CMP Program A


Mulligan Concept

Cervical & Upper Quadrant
Prepared and presented by:
Dr. Hussain Nasser tDPT, MSc, BSc PT
CMP, MCTA (Middle East)
FT Inventor, PGC Coordinator
BPTA President (2006 to 2010)
ACPTA President (2009)
Medbridge education Affiliate
Chief of Therapy Center
Kingdom of Bahrain
 Dr. Hussain’s Workshops
1. Mulligan Workshops 2015
➢ Bahrain
➢ Kuwait
➢ Lebanon
➢ Jordon
2. Facilitation Techniques (FT)
3. Spinal Rehabilitation- Clinical Paradigm
4. Physio Taping- Clinical Model
5. Headache Management
6. Managing chronic LBP
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Dr. Hussain Nasser’s Social Media

mulliganbahrain@gmail.com
+97339210099

Hussain Nasser@Mulliganbahrain

Drhussainnasser hussainnasser
MCTA
MCTA 2015 Sydney
Code of conduct:
• Switch your
mobile off.
• Keep your
question at
the end of the I am Ali
presentation.
• Participate openly.
Participate
Keep practicing

Mohammed
Mulligan Courses
Bahrain

Lebanon

Jordan

Qatar

Kuwait

UAE

Iraq

Iran
 Workshop Plan
Day One Day Two
• Mulligan concept • Mulligan concept
• Cervical • Cx MWM
– NAGS • Transverse SNAGS
– SNAGS
• SMWAM
– Self Rx
• Fingers MWM
• Wrist MWM
• Cervical Headache
• Carpals & MC MWM
• Shoulder MWM
• Elbow MWM
 Course Goals
• Introduce the Manual therapy based on Mulligan
approach.
• To teach the Mulligan Concept with a high
standard level.
• Make you ready for the CMP Exam.
• I can not teach you every thing, but I can help
you to learn the Mulligan concept.
• CMP A covers the Cx and Upper Extremities.
• Add to your technique toolbox.
 What is Manual Therapy?


• A group of philosophies or
paradigms, each consisting of
techniques/ skills that adheres to an
adopted a set of principles.
 Schools of Thought

• No One has all solutions, B Mulligan.

• “In the field of discovery, chance
favors only the prepared mind!” -
Louis Pasteur
 Cont. Schools of Thought
1. Manipulation philosophies based on
relieving nerve root pressure.
Cyriax: The spinal techniques are designed
to move the disc, and thus relieve nerve
root pressure. Cyriax techniques are
nonspecific and effected many
structures including muscle and facet.
2. Manipulation philosophies based on
relieving pain.
Maitland: Oscillations are used to eliminate
reproducible signs. The techniques are
specific.
McKenzie: Repetitive motion is used for
centralization of pain which many
interpret as centralizing the disc.
3. Manipulation philosophies based on
normalizing joint mobility.
Kaltenborn: Emphasis is on
arthrokinematics, particularly convex-
concave relationships. Techniques are
very specific.
Mulligan: Promotes natural apophyseal
(facet) glides by assisting the motion
being performed by the patient usually in
a weight bearing position.
 Ralph Waldo Emerson


“AS TO METHODS THERE MAY BE MILLION

AND THEN SOME, BUT PRINCIPLES ARE FEW.
THE MAN WHO GRASPS PRINCIPLES CAN
SUCCESFULLY SELECT HIS OWN METHODS.
THE MAN WHO TRIES METHODS, IGNORING
PRINCIPLES, IS SURE TO HAVE TROUBLE.”
 The Who’s Who of Manual Therapy


• Robin McKenzie
• Geoff Maitland
• Jenny McConnel
• Brian Mulligan
• Stanley Paris
• Freddy Kaltenborn
• Bob Elvey
• Janet Travell, MD
• Etc…..
 Brian R. Mulligan
• Brian R. Mulligan FNZSP
(Hon), Dip MT
• Physiotherapist 1954 (no MT
at Otago Uni!)
• First locum for Robin
McKenzie & Paris
• MT: Cyriax and Kaltenborn
approach.
• Teaching Kaltenborn from
1970 in Newzeland and in
1972 in Australia.
 Brian Mulligan cont.
• Discovery of MWM in 1984 and teach it in
1986.
• Founding member NZMTA with Mckenzie.
• Meets Toby Hall, Sarah Counsell and Linda
Exelby at Curtin- in 1990.
• APTA poll: of the worlds 7 most
influential persons in OMT
Brian Mulligan’s Books
Mulligan concept
 How did Mulligan discover MWM?

• By Chance, when he was treating a lady

with Index IP joint dysfunction (swollen and
restricted flexion) due to sport injury.
• He treated her with US, traction and glide
with nor effect.
• MWM provided instant full range with pain-
free movement.
What does Mulligan teach?
 PILL
• Pain Free
• Instant
• Long Lasting

27
 Manual therapy

• Follow the Traffic Lights

rule.

28
 CROCKS
• C: contraindications of
Manual Therapy.
• ‘no absolute
contraindication for manual
therapy’ St. Paris
• IN General:
★Infection
★inflammation
★fracture

29
 CROCKS
• R: repetitions
• Several repetition should be done during
the mobilization.
• The purpose of symptom-free repetition
of movement and mobilization is
ultimately to sedate the CNS, to
reestablish dynamic natural.
• 6-10 repetition for 3 sets depends on SIN.

30
 CROCKS
• O: overpressure
• To gain max movement.
• it is equal to
manipulation.
• it is must to gain full
recover.
• done by patients.

31
 CROCKS
• C: communication and co-operation
• give a clear command.
• use an easy language.
• be sure that your patient is cooperative.

32
 CROCKS
• K: Knowledge
1. Anatomy (joint planes)
2. Biomechanics
3. Positional Fault

33
 CROCKS
• Sustain
• Sense
• Skill
• Slow
• Subtle Change

34
 Terminology
• NAGS
• SNAGS
• Positional SNAGS/Transverse SNAGS
• SMWAM
• MWM
• PRP
 Techniques Description
• Patient position
• Therapist position
• Hand Position
• Mobilization
• Joint Motion
• Outcome
 Manual therapy keys


• 50% = success is in the setup

• 40% = therapist hand position
• 10% = just do it; frequency etc
• Critical to this:
»Contact
»Force
» Direction
 Cx Technique
• NAGS
• Reverse NAGS
• SNAGS
• Flexion
• Extension
• Side Flexion
• Rotation
• Fist Traction
• Self Treatment
NAGs = Natural Apophyseal Glides
• Passive oscillatory mobilisation applied in the
cervical and upper thoracic spine (C2- T3)
• Moving the SUPERIOR vertebral segment
anterior and superior on a relatively fixed
Inferior (lower) spinal segment
• A pain-free technique.
• Performed in weight bearing typically Mid
range to end range techniques
• Not MWM!!
• Traction can be applied if needed.
NAGS
 NAGs
• Patient: seated; head cradled by PT axilla
• Therapist: stand anterior-lateral to right side
of the patient.
• Mobilization: direction: middle phalanx 5th
digit over SP reinforce by the thenar eminence
and glide anterior-cranial (facet plane)
– Start your palpation below the segment to NAG
– Take up the soft tissue slack.
– Change the glide angle when pain occurs.
– 2 per second; 5-10 reps; move up, etc.
 NAGS Indications
• Elderly
• Acute neck
• Unsure of condition ‘irritability’
• Multidirectional movement loss
• Relieve post treatment “soreness”.
• Other Considerations:
– Test for irritability
– If they cannot tolerate NAGs may be too
irritable
NAGs - Unilateral
 NAGs - Unilateral
• Indications:
• When central NAGs does not work
• Unilateral pain or dysfunction
• Spinous process is tender.
Reverse NAGS Grip
Contact for Reverse NAGs
Reverse NAGs
 Reverse NAGs
• PP: well seated in a chair without arm
support.
• TP: More lateral PT
• M: anterior-cranial mid to end range glide
using flexed I/P joints index; extended I/P
joint thumb; forms ‘V’; fingers flexed
– 1-2 per second
– C5/6 down to T4; more effective C/T region
• Variations: unilateral ( Recommended)
• Note: tenderness diminished by foam pad
 Indications of Reverse NAGs
• end range loss of neck movement
• postural dysfunction - forward head
posture with upper trapezius pain
• degenerative lower cervical or upper
thoracic spine.
• Where chin retraction exercise is
indicated.
• Bridge technique is an alternative.
 SNAGs - Sustained Natural 

Apophyseal Glides
• SNAGS= MWM: sustained passive accessory
translatory movements (glides) combined with an
active physiological movement.
• Weight bearing
• MOVEMENTS
➢ FLEXION, EXTENSION, SIDE BENDING – L/R, ROTATION – L/R
• TIPS
➢ Flexion and Extension often require a central SNAG
➢ Side Bend and Rotation will often respond better to a unilateral
SNAG
➢ Sustain 2 seconds at end of motion
Hand Grip
 SNAGS
• Grip: medial thumb of contact hand on vertebra; thumb
pad of superimposed active hand on lateral border of
contact thumb; fingers stabilize lateral neck or cheek
(depends on level/ hand size)
• Contact: Central = SP; Unilateral = articular pillar
• Location: All Spinal Segments
• Direction: anterior-cranial (45° but varies) = parallel to
treatment plane
• Force: mid to end range (as appropriate)
• Overpressure: by patient, Extension= weight of head
• Reps: Rule of 3; up to 10 first set
• (Note: if any pain, patients stops and returns)
 SNAGS for Cx Extension
Follow the change in the angle of the joint
plane
SNAGS for Cx flexion
SNAGS for Cx Side flexion
SNAGS for Cx Rotation
 Troubleshooting


• If symptoms remain unchanged after MWM,

it could be due to:
• Clinical reasoning
• Incorrect joint selection eg. AC vs GH; C3 vs C4
• Improper technique choice
• Poor handling skills
• Wrong direction or force
• Poor communication eg. Pain vs tenderness
 SNAGS Cx Self Rx
• Extension
• Side flexion
• Rotation
 SNAGS Self Rx- Extension
•Towel stays
in Same
position
relative to
eyes; lift
elbows!!
SNAGS Self Rx- Side flexion
SNAGS Self Rx- Rotation
 Fist Traction
• Fist under chin (comfortably against throat);
• Other hand pulls forwards using fulcrum of fist
• Use towel on sternum to pad if needed, or
• neck ‘long’
• Stretch experienced posteriorly; Vary angle of
• pull (oblique R/L)
• Sustain 10 seconds x 3, retest; 3-5 reps
• NOTE: used as a self-treatment for reverse
headache SNAG
Fist Traction self Rx
 Fist Traction
Indications:
• Loss of flexion
• Pain with mid to end range flexion
• Stiff low cervical and/or upper thoracic
spine
Cervical Belt Traction
 Cervical Belt Traction
• Grip: Position middle fingers within the
belt loop with leaving gap between
fingers for SP
• Belt position: alter height of belt around
your body as needed
• Duration: Perform sustained holds of 10s
• Uses: disc; not responsive to mobs
 MWM Fingers - IPJ

•Glide distal phalange medial or lateral; +/- rotation.

•Comment: move distal segment towards side of pain
 Thumb - CMC


• Internal rotation of the base of the thumb

+ use
• taping to secure the position
• Sustained traction 20 sec
• (PRP)
Metacarpal MWM - fist
5th MC mob A/P or
P/A with patient gripping
 MWM Metacarpals

• Mobilize up or down relative to

neighboring MC or carpal
• Anterior of 5th and/or 4th MC “Arcuate
swing” - making a fist
NOTE:
• Useful after boxers fracture
MWM Scaphoid
 MWM Scaphoid
❑ Mobilization:
➢Ventral glide of scaphoid on radius; vary
angle as needed
❑ Contact: Use medial border of thumb
reinforced (similar to ‘SNAG’)
❑ Movement: Wrist extension
❑ Note: allow for the extensor tendons to
push your thumb out the way IN extension
 MWM Wrist

Proximal carpal row: Radial glide
 MWM Wrist

Proximal carpal row: Radial glide
 Proximal carpal row: Radial glide

• Grip: Active hand web space, open hand
• Location: Proximal row of carpals on distal
radioulnar
• joint
• Direction: lateral/radial glide; may need rotation
• (or combination)
• Indications: Loss of wrist extension/ flexion due to
• minor positional fault of proximal row of carpals
• *Other considerations: scaphoid, distal and proximal
• RU joints
MWM Distal R/U Joint Supination
Distal R-U Joint - Supination
 Distal Radio - ulnar Joint
❑ Grip: Ulna P-A mobilization (most commonly
used) for both supination and pronation
❑ Direction: Overlapped thumbs on ulna,
fingers on ventral border of the radius
❑ Note:
➢Supination - therapist stands at the side of
the patient.
➢ Pronation - therapist stands facing the
patient
❑ Note: Proximal RU joint, combination
 Taping techniques
❑ 5th Metacarpal volar direction
➢ Tape medial and inferior to thenar base
❑ Lateral glide proximal carpal row
➢ For supinatory or pronatory emphasis: one strip
➢ For lateral glide only: 2 strips; must cross at joint;
usually too distal!; check circulation
❑ Scaphoid:
➢ Anchor dorsal aspect of hand, spiral antero-
medially; in prontation
❑ Volar glide of ulna
➢ Done in supinatory position
➢ Spiral tape
Proximal Carpal Row – lateral glide

taping
 MWM Elbow Joints
❑ MWM Flexion
➢Medial glide -- Lateral glide
❑ MWM Extension
➢Medial glide -- Lateral glide
❑ MWM Flexion using belt
❑ MWM Extension using belt
❑ MWM Tennis Elbow
❑ MWM Tennis Elbow self treatment
 

MWM Elbow Flexion

 MWM for Elbow Flexion/Extension

Manual glide
❑ Mobilisation (lateral glide):
➢ FLEXION of elbow
➢use ‘palm down’ hand
➢ apply force through lateral aspect of hand on ulna
(medial contact)
➢do not block anterior elbow
➢ EXTENSION of elbow
➢use web space of lateral hand
➢stand medial to arm bracing with trunk
❑ Comment:
➢ First choice: glide forearm towards side of pain
➢ PT elbows ‘out’ for effectiveness; add minor
rotation?
MWM for Elbow Flexion/ Extension
using belt
MWM for Elbow Flexion and Extension
❑ Position: Patient supine
❑ Grip: One hand stabilizes the lower end of
the
humerus with the belt around hips and proximal
elbow joint, the other controls the distal
radius/ ulna
❑ Direction: Glide ulna laterally with belt
*Note: Carrying angle in elbow extension causes
slight change in treatment plane and
therapist must alter direction of glide
MWM for Tennis Elbow
 MWM for Tennis Elbow

lateral epicondylalgia
❑ Pain/restriction with: gripping; 3rd-4th finger E,
wrist E; often worse in elbow extension
❑ Mulligan rationale: positional fault of the
radiohumeral joint
❑ Other rationale:
➢ Altered tracking of the radial/humeral joint (Wilson,
Miller)
➢ Entrapped meniscoid structure (Rivett, Mercer)
➢ Abducted ulna (Lee).
❑ Mobilize:
➢ #1 Perform a lateral glide at elbow
➢ #2 Perform a radial head mobilization
 Lateral glide for Tennis elbow (L)
❑ Position: For left elbow, PT with belt over right
shoulder facing feet of supine patient.
❑ Grip: Right hand stabilizes lower end of humerus
while shoulder is internally rotated; Left hand
stabilizes at wrist
❑ ‘Movement’: pain generating activities, can
combine!
❑ Direction: Lateral glide of elbow
❑ Reps: x10 pain free activities per angle, F to E
❑ Note: Begin with flexion to ensure TRUE lateral glide
❑ May require cephalic or other vector
 MWM Tennis Elbow Self Rx
❑ Using a doorway
❑ Patient stands with elbow in 90 F, joint
‘just past’ the door frame
❑ Self- lateral glide using web space of
other hand as close to joint line as
possible
END OF DAY ONE
 Mulligan Concept
1. Positional Fault
2. Treatment Plane
3. Pain Free
4. Repetition
Positional Fault Hypothesis (PFH)
❑ Mulligan (1995) proposed that minor
positional fault of the joint occurs
following injury or strain resulting in
movement restrictions or pain.
❑ Mulligan’s mobilization can correct the
positional fault and restore a restricted,
painful movement to a pain free and full
range state.
 Cont PFH
❑ PFH evolved out of MWM improving motion,
relieving pain and restoring function
❑ Preliminary evidence (LOW LEVEL) that
most effective direction in MWM will be
direction opposite to existing PF
❑ Amelioration of symptoms does not prove a
positional fault
❑ Some evidence PF may exist at some joints
(PF, GH, inf Tib-Fib)
 Cont PFH
• Measuring of PF is achieved by imaging
techniques.
• There is evidence that PF exist at:
➢Inferior TibFib joint: decrease distance
between maleolli
➢PF joint: increase angle between
Patella& condyles
➢GH joint: decrease distance between
Acromion and humeral head
 Review by Vicenzino 2007
• Title: Mulligan’s mobilization with movement, positional
faults and pain relief: Current concepts from a critical
review of literature.
• Aim: to critically evaluate the relevant current
literature under two paradigms: Biomechanical and
neurophysiological.
• Methods: 45 19: 9 clinical based & 10 Laboratory
based studies (biomechanics & pain).
• Result:
– Clinically: level of evidence for the clinical efficacy is
low. Data support rapid improve in pain and function.
– Laboratory: No evidence to support or refutes.
 2. Treatment (Rx) Plane
• Peripheral Joints
1-Glide should be
parallel to the Rx plane
on concave part.
2-AP glide can be used
3-Glide force should be
close to the Rx plane
and in a different
direction.
 Rx Plane
• Cervical Spine
1-Glide force should be in the
same direction of active
movement..
2-Glide can be on the SP or TP.
3-Changing the curve involve
changing in the glide
direction.
 Rx Plane
❑Cervical Spine ❑Wrist joint
❑Shoulder joint ❑Carpal bones
❑Elbow joint ❑Metacarpal bones
❑R/U joint ❑Phalanxes
 3- Pain Free
• All Mulligan’s techniques must not
reproduce the patient’s symptoms. Mild
palpation discomfort might be
experienced upon application of the
techniques.
 4. Repetition
• Several repetition should be done during
the mobilization.
• The purpose of symptom-free repetition
of movement and mobilization is
ultimately to sedate the CNS, to
reestablish dynamic natural.
• Rule of 3
• 6-10 repetition for 3 sets depends on SIN.
 Manual Therapy compared

SIMILARITIES
❑ Similar to Kaltenborn ➢ DISSIMILAR
in some glides ❑ No provocation
❑ Similar to Maitland in ❑ No centralization
accessory glides
❑ No grades of
❑ Similar to McKenzie in movement
self-treatment and ERL
❑ Not generally Passive
❑ Response determines
treatment ❑ Move towards pain
 Notation
• SNAGS Cx 5-6 flex
Rt
• MWM Rt Elbow flex
Lat glide
 Principles of Treatment
1.Do your full assessment and identify
the comparable sings.
2.Mobilization should not cause pain.
3.Follow the treatment plane.
4.In SNAGs & MWM sustain glide while
active movement then overpressure is
taken place…maintain until the joint
returns to the starting position.
5.Failure to improve the comparable
sign would indicate that treatment
plane was not correct or the
technique is not fit.
6. Look at the source of the problem.
7. Self-treatment should be taught to
maintain the results.
8. Taping is important to maintain the
correction that gain form the
mobilzation.
9. If you are unable to improve the
comparable sign with Mulligan
approach, try another approach.
10. Follow the Rule of 3.
11. Treatment session typically
involving 3 sets of 6-10 repetitions.
12. You can always perform other type
of physiotherapy with the Mulligan
techniques.
C5/C6 Transverse MWM with Sh elevation
C5/6 Transverse MWM – L Rotation
C5/C6 Transverse MWM - L Rotation
C5/6 Transverse MWM – L Rotation
• Grip: tip right thumb right side of C6 SP
lateral to muscles (blocks), left thumb left
side of C5 SP lateral to muscles
• Arms elbows OUT
• Use foam pad
• Direction: transverse glide of C5 SP to right,
C6 SP to left
• Overpressure
• Variations: repeat above or below; upper T;
combined movements
• Value in lower C to upper T
 Transverse MWM Indications
• Cervical rotation is painful/limited @ 50-75%
of normal AROM.
• Loss of combined movements – rotation,
extension, SB.
• SNAG not effective
• Resistant loss of movement
• Non-irritable cases
• Tips:
• Take up “skin slack” by starting quite lateral
• Use foam pad for comfort
 Cervicogenic Headache
❑ CH is arises from musculoskeletal
impairment in the neck (HIS 1988)
❑ Physical therapies such as manipulative
therapy, therapeutic exercise and
electrophysical agents have traditionally
been the treatments of choice.
❑ 15-20 %, of all chronic and recurrent
headaches are cervical headaches.
❑ The main cause is neck trauma.
❑ The success of any treatment depends on
the patient having the condition for which
treatment is applicable.
❑ The first step to successful management is
to perform an accurate differential
diagnosis.
❑ The diagnosis of cervical headache requires
the presence of a pattern of symptoms and
cervical musculoskeletal signs that
distinguishes it from other types of
headaches.
❑The diagnosis might be an easy or
extremely difficult task.
❑Treatment must address the specific
impairments.
❑Successful outcomes rely on skilled
delivery of treatment.
 Features
❑Some features appear to be quite
discriminatory while others do not
have such high sensitivity or
specificity. This probably reflects the
shared access to the
trigeminocervical nucleus by all
headache forms.
 Features
❑ It is an Unilateral headache.
❑ It can be bilateral with often one side
predominant.
❑ It should not change sides within or
between attacks.
❑ It is associated with pain in the neck or
suboccipital region.
❑ Pain starts in the neck then spread to other
areas of the head.
❑ Severity: most commonly Moderate
❑ Cervical headaches often lack a regular
pattern.
❑ Other symptoms:
❑ nausea, lightheadedness or dizziness, or
visual disturbances
❑ The area of head pain:
➢Commonly occipital.
➢Suboccipital area,
➢Radiating to frontal,
➢Retro-orbital or
➢Temporal areas.
❑ Stress may be a provocative factor.
❑ It can be controlled by Analgesic, rest and
lying down.
❑ Onset of cervical headache can occur at
any age and commonly relates to trauma,
degenerative joint disease or, with the
increasingly sedentary nature of modern
day work, to postural strains.
❑ The length of history is variable and often
prolonged.
❑ It is more prevalent in females.
❑ No particular familial tendency.
 Outcome measures
❑ simple outcome measures can be used in
the clinical setting.
❑ Records of frequency, intensity (VAS scale)
and duration of headache on a daily or at
least a weekly basis.
❑ The Neck Disability Index (Vernon & Moir
1991) or
❑ the Northwick Park Neck Pain
Questionnaire.
 Cx Headache techniques
1. C1-C2Rotational test
2. C1-C2 SNAGS Rotation
3. C1-C2 SNAGS Rotation Self Treatment
4. SNAGS Headache
5. Reverse SNAGS Headache
6. SNAGS Headache with Cx Extension
7. Upper Cx Traction
8. Fruit can Technique
C1-C2 Rotational Test
Manual C1/2 SNAG – R TVP
C1-C2 SNAGS Rotation
 C1/2 Dysfunction

GUIDELINES
❑ Teach self SNAG for C1/2
❑ VERY IMPORTANT: Strap/ Towel level = top
lip
❑ Only 2 repetitions DAY ONE!
❑ Overpressure by Physio (CAUTION if normal)
❑ Reassess
➢ If restricted grossly in both directions clear
both sides!!
❑ Sensitivity to end range feel
❑ If you observe greater than 45° rotation you
missed the end range!
C1-C2 Self Treatment
 HEADACHES: SELF SNAGS
❑ Common errors in technique
➢Not localised
➢ Pulling with the strap
➢Flexing the head on the neck
➢ Direction of pull of strap is not correct
➢ Glide not maintained until head returns
to neutral
SNAGS Headache
 Headache SNAG

❑ Mobilization:
➢Anterior glide of C2 through contact on
spinous process
➢ Angle left/ right as needed
❑ Movement:
➢None
➢ Very gentle: G1 ‘minus’
❑ Tips:
➢ Do not oscillate
➢ Treatment plane is horizontal
➢ Vary flex/ext +/- rotation if needed
Headache self-SNAG
 Headache Self-SNAG

Home treatment
❑ Using a towel
❑ Patient locates towel C2
❑ Anterior glide of C2, patient gently
retracts head against stationary towel
❑ Key : not an aggressive technique – not a
“stretch”
❑ Alternative: can teach overlapped index
fingers instead of towel for frequent use!
Reverse SNAGS Headache
 Reverse Headache SNAG

• Mobilization:
➢Head & C1 anterior on stable C2
➢Angle left/ right as needed
• Tips:
➢Treatment plane is horizontal
➢Do not oscillate
Upper Cx Traction
 Upper Cervical Traction for H/A
❑ Supine position – no pillow
❑ Place your forearm (in mid range supination/
pronation) at the occipital base
❑ If coming from LEFT use LEFT arm and vv
❑ Use slight pronation moment – head nod
confirms position
❑ Counteract pronation moment with gentle
traction at the mandible or on prevent nod at
forehead
❑ Sustain traction 10s – HA change?
 Shoulder girdle

❑ The 3 major osseous components:
➢ Scapula
➢ Clavicle
➢ Humerus
❑ Integrity of the shoulder complex is
reliant on muscular and ligamentous
components – Hawkins et al 1991
 Shoulder girdle


❑ The articular components are:

➢ Gleno-humeral joint
➢ Acromio-clavicular joint
➢Sterno-clavicular joint
➢Scapulo-thoracic articulation
Hand position
MWM for GH elevation
 GH: postero-lateral glide
• Direction: posterolateral, possibly some
inferior glide.
• Grip: stabilize scapula, thenar eminence of
active hand from infero-medial TOWARD head
of humerus
• Indications: Painful arc, pain and/or
restricted flexion or abduction
• Variations: Belt technique, wall technique
(more passive, thus affective for stiffness)
*Perform repetitions with weight or
overpressure
Over Pressure
MWM Sh elevation with weight
MWM Sh elevation using Belt
MWM Sh- Belt & weight
MWM Sh-WB wall
GH: postero-lateral glide WB wall
• Therapist: Stand ipsilateral to shoulder
• Patient: Hands fixated on wall; increase ER by
having elbows bent
• Mobilization: Hypothenar contact of antero-
medial GHJ; postero-lateral glide
• Movement: Patient drops hips backwards
resulting in shoulder elevation
• Comments: External rotation of the humerus
is considered essential for maximal elevation
(Morrey and An 1990)
 GH: Inferior/Posterior glide –

Internal Rotation MWM (Gross limitation)
Internal Rotation - early limitation
Position: Standing ipsilateral side of
dysfunction,
holding arm in abduction with therapist
‘anterior’arm under elbow of patient
Grip and mobilization:
Anterior hand provides AP and Inferior glide,
with posterior hand placed over scap for
counterpressure.
Movement:
Patient attempts to reach posteriorly into
internal rotation
GH: Inferior glide/ Adduction –

Internal Rotation MWM
 GH: Internal Rotation
Position: Standing ipsilateral side (right)
Grip:
• left hand in axilla to stabilize scapula
(cephalic and medial direction )
• right thumb in cubital fossa (inferior
glide/depression)
Mobilization: therapist uses abdomen to
provide adduction at the elbow
• Patient: reaches up behind back.
 MWM GH: Inferior glide/
Adduction – Internal Rotation with Belt
GH: Self treatment

Belt/ T band in door

1/4 inch webbing and
towel – pull
posterior
inferior
diagonally
across back
Scapulothoracic/ Clavicular MWM
 MWM - scapulothoracic/ clavicular
❑ Therapist position/ contact:
➢ Stand opposite side;
➢ Posterior hand: thumb in supraspinous fossa with
fingers descending over scapula
➢ Anterior hand: anteriorly on clavicle – provide
posterior glide/ pressure
❑ Mobilization:
➢ Inferior/ depress, medial rotation, adduct.
❑ Movement:
➢ Patient performs active range of motion into flexion
(impingement)
➢ Add humeral repositioning PRN: eg. Long axis
posterior gliding of the humerus / or rotation (?
Frozen shoulder)
The END