vicenzino keynote1 mullconf09

MULLIGAN’SMobilisation with

Movement:

The science, theevidence and

the art.

Bill VicenzinoProfessor in Sports Physiotherapy

Head of Division of Physiotherapy

The science, the evidenceand the art .

MULLIGAN’SMobilisation with

Movement:

Mobilisation With Movement =

sustained force (accessory glide)while a previously painful

(problematic) movement is performed

or ?


discern and measure problem movement

apply glide &repeat problem movement

repeat iteration (max 4 times) &observe outcome

or ?


only used in treatment plan if thepreviously painful (problematic)movement is much/substantially

improved

& !

Sunday: 1:00 – 1:30 Dr Darren Rivett: MWM and clinical reasoning

…so what is the evidence?

THIS CONFERENCE!!!

Next … Hewitt - MWM: A systematic, critical narrative review.

Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K.Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in

the management of cervicogenic headache. Journal ofOrthopaedic & Sports Physical Therapy. 2007 Mar;37(3):100-7.

1:00 – 1:30 Key Note Hall - Are all headaches just a pain from the neck?

Bisset L, Beller E, Jull G, Brooks P, Darnell R, Vicenzino B. MWM andexercise, corticosteroid injection, or wait & see for tennis elbow:

randomised trial. BMJ 2006, doi:10.1136/bmj.38961.584653.AE

MWM + exercise speeds up recoveryReduces need for other therapiesFewer recurrences than steroid injections in long term

2:00 - 2:30 MWM for soft tissue injuries such as tennis elbow

MWM works!

THIS CONFERENCE!!!

Next … Hewitt - MWM: A systematic, critical narrative review.

How does it work?

or

What do you tell your patients?

Biomechanical

Boney luxations

Reversing luxations

• Straighten spine (Pare 1958)

• Unlocking locked joint(Twomey 1992)

• Shift an IVD fragment (Cyriax1975)

• Reduce annular distortion(Farfan 1973)

• Stretching, tearing or rupturingadhesions that limit joint ornerve range (Zusman 1986,Chrisman et al 1964)

• Remove blockage orinterference of blood flow (Still1899), nerve compression(Palmer 1910), sympatheticchain (Kunert 1965), andcerebrospinal fluid circulation(DeJanette 1967)

Biomechanical

Neurophysiological

Paradigms in practice/research

• Correct abnormalsomatovisceral reflexes andvisceral organ dysfunction(Dhami & DeBoer 1992)

• Stretch contracted muscles,causing relaxation (Perl 1975)

• Remove ‘irrtable’ spinal lesions(Korr 1976)

• Intense reflex effects (mainlymusculature, Lewit 1985)

• Modulate peripheralnociceptors (Zusman 1987)

• Inhibition of reflex musclecontraction (Zusman 1987)

• Activates gating mechanism,neurotransmitters, opioidepeptides (Dhami and DeBoer1992)

Neurophysiological

Biomechanical

Neurophysiological

MWM

Paradigms in practice/research

Biomechanical

MWM

Positional fault hypothesis

Sunday:10.30 – 11:00 Key Note Wayne Hing - Positional Fault – Fact or Fiction

O’Brien & Vicenzino (1998) A study of effectsof a MWM for lateral ankle pain using a casestudy design. Manual Therapy 3: 78-84.

4.5 cm PVAS reduction following 1 treatment

7.4 units/day on Kaikkonen scale withtreatment over 5 weeks compared to 1.4units/day with natural resolution

Hubbard T, Hertel J (2008) Anterior positional fault ofthe fibula after sub-acute lateral ankle sprains.Manual Therapy, 13: 63-67.

Sub-acute ankle sprain (n =11) Non-injured (n =11)

Aff ankle Matched

Unaf ankle

Biomechanical

MWM

Positional faults: may well occur butdifficult to measure?

Does the MWM reverse positional fault?

R 1st MCP pain with F after hyperabduction injury

Positional fault on MRI: 4° pronationof R 1st MCP

Hsieh C-Y et al 2002 Mulligan’s MWM for the thumb: a singlecase using MRI to evaluate the positional fault hypothesis.Manual Therapy 7: 44-9.

Glide reversed positional fault on MRI

Post-3 weeks self treatment: pain andfunction improved but positional faultstayed same

Note: therapist was blind to this finding

MWM

BIOMECHANICS

Human studies

Transient changein bone position

Teys P, Bisset L, Vicenzino B. The initial effects of a Mulliganmobilization with movement technique on ROM ad pressurepain threshold in pain-limited shoulders. Manual Therapy(2008) 13: 37-42.

• MWM versus Sham versus Control• 11 male & 13 female• mean age 46.1 ± SD 9.86 yrs

Results - ROM

ROM: ICC = 0.98 and SEM 1.33°

* 15.6°

11.4 (2.3 to 20.5)9.9 (4.3 to 15.6)

PPT: ICC = 0.96 and SEM 10.7 kPa

Interaction Plot PPT

275

295

315

335

355

375

395

Pre Post

PP

T

Treatment

Sham

Control

* 62.5 kPa

45.1 (1.7 to 88.4)

46.3 (9.1 to 83.6)

MWM

BIOMECHANICS

Human studies


&Increase ROM

MWM

BIOMECHANICS

Human studies


&Increase ROM

Pain effects human

animal

Associated systems & modeling

NEUROPHYSIOLOGIC


&Increase ROM

Pain effects human

NEUROPHYSIOLOGIC

MWM produces an initial hypoalgesia

Treatment effect > placebo/control procedures

Initial hypoalgesia = non-opioid mechanisms

(e.g., Vicenzino et al (2001) Paungmali et al (2003a,b and 2004))

113 anaesthetizedSpraque-DawleyRats

Knee Full & EndROM + Tibia PA/APfor capsaicininducedinflammation offoot.

Mechanicalwithdrawal test

Skyba et al (2003) Joint manipulation reduces hyperalgesia byactivation of monoamine receptors but not opioid or GABA receptors inspinal cord. Pain 106: 159-68.

5-HT & Norad (DPIS)

No local spinalcircuitry & noopioid involvement

MWM

Pain effects human

animal

NEUROPHYSIOLOGIC

Initial non-opioidhypo-algesia:

DPIS

BIOMECHANICS

Human studies


&Increase ROM

MWM

Pain effects human

animal

NEUROPHYSIOLOGIC


DPIS

BIOMECHANICS

Human studies


&Increase ROM



&Increase ROM

animalPain effects human

NEUROPHYSIOLOGIC

Initial sympatho-excitation

(e.g., McGuiness et al 1997, Paungmali et al (2003), Simon et al 1997,Slater et al 1994, Vicenzino et al 1994, Vicenzino et al 1998)


Adapted from Lovick (1991) & Fanselow (1991)

Stimulus

Dorsal/LateralPAG

Analgesia (non-opioid)SympathoexcitationMovement

Analgesia (opioid)SympathoinhibitionImmobility

VentrolateralPAG

Characteristics of pain relief:

Mechanical hypoalgesia associated withchanges in sympathetic and motor systemfunction

Mimics findings from spinal manipulationinferring involvement of descending paininhibitory systems

Preliminary animal studies confirming role ofendogenous non-opioid mechanisms in manual

therapy

MWM

Pain effects human

animal


NEUROPHYSIOLOGIC


DPIS - PAGmediated?

BIOMECHANICS

Human studies


&Increase ROM

MWM

Pain effects human

animal

Associated systems & modeling:Sensory motor system

NEUROPHYSIOLOGIC


DPIS - PAGmediated?

BIOMECHANICS

Human studies


&Increase ROM

Mobilisation With MovementEffects on Joint Position Sense:Preliminary Studies

Saturday: 9.00 - 9:30 The role of MWM in ankle injuries

Jordan K, Branjerdporn M, Teys P, Bisset L, Vicenzino B, (2003)Unpublished Hons Project

N=22Recurrent ankle sprain

Deficit in Joint Position Error

ControlWB-MWM

NWB-MWM

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

JPS 30% JPS 60% JPS 90%

Pre Post Pre Post Pre Post

° A

bso

lute

Err

or

Jordan et al (2003) Unpublished Hons Project

N=22Recurrent ankle sprain

Deficit in Joint Position Error

ControlWB-MWM

NWB-MWM

Are these findings an expression ofthe ‘restoration of joint memory’

explanation provided by Mulligan?

23 subjects with LE and reduced shoulder externalrotation pre-intervention.

MWM for LE reversed the deficit in shoulderrotation.

Interpreted as MWM induced changes in shouldermuscle tone

implying neurophysiological effect

Abbott JH (2001) MWM applied to the elbow affects shoulderROM in subjects with LE. Manual Therapy 6(3): 170-7

MWM

Pain effects human

animal

Associated systems & modeling:Sensory motor system

NEUROPHYSIOLOGIC

Initial non-opioid hypo-algesia:

DPIS - PAG mediated?/ Sensorimotor

integration

BIOMECHANICS

Human studies


&Increase ROM

MWM

Pain effects human

animal

Associated systems & modeling:Motor system

NEUROPHYSIOLOGIC



integration

BIOMECHANICS

Human studies


&Increase ROM

100

125

150

175

PRE DURING POST

275

300

325

Pain Free Grip Force (N)

Affected Side

Unaffected Side

MWM

Placebo

Control

Vicenzino B, Paungmali A, Buratowski S, Wright A. Specific manipulativetherapy treatment for chronic LE produces uniquely characteristichypoalgesia. Manual Therapy 2001 6(4): 205-212.

Abbott J, Patla C, Jensen R 2001 The initial effects of anelbow MWM technique on grip strength in subjects with LE.Manual Therapy 6: 163-169

N=25 (17 male; age: 46 years, range: 29-60) withunilateral LE (16 months: range 2-96)

Mean deficit in PFGS: 38.4 pounds of force

Mean difference pre to post application of MWM:• Affected = 10.4 pounds• Unaffected = -2.7 pounds

MWM

Pain effects human

animal

Associated systems & modeling:Motor system

NEUROPHYSIOLOGIC



integration

BIOMECHANICS

Human studies


&Increase ROM

MWMSpecificity ofapplication

Pain effects human

animal


NEUROPHYSIOLOGIC


DPIS - PAGmediated?

BIOMECHANICS

Human studies


&Increase ROM

Factors such as:Direction, Force,

Velocity/Frequency,Technique,Localization

Lateral glide with0 or 5° posterior inclination

NOT 5° anterior to direct lateral

Direction of force:

Abbott et al, 2001, The initial effects of an elbow MWM techniqueon grip strength in subjects with LE. Manual Therapy 6: 163-9

McLean et al 2002 A pilot study of manual force levels required toproduce manipulation induced hypoalgesia. Clin Biom 17: 304-8

-25

-15

-5

5

15

25

35%

PFG

S

33 50 66 100 Force Levels (% maximum)


Pain effects human

animal


NEUROPHYSIOLOGIC


DPIS -PAGmediated?

BIOMECHANICS

Human studies


&Increase ROM

DirectionForce levelFrequencyTechnique

Localization?


Pain effects human

animal


NEUROPHYSIOLOGIC


DPIS -PAGmediated?

BIOMECHANICS

Human studies


&Increase ROM


Localization?

Adequate st

imulus?

Complex multifaceted

Wright (1995)

Nociceptoreffects

Segmentalinhibition

Supraspinal inhibition

Psychologicaleffects

Total MIA effect

Treatment applicationTime

Jointrepair

Pre-existing beliefs:Injury & damageCatastrophisationFear-avoidance

Expectations:Placebo

PractitionerTreatments

Chronic pain =conditioned (learned) phenomenon (Zusman 2004)

MWM = a re-conditioning of a pain-movement association -

[possibly through non-associative learning theory mechanism (Zusman 2004))]

Repetition seems to be critical in successful treatment!

Chronic pain =conditioned (learned) phenomenon (Zusman 2004)

MWM = a re-conditioning of a pain-movement association -[possibly through non-associative learning theory mechanism (Zusman 2004))]


Pain effects human

animal


NEUROPHYSIOLOGIC


DPIS -PAGmediated?

BIOMECHANICS

Human studies


&Increase ROM


Localization?

Adequate st

imulus?

vicenzino keynote1 mullconf09

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