darren, and thank them and Elsevier sincerely for this wonderful publication. Brian Mulligan
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Today the concepts that have grown from this chance finding have come a long way and guidelines are now in place for their successful clinical use; these are fully described within this textbook. To optimally succeed with our concepts, you need advanced clinical reasoning and excellent handling skills. The detailed descriptions in this book will help you immensely in both these aspects. Ideally of course, the reader should attend the courses that are available around the world by accredited Mulligan Concept teachers. Teachers and courses are listed at www.bmulligan.com While on the topic of teachers, I always acknowledge and thank my mentor Freddy Kaltenborn. Freddy came many times from Europe to teach in faraway New Zealand. He taught me how to manipulate every t in the spine and to mobilise the extremity ts. His able teachings gave me excellent handling skills. He also increased my knowledge and the importance he placed on the clinical significance of treatment planes led me to successfully develop Mobilisations With Movement. If you do not know each t’s treatment
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reasoning underlying the application of the Mulligan Concept, including consideration of the evidence base. The case studies followed the application of the Mulligan concept from the first session to discharge, showing how the techniques were selected, applied and progressed over the treatment program. However, the purpose of that first book was not to provide a detailed description of all the techniques under the Mulligan Concept umbrella, which is the scope of this current book as it continues the work of the preceding landmark Mulligan’s Manual Therapy: NAGS, SNAGS and MWMs book. There was a real need for a comprehensive presentation of the wide array of techniques under the umbrella of the ‘Mulligan Concept’. These techniques include MWM and other Mulligan techniques such as pain release phenomenon (PRP). Each technique has been described in a consistent and logical format fully explaining the indications, application and modifications for each technique. In addition, we have detailed the current available evidence for each technique and provided Clinical Reasoning Gems, the aim of which is to illustrate pertinent information regarding clinical reasoning relating to techniques presented in each chapter. The book is divided into 14 regional chapters, covering the whole body, and encoming the whole range of musculoskeletal disorders that present to clinical practice, including apparent non-t disorders such as lateral epicondylalgia. The first chapters focus on MWM, exercise and taping techniques for the upper quadrant that include the cervical spine through to the thorax. These chapters include cervicogenic headache and cervicogenic dizziness, the temporomandibular t, shoulder complex, elbow, forearm, wrist and hand. The subsequent chapters cover the lower quadrant, including the lumbar spine, sacroiliac
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This book entitled The Mulligan Concept of manual therapy: textbook of techniques presents over 160 Mulligan Concept techniques and includes therapist techniques as well as home exercises and taping techniques. The book is aimed at being a comprehensive and easy to follow resource for the novice and experienced clinician, as well as researchers. The book has been written for the clinician, teacher and student interested in furthering their familiarity to the wide array of techniques under the Mulligan Concept umbrella. Mulligan Concept techniques are effective and safe when applied in accordance with easy to follow guidelines and clearly identified underlying principles. When Brian Mulligan first described Mobilisation with Movements (MWM) in 1984 he shared his techniques through his original book entitled Manual Therapy: Nags, SNAGs and MWMs of which there have been six editions over the past 30 years. This book has been written to expand on and fully describe in a standardised format all the techniques mentioned in Brian Mulligan’s aforementioned original texts, as well as include new techniques that were not included in those earlier landmark editions. This book is also intended as an accompaniment to our first book entitled Mobilisation with Movement: the art and the science which was published in 2011. Our first book presented the science underpinning MWM and also described aspects of ‘the art’ inherent in its successful implementation. In that book the basic principles of MWMs were outlined, potential mechanisms underpinning the successful application of MWMs were canvassed, and in depth aspects of its clinical application were critiqued including guidelines on dosage and troubleshooting. Over half of the first text presented the application of MWM in a series of case reports. These case studies focused on the clinical
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with an explanation of the rationale underlying the system of annotations.
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Professor Wayne Hing Auckland, New Zealand, 2014 Adjunct Associate Professor Toby Hall Perth, Australia, 2014 Professor Bill Vicenzino Brisbane, Australia, 2014 Professor Darren A. Rivett Newcastle, Australia, 2014
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t, hip, knee, ankle and foot. The final chapter covers commonly used PRPs, which are distinct to MWM, but can be very helpful in the right clinical presentation, usually after the condition being treated have proven resistant to other Mulligan Concept techniques. The techniques in this text are drawn from those presented on the Mulligan concept courses taught worldwide and as such form the curriculum of the different levels of those Mulligan Concept courses. Also presented is a dictionary of annotations for the techniques described, along
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(IV\[[OLH\[OVYZ Brian Mulligan, FNZSP (Hon.) Dip MT Lecturer, Author, President MCTA
Toby Hall, PhD, MSc, Post Grad Dip Manip Ther Adjunct Associate Professor, School of Physiotherapy and Curtin Health Innovation Research, Curtin University, Perth, WA, Australia Snr Teaching Fellow, The University of Western Australia, Perth, WA, Australia Fellow of the Australian College of Physiotherapists
Bill Vicenzino, PhD, MSc, Grad Dip Sports Phty, BPhty Chair in Sports Physiotherapy, University of Queensland: School of Health and Rehabilitation Sciences: Physiotherapy, QLD, Australia
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Darren A Rivett, BAppSc(Phty), GradDipManipTher, MAppSc(ManipPhty), PhD, MAICD, APAM, MMCTA(Hon) Professor of Physiotherapy and Head of the School of Health Sciences, The University of Newcastle, Australia; Board Director, Australian Physiotherapy Association
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Wayne Hing, PhD Professor, Bond University, QLD, Australia
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Headache is both a symptom and a disorder in its own right, hence classification of headache is important to ensure that correct treatment is istered (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 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 important for manual therapist’s considering physical intervention for headache, where such intervention is unlikely to be effective for disorders other than those affecting the musculoskeletal system (Hall, 2011). Mechanisms underlying CGH are those of convergence of afferent input from the upper three cervical 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 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 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 mixed headache forms (Hall, Briffa, Hopper & Robinson, 2010a). The positive cut-off point is 32–33° (Hall, Briffa, Hopper & Robinson, 2010b; Hall, Briffa & Hopper, 2010; Ogince, Hall, Robinson & 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 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 the test has utility regardless of the age, gender or lifestyle of the person tested. Further study is required to identify the FRT’s sensitivity to change as an outcome measure. 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 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 istered first. On subsequent visits, if symptoms are reduced but the FRT remains positive, then a C1/2 self-SNAG should be considered at that point. The application of a self-SNAG to people with chronic CGH and a positive FRT was shown to be 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° (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 approximately 54/100).
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Rather than using the self-SNAG strap, it is also possible to use the selvedge edge of a towel to perform the C1/2 self-SNAG (see Figure 1.4). Alternatively, it is also possible for the therapist to use their thumbs to exert pressure on the C1 transverse process, on the contralateral side (Chapter 2, C1 dizziness technique). A strap or towel is preferred, as the patient will gain optimal benefit from self-treatment, both at the time of treatment, but also in event of recurrence later.
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Wayne Hing Toby Hall Darren Rivett Bill Vicenzino Brian Mulligan
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is an imprint of Elsevier Elsevier Australia. ACN 001 002 357 (a division of Reed International Books Australia Pty Ltd) Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
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Every attempt has been made to trace and acknowledge copyright, but in some cases this may not have been possible. The publisher apologises for any accidental infringement and would welcome any information to redress the situation.
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This publication is copyright. Except as expressly provided in the Copyright Act 1968 and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication may be reproduced, stored in any retrieval system or transmitted by any means (including electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior written permission from the publisher.
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This edition © 2015 Elsevier Australia
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9780729541596 National Library of Australia Cataloguing-in-Publication entry
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Hing, Wayne, author.
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National Library of Australia Cataloguing-in-Publication Data
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This publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication.
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The Mulligan concept of manual therapy : textbook of techniques / Wayne Hing, Toby Hall, Darren Rivett, Bill Vicenzino, Brian Mulligan.
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Physical therapy—Handbooks, manuals, etc Movement therapy—Handbooks, manuals, etc. Manipulation (Therapeutics)—Handbooks, manuals, etc Hall, Toby, author. Rivett, Darren, author. Vicenzino, Bill, author. Mulligan, Brian, author.
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Content Strategist: Melinda McEvoy Content Development Specialists: Martina Vascotto Project Manager: Anitha Rajarathnam Edited by Forsyth Publishing Services Proofread by Fiona Van Dam Cover and internal design by Lisa Petroff Index by Robert Swanson Typeset by Toppan Best-set Printed by China Translation & Printing Services Ltd.
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Our concepts have come a long way from 1985 when, by chance, I had an unexpected instant pain-free success with a traumatised finger using what are now known as ‘Mobilisations With Movement’. The patient, who was a young woman in her early twenties, presented with a swollen interphalangeal t which was painful and would not flex. I tractioned the t several times which accomplished nothing. I then applied t (glide) translations in the recommended biomechanically appropriate direction for flexion. Like the tractions, these glides were also ineffective and painful. I then tried a medial translation accessory movement which was unacceptable to the patient because of pain. Without much enthusiasm I then gently tried a lateral translation which prompted the patient to say ‘it does not hurt’. Something prompted me to sustain this translation and ask her if she could flex her finger. To my astonishment and her delight the finger flexed without pain! She then said something like ‘You have fixed me’. ‘Of course!,’ I replied. She still had a small loss of flexion range due to some residual swelling but she departed my rooms with a smile. The young woman returned two days later and her finger had completely recovered. Why, I asked myself? The only explanation I could come up with for my chance success was that as a result of her trauma there was a minute positional fault of the t preventing flexion movement. When this positional fault was corrected it enabled a full recovery to take place. It was a simple hypothesis and because of this I began to look differently at all ts that I treated and experimented to see if I could achieve similar results by repositioning other t surfaces. I began having unbelievable successes in the clinic. A ‘miracle a day’ I called them. Louis Pasteur once said that chance only favours the prepared mind. When I, by chance, had my first miracle with the young woman and her painfully limited interphalangeal t, I did indeed have a prepared mind.
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In 2011, I had the privilege to write a foreword for a new textbook on my concepts authored by Bill Vicenzino, Wayne Hing, Darren Rivett and Toby Hall. This was a timely, excellent publication entitled Mobilisation With Movement: The Art and the Science. My own manual on my concepts, now in its 6th edition, badly needed to be updated to include more detail and an improved format. This task has been undertaken and led by Wayne Hing, with all the above authors again being involved. It has taken over two years to complete this task. These erudite authors also had the wisdom to involve many of my Mulligan Concept international teachers. They have contributed by writing much of the text, each being allocated different regions of the body and different techniques. I must here particularly acknowledge and thank my colleagues Mark Oliver and Frank Gargano for the new techniques and material they have contributed. I believe that the contents in this book, in its new format, are priceless. All who deal with musculoskeletal conditions and practise manual therapy should have a copy. What makes our concepts so special is that all the Mobilisation With Movement techniques described within this book are only to be used when they produce no pain on application and because they should be immediately effective if indicated. I know of no other manual therapy procedures for the entire body, which follow these guidelines. What is really special about them is that it only takes about two minutes to decide if they are indicated. Not to be able to use our concepts may be denying patients their best treatment option. I now have many hours of video showing the efficacy of our concepts, personally treating patients on stage in many cities in America before my peers. The hundreds who have witnessed these occasions are left in no doubt as to the efficacy of these techniques because of the regular positive and instant pain-free outcomes.
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plane you will never be able to successfully manipulate or effectively apply the Mulligan concepts. I must stress that the techniques contained with this book are not set in stone. They are all based on repositioning t surfaces, or muscles and their tendons, to see if one can achieve pain-free resolution of a musculoskeletal problem. The techniques described in the book are those we in the Mulligan Concept Teachers Association have clinically found to be effective. If any clinicians applying them, who have the requisite knowledge and handling skills, can improve upon these techniques then this would be most welcome. It is hoped they would share their significant worthwhile improvements with other clinicians and teachers. I feel very humble to have the of such scholars as Wayne, Toby, Bill and Darren, and thank them and Elsevier sincerely for this wonderful publication. Brian Mulligan
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Today the concepts that have grown from this chance finding have come a long way and guidelines are now in place for their successful clinical use; these are fully described within this textbook. To optimally succeed with our concepts, you need advanced clinical reasoning and excellent handling skills. The detailed descriptions in this book will help you immensely in both these aspects. Ideally of course, the reader should attend the courses that are available around the world by accredited Mulligan Concept teachers. Teachers and courses are listed at www.bmulligan.com While on the topic of teachers, I always acknowledge and thank my mentor Freddy Kaltenborn. Freddy came many times from Europe to teach in faraway New Zealand. He taught me how to manipulate every t in the spine and to mobilise the extremity ts. His able teachings gave me excellent handling skills. He also increased my knowledge and the importance he placed on the clinical significance of treatment planes led me to successfully develop Mobilisations With Movement. If you do not know each t’s treatment
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reasoning underlying the application of the Mulligan Concept, including consideration of the evidence base. The case studies followed the application of the Mulligan concept from the first session to discharge, showing how the techniques were selected, applied and progressed over the treatment program. However, the purpose of that first book was not to provide a detailed description of all the techniques under the Mulligan Concept umbrella, which is the scope of this current book as it continues the work of the preceding landmark Mulligan’s Manual Therapy: NAGS, SNAGS and MWMs book. There was a real need for a comprehensive presentation of the wide array of techniques under the umbrella of the ‘Mulligan Concept’. These techniques include MWM and other Mulligan techniques such as pain release phenomenon (PRP). Each technique has been described in a consistent and logical format fully explaining the indications, application and modifications for each technique. In addition, we have detailed the current available evidence for each technique and provided Clinical Reasoning Gems, the aim of which is to illustrate pertinent information regarding clinical reasoning relating to techniques presented in each chapter. The book is divided into 14 regional chapters, covering the whole body, and encoming the whole range of musculoskeletal disorders that present to clinical practice, including apparent non-t disorders such as lateral epicondylalgia. The first chapters focus on MWM, exercise and taping techniques for the upper quadrant that include the cervical spine through to the thorax. These chapters include cervicogenic headache and cervicogenic dizziness, the temporomandibular t, shoulder complex, elbow, forearm, wrist and hand. The subsequent chapters cover the lower quadrant, including the lumbar spine, sacroiliac
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This book entitled The Mulligan Concept of manual therapy: textbook of techniques presents over 160 Mulligan Concept techniques and includes therapist techniques as well as home exercises and taping techniques. The book is aimed at being a comprehensive and easy to follow resource for the novice and experienced clinician, as well as researchers. The book has been written for the clinician, teacher and student interested in furthering their familiarity to the wide array of techniques under the Mulligan Concept umbrella. Mulligan Concept techniques are effective and safe when applied in accordance with easy to follow guidelines and clearly identified underlying principles. When Brian Mulligan first described Mobilisation with Movements (MWM) in 1984 he shared his techniques through his original book entitled Manual Therapy: Nags, SNAGs and MWMs of which there have been six editions over the past 30 years. This book has been written to expand on and fully describe in a standardised format all the techniques mentioned in Brian Mulligan’s aforementioned original texts, as well as include new techniques that were not included in those earlier landmark editions. This book is also intended as an accompaniment to our first book entitled Mobilisation with Movement: the art and the science which was published in 2011. Our first book presented the science underpinning MWM and also described aspects of ‘the art’ inherent in its successful implementation. In that book the basic principles of MWMs were outlined, potential mechanisms underpinning the successful application of MWMs were canvassed, and in depth aspects of its clinical application were critiqued including guidelines on dosage and troubleshooting. Over half of the first text presented the application of MWM in a series of case reports. These case studies focused on the clinical
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Professor Wayne Hing Auckland, New Zealand, 2014 Adjunct Associate Professor Toby Hall Perth, Australia, 2014 Professor Bill Vicenzino Brisbane, Australia, 2014 Professor Darren A. Rivett Newcastle, Australia, 2014
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t, hip, knee, ankle and foot. The final chapter covers commonly used PRPs, which are distinct to MWM, but can be very helpful in the right clinical presentation, usually after the condition being treated have proven resistant to other Mulligan Concept techniques. The techniques in this text are drawn from those presented on the Mulligan concept courses taught worldwide and as such form the curriculum of the different levels of those Mulligan Concept courses. Also presented is a dictionary of annotations for the techniques described, along
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(IV\[[OLH\[OVYZ Brian Mulligan, FNZSP (Hon.) Dip MT Lecturer, Author, President MCTA
Toby Hall, PhD, MSc, Post Grad Dip Manip Ther Adjunct Associate Professor, School of Physiotherapy and Curtin Health Innovation Research, Curtin University, Perth, WA, Australia Snr Teaching Fellow, The University of Western Australia, Perth, WA, Australia Fellow of the Australian College of Physiotherapists
Bill Vicenzino, PhD, MSc, Grad Dip Sports Phty, BPhty Chair in Sports Physiotherapy, University of Queensland: School of Health and Rehabilitation Sciences: Physiotherapy, QLD, Australia
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Headache is both a symptom and a disorder in its own right, hence classification of headache is important to ensure that correct treatment is istered (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 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 important for manual therapist’s considering physical intervention for headache, where such intervention is unlikely to be effective for disorders other than those affecting the musculoskeletal system (Hall, 2011). Mechanisms underlying CGH are those of convergence of afferent input from the upper three cervical 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 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 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 mixed headache forms (Hall, Briffa, Hopper & Robinson, 2010a). The positive cut-off point is 32–33° (Hall, Briffa, Hopper & Robinson, 2010b; Hall, Briffa & Hopper, 2010; Ogince, Hall, Robinson & 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 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 the test has utility regardless of the age, gender or lifestyle of the person tested. Further study is required to identify the FRT’s sensitivity to change as an outcome measure. 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 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 istered first. On subsequent visits, if symptoms are reduced but the FRT remains positive, then a C1/2 self-SNAG should be considered at that point. The application of a self-SNAG to people with chronic CGH and a positive FRT was shown to be 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° (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 approximately 54/100).
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