CLINICAL METHODS

The Mulligan concept: NAGS,

SNAGS and mobilizations
with movement
. . . . . . . . .

Ed Wilson

Introduction techniques must not reproduce

the symptoms that the patient
Developed in the 1980s by Brian
is complaining of. Indeed
Mulligan, a New Zealand based
these symptoms (pain,
physiotherapist, NAGS, SNAGS
weakness, stiffness) must be
and mobilizations with movement
eliminated or the technique is
(MWMs) are essentially articular
abandoned as unsuitable and
techniques with neuro-muscular
other methods are substituted
consequences. They share some ideas
for it.
and methods with Kaltenborns seat
The amount of force used to
belt techniques (Kaltenborn 1980)
glide a joint tends to be minimal,
and with the Positional Release
although they can be quite
concept (Jones 1981).
vigorous if so indicated if
NAGS (natural apophyseal
being used to treat stiffness
glides) are essentially accessory
rather than pain, for example.
movements, gliding one spinal facet
(b) In NAGS and SNAGS the
upon its neighbour, and are
accessory treatment force is
performed on a passive patient
applied along the facet planes of
(Fig. 1). SNAGS (sustained natural
the spinal joints, therefore the
apophyseal glides) are similar
direction is different for a C1/2
accessory glides performed on a
problem compared to that of a
Ed Wilson BA MCSP patient who is simultaneously
T1/2 problem (Fig. 3). With
Member of the Mulligan Concept Teachers actively moving through the
Association peripheral joints the direction of
previously painful or restricted
force will depend upon the type
Correspondence to: E. Wilson range of movement (Fig. 2). MWMs
of joint being treated. If it is a
Highthorn Physiotherapy Clinic, apply the principle of accessory glide
132 Lawrence Street, hinge-type joint, i.e. basically it
plus active movement too, but they
York, YO10 3EB, UK articulates in the sagittal plane
are applied to peripheral joints.
Received June 2000 and is a bone end-to-end
The central tenets of Mulligans
Revised July 2000 articulation, like the knee, then
concept are:
Accepted August 2000 the force is applied at right
...........................................
Journal of Bodywork and Movement Therapies (2001)
(a) all techniques are carried out angles to the movement taking
5(2), 81^89 within a painfree framework. place (Fig. 4).
# 2001 Harcourt Publishers Ltd
doi:10.1054/jbmt.2000.0191, available online at
Some palpation or pressure If the joint is of the parallel
http://www.idealibrary.com on pain is permitted, but the type, i.e. the bones are long

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Fig. 1 Cervical NAGS.
bones and articulate in a side-
by-side manner, like the inter-
metacarpal joints, then the force
applied will alter that parallel
relationship during movement
(Fig. 5).
With MWMs, the direction of
application of the force can be
predicted to a large extent by the
shape of the articular surfaces,
and/or by knowledge of the
forces acting upon the joint.
This is not 100% accurate,
Fig. 2 Cervical SNAGS.
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
Fig. 3 Facet planes upper cervical spine.
shape of the articular surfaces,
the thickness of the cartilage, the
orientation of the fibres of
ligaments and capsule, the
direction of pull of muscles and
tendons, facilitate free but
controlled movement while
simultaneously minimizing the
compressive forces generated by
that movement. Normal
proprioceptive feedback
however, as anomalies
maintains this balance.
frequently occur, so the
Alteration in any or all of the
therapist should be prepared to
above factors would alter the
experiment a little to find the
joint position or tracking during
optimum effective degree of
movement and would provoke
force and its direction.
symptoms of pain, stiffness or
(c) The techniques have been
weakness in the patient. It is
developed to overcome joint
common sense then that a
tracking problems or
therapist would attempt to re-
positional faults, i.e. joints with
align the joint surfaces in the
subtle biomechanical changes.
least provocative way.
Normal joints have been
designed in such a way that the How does the therapist know
that they have correctly re-
aligned the joints biomechanics?
Simply by eliminating the
patients symptoms. Hence
Mulligans (1985) insistence on
the techniques being painfree,
because only if they are can we
be sure that all is well with the
joint. Frequently remarkably
Fig. 4 Hinge-type joint.
82

Fig. 5 Joints with bones in parallel planes.
little force (and hence subtle
movement at the joints
surfaces) is required to achieve
this painfree status. Indeed, in
some instances the patient is
unaware that treatment is
occurring at all!
To summarize this section, we
see that Mulligan has developed
methods of correcting joint
biomechanics during active
movement in the case of SNAGS
and MWMs which rely on the
patient to report freedom from
symptoms as the indicator of their
successful application. Manual
therapists who are experienced in
their use quickly learn not to persist
with that particular form of
treatment if the symptom-free
response is not almost immediate.
Learning to admit that one is not
being effective is a difficult lesson to
learn for most therapists, but it is
one which Mulligans ideas force
one to accept.
Indications for use
As the previous section suggests,
The techniques have been designed
to overcome movement problems by
subtly altering joint biomechanics in
a precise way. They are not aimed at
resting pain unless it is relatively
minor but is made significantly
worse by movement. Substantial
resting pain usually indicates an
underlying pathology or active
inflammatory process which may be
causing the tracking problem but
will not be relieved by merely
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
correcting articular relationships.
Indeed, techniques involving both
accessory and active movements are
likely to exacerbate symptoms
rather than relieve them. Hence if
Mulligan cannot achieve normal
movement rapidly with his
techniques he abandons them in
favour of other treatment
modalities.
Mild resting aches may well
be an indicator of disturbed
proprioception being misinterpreted
by an agitated central nervous
system, and being made worse by
active movement. This would be
entirely suitable for Mulligans
approach.
So, symptoms of pain, stiffness or
weakness on movement are the
primary indicators for these
techniques. Otherwise, the
appropriateness of the techniques
for a particular patients must be
judged on what Maitland (Maitland
1986) calls the SIN factor, i.e.
severity, irritability and nature of
the presenting condition. In this
respect Mulligans techniques are
the same as all other manual therapy
approaches, as indeed they are in
regard to contraindications.
However, the relative gentleness
and the insistence on the application
of the techniques within a
symptom-free framework make
them safer than many other manual
therapy approaches. Indeed NAGS,
for example, can be used where
more vigorous, manual therapy
techniques have exacerbated the
problem.
Methodological principles
The methodological principles for
MWMs and SNAGS are essentially
similar so they will be outlined first.
A detailed description of techniques
for individual joints is not
appropriate here. They can be
found in Mulligans book and his
videos. The address of the stockist
83
can be found at the end of this
article.
MWMs
The patient presents with a history
which indicates that manual therapy
would be an appropriate response.
Particularly they complain of
symptoms only on movement or
activity. There are little or no resting
symptoms: no indicators of serious
pathology. For example, any
reported weakness should suggest
muscle inhibition rather than
neurological deficit, although one
can mimic the other of course.
The first element of treatment
now commences: it is explained to
the patient that their symptoms are
benign and are due to mal-tracking
of the joint, and that treatment will
consist of gently correcting that
tracking as they perform the
movement through the range
previously provocative of their
symptoms. This simple explanation,
using lay terminology allays their
fears and recruits the downward
inhibitory modulation systems
which can be extremely helpful in
reducing symptoms (Shacklock
1999).
Next it is emphasized just how
important it is to report accurately
on the symptoms as treatment
proceeds. They must not experience
their symptoms, and if they do they
must report it at once so that
appropriate changes can be made to
the treatment. Knowing that they
are in the hands of a therapist who is
not about to hurt them is also very
reassuring for most patients.
With the painfree concept
established and agreed, the speed at
which the patient is to perform the
given movement is negotiated, along
with a signal for when to commence
the movement. This ensures that the
treatment technique and the active
movement are truly simultaneous.
In the case of an MWM for a
hinge-type joint, the elbow for
 Wilson

example, the technique would be to

fix or stabilize the proximal bone
the humerus with one hand whilst
gliding the forearm laterally with the
other as the patient carries out active
flexion or extension (Fig. 6). The
therapists hands must be positioned
just above and just below the joint
line to avoid the technique becoming
a collateral ligament stress test, or to
avoid compressing the radial head
against the capitulum. It must also
be remembered that the direction of
the accessory technique must follow
the joint line, which in the case of
the elbow is oblique, slanting
cephalad towards the lateral side. Fig. 6 Lateral glide of forearm on humerus.
With the glide applied as the
patient performs the previously
symptomatic movement their
feedback is critical. If the symptoms 2. Painfree over-pressure at the end Again, basically, we are altering
are worsened then the glide is of range. the relationship of one bone to its
patently in the wrong direction, or 3. Teach the patient how to neighbour as the patient carries out
the problem is unsuitable for MWM replicate the technique for an active movement. Obviously we
at that particular time. (If reversing painfree repetitions at home. can no longer effectively stabilize as
the direction of the accessory glide 4. If appropriate, tape the joint in we did in MWMs, nor can we strap
also exacerbates the problem then the desired position and the joint into position, but in other
the likelihood is that the technique encourage home exercise again respects SNAGS and MWMs can be
should be abandoned.) (Fig. 7). considered as being the same.
If, however, by the application of It should be pointed out, however,
SNAGS
the symptoms on movement are that Mulligan recommends only
improved but not eradicated this The methodological principles for three repetitions of the successful
suggests that the technique is SNAGS are similar to MWMs and snag in the cervical spine. It is a
correctly chosen but requires fine are performed in the manner notoriously unpredictable area and
tuning. An alteration in the amount mentioned above. this advice should be heeded.
of pressure used and/or a subtle
alteration in the angle of that
pressure should render the
movement painless. When it does so
we then perform perhaps 10
repetitions of the now asymptomatic
movement, maintaining exactly the
amount and direction of glide
pressure.
Following the painfree repetitions
the movement is then tested without
the glide being applied. In a
remarkable number of cases the
movement remains asymptomatic. If
it does not then there are several
options available to the therapist.

1. More repetitions of glide with

active movement. Fig. 7 Strapping for lateral glide at the wrist.

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 The Mulligan concept

Other factors to be born in mind

are:

1. The structural osseous anatomy

of the spine. It was pointed out
earlier that the accessory force of
a snag is applied along the facet
plane to facilitate glide
and to avoid joint surface
compression. These planes differ
from area to area and the
therapist must be well informed
regarding the angle of facet
planes in the particular region to
be treated.
2. The facet planes change their
Fig. 8 Lumbar SNAGS in sitting.
orientation to each other in
different phases and directions of
movement. The therapists
accessory force must follow this
throughout the movement and
back. For example, in cervical
rotation the upper cervical facets
travel much further than those in
the lower cervical region.
Therefore, if treating the upper
cervical spine with SNAGS the
therapist must adopt a starting
stance which permits the
comfortable rotation of their
arm, trunk and hips in order that
the facet plane can be followed as
it moves.
3. With lumbar SNAGS (Fig. 8)
Mulligan recommends treatment
in sitting if the patients
symptoms can be reproduced in
sitting. If they are only manifest
in standing then they must be
treated in standing.
4. It is of course possible to perform
SNAGS either centrally by
exerting pressure on the spinous
process, or unilaterally by
exerting pressure on the articular
pillar.
5. As with MWMs, self SNAGS can
be taught to the patient (Fig. 9).
6. To finally eradicate symptoms
the therapist may elect to use
over-pressure of the movement.
However, care must be taken
especially with the upper cervical
spine. Staying within the painfree Fig. 9 Self SNAGS into extension lumbar spine.

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 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.

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Fig. 11 Spinal mobilization with arm movement.
Although not in Mulligans
book there are techniques born
of his concept which can be
used to address apparent
pathoneurodynamics (Wilson 1994,
1996) or to enhance muscle tone
directly (Wilson 1997).
Discussion
Two points inevitably arise when
discussing Mulligans concept and
techniques with colleagues.
(a) How does it work so rapidly?
(b) Why do the beneficial effects
persist after perhaps only three
of four repetitions of symptom
free movement when the
symptoms may have been
longstanding?
When treating patients Mulligans
response to them is to say it gets the
joint used to tracking properly. This
is usually a satisfactory answer for
lay people but it is only a partial
answer. However, a full explanation
is possibly not available with current
investigative paradigms and
methods. An attempt at explanation
should be made nevertheless.
Perhaps Mulligans response can
be phrased differently but maintain
the same essential meaning:
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The Mulligan concept
It sedates an agitated, facilitated
nervous system, particularly the
dorsal horn, by bombarding it with
the painless normality it has always
been patterned to receive. Normal
afferent discharge provokes a
reciprocal normal efferent discharge
to the structures controlling joint
movement.
Thus we are probably overcoming
symptoms generated by neuro-
muscular imbalance. The techniques
will not be effective if applied to
chronically adaptively shortened
situations, or where serious
pathology exists. They may alleviate
the symptoms of the latter
temporarily but they will
undoubtedly recur.
In acute conditions it may be that
the response of the mechano-
receptors to sudden over-stretch of
soft tissue lies at the root of the
problem. There is minimal trauma,
if any, but the receptors continue
their protective firing and evoke
muscle response in consequence.
This over-reaction may be as a result
of pain memory (Gifford 1998) or
perhaps merely an anomalous
reaction (Di Giovanna 1991).
Whatever the reason for the
exaggerated response, the selective
alteration in muscle tone
87
automatically alters biomechanical
joint function creates a tracking
problem in fact. Then the disturbed
proprioceptive output from the
malaligned joint itself contributes
abnormal stimuli to a central
nervous system already operating
at an enhanced level of excitability.
This will affect efferent output too,
and then the joint is contributing to
its own malfunction (Fig. 12).
Manual re-positioning of the joint
by the therapist now looks like a
good treatment approach. Correct
alignment of the joint would remove
the abnormal barrage, and gentle
handling plus painfree initiation of
movement may well rapidly re-assert
a normal response from the central
nervous system. Thus we have the
process of mobilization induced
analgesia (Zusman 1985, 1994).
Recruiting downward inhibitory
modulation by a non-emotive
explanation, caring manner and
gentle handling helps too, of course.
In chronic conditions the same
overall process occurs but with the
added complications which
chronicity brings. Lateral
epicondylagia (LA) is a good
example for several reasons:
(a) Cyriax (1983) regards it as a
soft-tissue problem and treats it
accordingly with frictions,
manipulation and/or injection.
(b) Maitland (1977) meanwhile
states that in cases of chronic
LA there is inevitably some joint
dysfunction too. He goes on to
treat the joint dysfunction and
reports that the soft-tissue
component recovers
spontaneously.
(c) For chronic LA, Mulligan
states that joint repositioning is
used to eliminate pain and
enhance grip strength (Vicenzino
1995).
(d) Positional release techniques
(Chaitow 1996) use painful soft-
tissue monitors (trigger points)

Fig. 12 Potential effects of initial soft tissue compromise.
then re-position the joint until
the soft-tissue pain disappears.
(e) LA is a common symptom of
fibromyalgia, the aetiology of
which is shrouded in mystery
and controversy.
All the above can be reconciled if
we accept that in many cases soft-
tissue tenderness is a manifestation
of an agitated central nervous
system (Cohen 1995) and does
not necessarily reflect a current
soft-tissue lesion.
We could argue as follows:
Muscular or tendinous tissue of the
common extensor group at the
elbow suffers traumatic over-strain.
The mechano-receptors will behave
as described above and exert their
effect on the neuro-muscular system.
Shortly afterwards the damaged
tissue will leak inflammatory
exudate which will in turn cause
chemo-receptor discharge into an
already excited CNS, thus increasing
its response. Joint biomechanics
its tracking will now be seriously
disturbed, and its proprioceptors
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Wilson
will add their excitatory discharge,
ultimately contributing to its own
dysfunction through altered efferent
activity.
However, whether or not the CNS
will recognize that both soft-tissue
and joint are complaining of distress
is debatable as it is already highly
sensitized to the soft-tissue afferent
discharge before the joint afferents
arrive. The CNS readily confuses
knee pain and hip pathology, or
experiences arm pain during a heart
attack, due to convergence of their
respective axons into the dorsal horn
receptor sites. It is therefore
conceivable that these sites will
confuse or misinterpret incoming
signals from soft-tissue or joint.
Later, because of the adaptive,
protective response of the nervous
system the soft-tissue trauma site is
not disturbed and quickly heals.
However, the CNS remains in a
state of heightened excitability
because joint proprioception has
remained abnormal throughout the
healing process. Convergence as
discussed above could lead the CNS
88
to project the abnormal discharge to
the soft tissue and to behave as if
that tissue is still damaged.
If a therapist gently re-positions
the joint into its correct alignment,
and normalize its proprioceptive
discharge, it may so quieten the
CNS that the soft-tissue pain would
seem to disappear as spontaneously
as Maitland, Mulligan and Chaitow
suggest. It would also release the
inhibition or hypertonicity of the
relevant musculature and increase
grip strength thereby (Vicenzino
1995). (There is no magic here: just
the application of a reasonably well
researched physiological process.
Attempting to justify manual
therapy interventions without
recourse to this process leaves a
large hole in clinical reasoning
paradigms.)
Example
The reader is invited to try this
small experiment.
Check your range of abduction at
the shoulder joint, being aware of
the experience of free movement.
Now with the index and middle
fingers place on the anterior greater
tubercle (Fig. 13) gently glide the
head of humerus posteriorly using
ounces of pressure. With this glide
in position perform abduction
again. In most cases a tightening
or stiffening of the joint will be
experienced due to subtle alteration
in joint biomechanics. This is what
the patient experiences, but with the
addition of the altered
proprioception being analysed by an
excited CNS.
Summary
Symptom free joint mobilization
added to muscular activity is the
core of Mulligans work. Well
executed on an appropriate patient
it can be rapidly and permanently
effective. It can be used alone or in

Fig. 13 Self-treatment: posterior glide of head of humerus.
conjunction with other therapeutic
approaches. The techniques are a
useful addition to the repertoire of
any manual therapist but they are
certainly not a panacea for all ills.
A careful and comprehensive
assessment will determine which
patients are suitable and which are
not, and those that are suitable fall
largely into the movement-induced
symptoms category. They are used
to correct minor joint derangements
which often display a
disproportionate array of effects.
That is the key to Mulligans
work.
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
Books and videos on the
Mulligan Concept are available
from: Houghtons, Rich Barton
House, Chideock, Bridport, Dorset
DT6 6JW, UK.
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