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ahmed -> Re: Mulligan for tennis elbow (November 17, 2004 4:29:00 PM)
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The Concept
The essential components of Mulligan’s concept are as follows.
Pain-free
This is absolutely crucial. The techniques must not reproduce the patient’s symptoms. Mild pressure or palpation discomfort may be experienced upon application of the technique, but the symptoms for which the patient has consulted the therapist must not be reproduced by the palpation or the movement.
Positional faults/tracking problems
Mulligan contends that many symptoms (pain, stiffness, weakness) result from joints with subtly malaligned biomechanics, and that these symptoms can be eliminated in many cases by equally subtle repositioning techniques, i.e. they assist in the restoration of biomechanical normality. The key word here is assist: ‘force’ has no place in Mulligan’s vocabulary.
That a normal joint will follow a normal ‘track’ or ‘path’ through any particular normal movement is axiomatic (Kapanji 1987). This articular track – incorporating spin, slide, glide, rotation, etc. – is a genetic inheritance and is dependent upon the shape of joint surfaces and articular cartilage, and upon the orientation and attachments of capsule, ligaments, muscles and tendons. To facilitate controlled, free movement while minimising compressive forces is the overall aim of such a design. Any anomalies in the recruitment or coordination of the sequential elements of the movement pattern will be signalled to the central nervous system (CNS), which may well seek to inhibit that inappropriate movement by pain, stiffness or weakness. Thus the therapist is guided as to what is normal movement by its symptom-free status.
Repetition
With the patient and the therapist having been reassured that the biomechanical anomaly has been overcome by the application of a technique and consequent symptom-free movement, it makes sense to bombard the agitated CNS with the normal signals – from the joint and attendant structures – that it has always been patterned to receive. Thus the purpose of symptom-free repetition of movement and mobilisation is ultimately to sedate the CNS, to re-establish dynamic neutral (Hoover 1969). The overlap with positional release concepts can readily be seen here.
Treatment planes
The techniques, of course, must allow for variation in articular structure and types of movement.
Hinge joints
Here the bones lie end-to-end and articulate in the sagittal plane, somewhat like a hinge (Fig. 11.1) Examples would be the elbow and the knee, although the wrist too can be considered to be basically a complex, compound hinge.
With such joint-types the accessory force of the mobilisation is applied at right angles to the movement taking place. In the example of the elbow, a glide laterally of the forearm on a fixed humerus would be applied through the limited range of flexion or extension (see case example in Box 11.7).
Figure 11.1 Hinge joint.
Parallel joints
Here the bones lie side-by-side and their articulation is characterised by alterations in that parallel relationship. The radius and ulna or the metacarpals, for example. In treatment situations, one of the pair would be stabilised and the other would be repositioned upward or downward as the patient performed active movement (Fig. 11.2).
Figure 11.2 Parallel joints.
Spinal facet planes
The angles of spinal facet planes varies from region to region and therefore the angle of the accessory mobilisation must correspond with them. The orientation of C1 and C2 differs from that of C5 and C6, which in turn differs from T6 and T7 (Fig. 11.3).
Figure 11.3 Spinal facet planes.
Indications for use
Because they involve simultaneous joint accessory mobilisation with active movement SNAGs, MWMs and SMWLMs are used exclusively to treat movement-generated symptoms. That is, they are not used where the patient complains of resting aches and pains, except perhaps where these are truly of minor significance to the patient, but are exacerbated by active movement. Significant resting symptoms are usually associated with a degree of underlying pathology far beyond that of relatively minor biomechanical abnormalities.
The therapist may be advised to treat the underlying pathology before concerning themselves with limitation of movement, especially as mechanical techniques run the risk of exacerbating the problem, especially if combined with movement. As far as the Mulligan concept is concerned, such a patient would be inappropriate for these techniques because it is highly unlikely that a pain-free status can be achieved, so the approach would be abandoned forthwith.
NAGs and headache techniques, meanwhile, are performed on passive patients and, to a limited extent, stand outside the above strictures, but even they have a mechanical rationale and would be inappropriate for use on a patient whose symptoms were of systemic origin (headache techniques are not used for classical migraine presentations, for example).
However, mild resting aches may simply be indicative of disturbed articular proprioception and inappropriate CNS modulation and are therefore worth considering from a mechanical viewpoint, including adding movement to mobilisation. Overall, the therapist should be guided in the use of Mulligan’s techniques by careful consideration of what Maitland (1986) has labelled SIN, i.e. severity, irritability and nature of the presenting symptoms. Inappropriate treatments are performed by even the most expert clinicians sometimes, but at least if the pain-free framework is adhered to then the consequences of such an action should be minimal.
In order to identify which vertebral segment requires treatment by NAGs or SNAGs the rules common to all manual therapy approaches apply, i.e. an interplay between interrogation, observation, palpation and on-going analysis (see Box 11.2).
Box 11.2 Summary of the pre-treatment assessment process
Patient enters
Observation begins
Patient speaks
Symptom description
Patient exposes area
Observation and palpation
Patient moves
Observation and palpation
Therapist palpates more searchingly
Tissue response
Symptom responses
Treatment of patient
The patient will describe the location of the primary symptoms and their history, if questioned well. This may support or undermine the therapist’s embryonic hypothesis formed as a general observation of gait/posture as the patient entered the room and sat down. Observation of muscle tone, body biomechanics during undressing and the formal, undressed observation phase will further build the hypothesis.
Active and passive spinal movements are then observed and analysed. What is the quality of movement? What is the range? What happens to the symptoms? How do the muscles feel when palpated during the movement?
During this process the therapist is considering the pathologies, physiology and anatomy which makes sense of the data thus far. For example, cervical/shoulder symptoms in the early stages of cervical rotation would implicate an upper cervical spine problem, because not until much later do the lower vertebrae become involved in cervical spine movement.
Thus, the original hypothesis is built upon layer-by-layer, or modified according to findings. Palpation of the vertebrae and surrounding soft tissues for stiffness, deformity and pain response will hopefully confirm the tentative hypothesis and treatment can commence. For NAGs and SNAGs, if the right facet joint between C6/C7 is implicated, the treatment of choice would be a unilateral NAG or SNAG (depending upon the irritability of the problem) at the right articular pillar of C6.
Tennis elbow
Ideally this technique is performed with the patient in supine lying. Their affected arm is along their trunk, in pronation. The humerus is fixed by the therapist holding it down with their web space positioned just above the elbow joint on the lateral humeral condyle.
Figure 11.10 Hand positions for elbow MWM.
Box 11.7 Case example of peripheral joint (elbow) treatment
Patient
A 26-year-old woman physiotherapist.
Complaint
Inability to extend her right elbow through the last 30° of extension. The patient reported that it felt ‘blocked’, although not painful unless forced into its end-range zone. This situation had persisted since a fracture of the radial head at the age of 9. There was no resting ache.
Previous recent treatments
Oscillatory mobilisation of the elbow joint as a whole, and of the radial head/capitulum joint and the superior radio-ulnar joint.
Manipulation.
Both failed to alter her movement restriction.
Presentation
Active and passive elbow extension seemed to be met by a solid end-feel, although there was some evidence of hyperactivity in the elbow flexors of the upper arm and forearm when end-range was reached.
Treatment
At approximately 10° short of her end-range the humerus was stabilised by the therapist’s left hand on the lateral condyle, immediately above the joint line. The therapist’s right hand was then placed on the medial condyle of the ulna, immediately below the joint line. Via pressure through the therapist’s right hand the forearm was induced to glide laterally in relation to the humerus. The direction of the glide specifically followed the obliquity of the elbow joint as a whole. The patient then attempted to fully extend her elbow.
Result
The patient was immediately able to regain full extension asymptomatically. With the glide maintained in the same precise direction with the same degree of pressure 10 repetitions into full extension were performed. At the end of these repetitions the patient was able to fully extend her elbow without the assistance of the accessory glide. In other words, it was now tracking correctly through the previously restricted range.
Follow-up
The patient remains symptom-free, several months after that treatment.
Note
This case example undermines the widely held belief that adaptive shortening automatically accompanies prolonged movement restriction. It may do, of course, but it is not axiomatic.
The seat-belt is then passed under the forearm of the patient, then over the scapula and acromioclavicular joint of the therapist’s shoulder nearest to the patient’s head. The therapist is slightly stooped and the shoulder carrying the seat-belt is over the patient’s elbow. With the belt taut it is then a simple matter for the therapist to move into a slightly more upright posture, which has the effect of tightening the belt and gliding the forearm on the fixed humerus (see Fig. 11.11).
Figure 11.11 Tennis elbow: lateral glide with active gripping.
With this glide in position the patient is asked to carry out an action previously provocative of their symptoms, e.g. gripping, wrist extension, etc.
To adjust the angle of the glide if the symptoms do not fully disappear initially, the therapist merely leans more forward or backward (minimally) to alter the line of pull of the belt.
Note
Tennis elbow is an irritable condition and this should be considered when establishing the number of attempts to be made to achieve the correct glide angle, and how many repetitions of a successful glide might sensibly be attempted.
Critics have complained that this technique does not involve movement, merely contraction. However, the common extensor group of muscles crosses the elbow joint and it is seemingly contraction of these muscles which elicits symptoms of terms elbow. Their contraction (acting as stabilisers of the wrist during gripping, of course) will exert a linear movement of the forearm on a fixed humerus and therefore increase intra-articular pressure between the radial head and the capitulum. This is particularly so in full elbow extension (close-pack position) when, coincidentally, tennis elbow symptoms seem to be most pronounced.
This technique is of value in tennis elbow conditions of 3 weeks or more standing.
If a lateral glide fails to resolve either restricted flexion/extension or a tennis elbow condition, yet clinically a tracking problem or positional fault seems to exist, it is worth applying an anterior or perhaps posterior glide on the radial head as the symptomatic action is performed
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