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nani: 28 Sep : 04:31 AM

plz pleasec tell me where to do phd in india

Nikhilphysio: 02 Jun : 03:55 AM

I am working as physiotherapist in Shalby hospital ahmedabad for 4 years. I have passed out from Rajiv gandhi university of health and sciences Bangalore. I want to apply for Newzealand physiotherapy board registration so anyone there from India who got registered as physiotherapist in new zealand please help me.

Arun: 10 May : 12:36 AM

Hi Priyank, welcome. Feel free to go through these forum threads returned by search [link]

Priyank: 09 May : 10:28 PM

Hi..need advice. What are the options in Australia after MPT?

Arun: 04 Mar : 02:01 AM

Happy birthday Boopathi and somasimple


The use of Mulligan techniques in combined movements and combined positions of the lumbar spine

on Monday 17 April 2006
by Mart de Kruijff, B.PT, MAS.O.M.T. author list
in article > Manual Therapy

Brian Mulligan has developed a most ingenious compilation of manual techniques. For the spine it includes techniques like NAG (natural apophyseal glide), SNAG (sustained natural apophyseal glide), MWM (mobilisation with movement), SMWAMS (spinal mobilisation with arm movement) and so on.

Brian Mulligan has developed a most ingenious compilation of manual techniques.(1) For the spine it includes techniques like NAG (natural apophyseal glide), SNAG (sustained natural apophyseal glide), MWM (mobilisation with movement), SMWAMS (spinal mobilisation with arm movement) and so on. The techniques are always parallel or in right angles to the treatment planes.
The treatment plane is lying across the concave articular surface. Almost all Mulligan techniques are performed weight bearing. Furthermore, the Mulligan techniques have to be pain free and are performed using the primary movements of the joint to be treated.It has been postulated, that it might be useful to use combined movements.(2) It enables the therapist to recognise a symptomatic pattern, i.e. a regular stretch or compression pattern, or an irregular pattern. The therapist will then be able to decide on a pathway of treatment, according to the symptomatic pattern and the pain category (i.e. acute, sub acute or chronic). Brian Edwards proposed, to start the treatment pathway towards the opposite from the symptomatic pattern, as the symptoms will be less there, and it will then be possible to treat the joint mechanics easier(3). The treatment techniques by Brian Mulligan and Brian Edwards have certain common features. Both have to be pain free, and both are performed according to the rules of the joint mechanics.The combination of both might provide the Mulligan concept with new techniques(for instance; SNAGLLFF, which would be sustained natural apophyseal glide in left lateral flexion in flexion) and might help practitioners by providing a pathway for treatment starting in a pain free range, using pain free techniques,working towards the symptomatical pattern. As Brian Edwards proposed accessory techniques in combined positions, incorporating Mulligan techniques allows us to use accessory techniques during combined movements and in weight bearing positions. There is however no evidence at all, that the use of NAGs, SNAGs and MWMs in combined movements is helpful in producing better therapy outcome.
I found however in some cases, that using the combined movement treatment pathway combined with NAGs and SNAGs, gave me the opportunity to improve the patients pain and movement problem, where I hadn�t been able to improve the patients condition using Mulligan techniques without combined movements. I must state though,that all patients, where I used the combined positioning and combined movement,showed an irregular pattern. It might be a coincidence, that all of these patients didn�t improve when treated with Mulligan techniques in neutral positions and only in primary movements. However, it might be, that the use of Mulligan techniques in combined positions is nothing more than something you might try when all else fails.

Chapter 1.
NAGS of the lumbar spine using combined movements


Brian Mulligan states, that when using SNAGs for the lumbar spine no change is elicited, then SNAGs are inappropriate. I would suggest trying NAGs in a combined weight bearing position first, then SNAGS in the appropriate combined movement and carry on along the combined movement treatment pathway.It remains important however, that all the techniques are pain free. Brian Mulligan states furthermore, that he rarely uses his techniques in lumbarlesion producing a lateral shift, and that the treatment of this condition has been described by Robin McKenzie sufficiently. As the repetitive motions in the McKenzie treatment might provide a patient with horrifying centralising pain, using repetitive combined movements and including mulligan techniques, might help the patient finding an easier way towards the pain producing (and in the McKenzie concept hopefully) centralising position.Unfortunately, there are no pictures of the techniques available yet, but will be at a later stage.

1. NAG Right rotation in flexion (NAGRRF)

The patient is rotated in flexion. The therapist stands to the right of the patient for right rotation and to the left for left rotation. The therapists right arm passes under the patients left arm gripping the left side of the patients thorax, hereby maintaining the flexion and rotation component. The therapists left hand is placed with the os pisiforme on the left side of the lumbar segment to treat. A unilateral NAG on the left side of the segment above will increase the movement while a unilateral NAG on the left side of the segment below will reduce the movement, thereby increasing or reducing symptoms. The treatment technique is pain free. The choice of technique should of course follow the combined movements treatment pathway.

2. NAG Right lateral flexion in flexion (NAGRLFF)

The therapist stands on the side to which the lateral flexion will be directed and crosses his right arm over the thoracic spine of the patient, pulling the patient in lateral flexion via the patients left shoulder and using his own body more or less as a fulcrum. The left hand performs a unilateral NAG on the left side of the upper vertebra of the segment to be treated. The pressure is slightly anterior to stick to the tissues and then cranially, to slide the articular surface of the inferior zygapohyseal facet of the vertebra above upwards on the articular surface of the superior zygapohysealfacet of the vertebra below, hereby increasing the movement

3. NAG Left rotation in extension (NAGLRE)

4. NAG Left lateral flexion in extension (NAGLLFE)

The NAG is an oscillatory mid- to end range mobilisation applied antero-cephaladalong the treatment planes . In the combined position, the NAG is used to increase or decrease the movement but the NAG must never cause pain, although a slight discomfort might be possible. Brain Mulligan hasn�t described NAGs for the lumbar spine, only SNAGs. I think the combined positions are particularly easy for using NAGs, and might help to improve the patient, especially when it appears that the Mulligan techniques might not work in a weight bearing neutral position. PIC3 shows a NAG right rotation in flexion (NAGRRF) with a little traction.The arrow shows the direction of the traction, which in this case is used to increase the movement especially on the left side of the spinal segment.


Chapter 2. SNAGS of the lumbar spine using combined movements

The �true miracles a day�, of course, are produced when using SNAGs in the lumbar spine. I would suggest using the belt techniques as described by Brian Mulligan in standing positions.The SNAGs in combined movements are used after the NAGs in combined positions. Naturally, progression should be as fast a possible and therefore, when the patient allows combined movements and the SNAGs can be performed pain free, then it is necessary to continue using SNAGs following the combined movement treatment pathway as described in an earlier article on combined movements

1. Unilateral SNAG Right rotation in flexion using belt in standing (SNAGRRF)

This SNAG is unilateral on the left. It will, when performed on the transverse process of the vertebra above, increase the movement, and decrease the movement when done on the transverse process of the vertebra below. The therapist gives anterior and cephalad directed pressure and maintains this pressure during the movement. The patient performs up to ten repetitions. When re-assessment reveals an improvement of the symptomatical pattern, the SNAG should be repeated. When the SNAG doesn�t improve the symptoms, there are a couple of possibilities to consider:- Was the SNAG performed correctly?- Was the therapists pressure on the appropriate segmental level? (i.e. the level above or below)- Was the combined movement treatment pathway correct?- Did the patient perform the combined movement adequately? Solutions to these questions could be, the repetition of the SNAG to check the technique, re-establish the correct segmental level and check the combined movements treatment pathway. As mentioned in a previous article on combined movements , there are certainly more possible pathways for treatment. Perhaps the pathway of first choice appeared to be the most difficult for the patient,and perhaps an alternative pathway should be chosen.

2. Unilateral SNAG Right lateral flexion in flexion using belt in standing (SNAGRLFF)

3. Unilateral SNAG Left rotation in extension in sitting (SNAGLRE)
4. Unilateral SNAG Left lateral flexion in extension in sitting (SNAGLLFE)


Chapter 3. Belt traction of the lumbar spine using combined movements


The belt traction technique as described by Brian Mulligan is a wonderful technique for relieving pain in the lumbar (but also thoracic spine). However a couple of years ago I treated a patient, who� s symptoms didn�t improve using Mulligan techniques. Using the belt traction as described by Brian Mulligan also didn�t improve the symptoms, but traction in a combined position opposite from the symptomatic pattern reduced the pain unbelievably fast. As I worked through the combined movement treatment pathway using belt traction only, the patient improved so much, that doing SNAGLLFE finally abolished the rest of the symptoms.

1. Belt traction in left lateral flexion in extension (BTLLFE)
2. Belt traction in left rotation in extension (BRLFE)
3. Belt traction in right lateral flexion in flexion (BTRLFF)
4. Belt traction in right rotation in flexion (BRRF)

There are also techniques for manual traction in side lying:

1. Manual traction in left lateral flexion in flexion (MTLLFF)
2. Manual traction in left rotation in flexion (MTLRF)
3. Manual traction in right lateral flexion in extension (MTRLFE)

4. Manual traction in right rotation in extension (MTRRE)


All these traction techniques should, of course, be pain free. I would suggest, that these traction techniques might be used, when the progression the patient makes is not sufficient, or rather less than expected. The traction techniques probably also increase or decrease the combined movement, thereby increasing or decreasing pain.According to this method, it might also be useful to apply traction while the patient is actively performing combined movements. Thus far I haven�t been able to come up with a method to apply a sustained traction at a specific level or region during a combined movement.


Ref:
(1) Mulligan B., Manual Therapy, 5th Ed. Plane View Press, Wellington, 1995
(2) De Kruijff M., The use of combined movements, Mdk-Physio, Jormannsdorf, 2005
(3) Edwards B., Manual of combined movements, Churchill Livingstone, 1992