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Satpute K, Bedekar N, Hall T. Mulligan manual therapy added to exercise improves headache frequency, intensity and disability more than exercise alone in people with cervicogenic headache: a randomised trial. J Physiother. 2024 Jul;70(3):224-233. doi: 10.1016/j.jphys.2024.06.002. Epub 2024 Jun 19. PMID: 38902195

Questions:

+ What is the effect of a 4-week regimen of Mulligan Manual Therapy (MMT) plus Exercise compared with Exercise Only for managing cervicogenic headache (CH)?

+ Is MMT plus exercise more effective than sham MMT plus exercise?

+ Are any benefits maintained at 26 weeks of follow-up?

Conclusions:

+Adding MMT to exercise for the long-term management of CGH is effective for reducing headache frequency, intensity, and disability, but not reducing duration.

+Adding MMT effectively addresses long-term management of impairments of upper cervical ROM and sub-occipital pain pressure thresholds (which may be a factor in HA generation)

Take Home Messages:

+Immediate benefit favoring the Mulligan Manual Therapy + Exercise Group to Exercise Only Group at 4, 13, and 26 weeks for HA Frequency

+HA Disability and Upper Cervical Flexion Rotation ROM showed clinically worthwhile benefits at 4, 13, and 26 weeks.

+HA intensity and patient satisfaction showed worthwhile benefits at 13 & 26 weeks.

+Strong association with reduction in HA with increased Upper C-Spine ROM.

Potential Mechanisms Suggested for Improvement:

+Improved C1-2 motion segment motion may decrease strain on articular and periarticular mechanoreceptors, therefore reducing nociceptive signaling, resulting in new afferent input to the CNS by increasing non-nociceptive signaling.

+ Changes in mechanoreceptor input have the potential to change local muscle activity, thus optimizing muscle control in the upper cervical spine.

+Reduction in HA may be linked with an indirect hypoalgesic effect of MT and Ex causing improvement in cervical msk dysfunction and consequent reduction in nociceptive input.

+Improvement in pain pressure thresholds at local and remote sites suggest mechanisms underlying the hypoalgesic effects of MMT were similar to other MT techniques encompassing peripheral and central mechanisms

 

1. Tell our newsletter community about yourself

My name is Erik Schmidt and I am proud to now be one of Canada’s 3 Mulligan Concept teachers.

Currently, I live in London Ontario Canada. My wife Sarah and I have been together for over twenty years and we are blessed with two young boys; Colin (7) and Declan (3).  In the rare free time I have I enjoy spending time outside with friends and family traveling, camping, hiking, biking, climbing, skiing, and fishing… (almost any activity that is active and gets me outdoors!)

Professionally, I am an owner, manager, and active clinician for two multidisciplinary clinics in London.  I hold two undergraduate degrees in both Kinesiology and Psychology and two master's degrees in the area of Physiotherapy.

Beyond my personal and professional duties, I have spent nearly 13 of my 17 years serving on various national executive boards such as the Canadian Academy of Manual and Manipulative Physical Therapists (CAMPT) and the Orthopeadic Division.  I have also been a longstanding adjunct lecturer for several university programs and community-based programs.

 

2.  How did you first become interested in the Mulligan Concept?

Fun story;  as a high school student I stumbled into Jim Millard’s clinic. I’m still not sure what he saw in me that day but he offered me an opportunity to shadow him at his clinic.

During my time, Jim exposed me to a host of physiotherapy concepts, most of which centered around the Mulligan Concept.  At that time, I was too young and inexperienced to understand what he was teaching me, but as I completed my physiotherapy Master's program, I came to appreciate the differences in the clinical reasoning and methodology that the Mulligan Concept could offer.

Truthfully, I was the only one in my physiotherapy program with any exposure to the Mulligan concept and that knowledge greatly benefitted me while I excelled on my clinical placements.  After that, there was no turning back - I knew that the concept would be part of my practice throughout my career.

 

3. Tell us about your journey to becoming an MCTA teaching member

My journey to become an MCTA teacher began in 2012. I completed my second Masters's program, set down roots in London Ontario, and informed Jim Millard of my desire to progress my way through the system.  It was a very gradual process.  The geography of Canada doesn’t always lend itself to a high volume of teaching opportunities, but Jim always went above and beyond to generate times when I could assist and learn.  Notably, there were two gaps in my process; the first was my choice when we started a family.  The second was in 2020 and affected everyone.  In 2022 I began the final steps in the process by completing the required literature review (hip) and case study (lateral epi). My first attempt at the practical exam was in 2023, followed by my successful attempt of the exam in June 2024.

 

4. Why do you love teaching the Mulligan Concept? 

Over Covid, there was a pivotal moment when I needed to decide where to invest my teaching time. The reason I chose the Mulligan Concept was for the same reasons I love the Concept.  Here are 5 examples;

1. Teaching the concept in Canada means introducing clinical reasoning and treatment behaviors that differ from many of the core concepts found in the university program.  Having an opportunity to challenge those paradigms while witnessing the change in the student’s perspective about what is possible as a manual therapist has always been exhilarating.
2. Offering a test-treat-retest concept that happens simultaneously is practical from both a treatment perspective and a clinical efficiency perspective
3. Offering a concept that generates a “wow” factor for the students when they see (or sometimes feel) the instantaneous change is always quite fun.
4. Even though the concept has been around for forty-plus years, it’s always fun to point out how the concept has grown in efficacy with each decade. The ease of which it the concept falls within the biopsychosocial model and how it has the power to bridge manual therapy, pain sciences, function exercise, communication, and a patient-centered approach is impressively relevant in today's healthcare landscape.
5. The growth in confidence (and sometimes the restoration of a student’s confidence) in the utility and joy of manual therapy is gratifying.

 

5. Why should someone consider taking a Mulligan Concept Course?

Perhaps a more interesting question; should anyone practicing manual and/or neuromusculoskeletal physiotherapist not take a Mulligan Concept Course??

To answer the question, students should consider our course when;

• They feel their manual therapy skills are not meeting the needs of their clientele
  Their confidence in their manual therapy skills is waining or they feel their education to date has not encouraged manual therapy.
• They feel manual therapy, pain sciences and functional exercise can’t compliment one-another or co-exist
• They would like the ability to practice in a “pain-free” methodology
• The power to generate instantaneous change appeals to them.

Any manual or neuromusculoskeletal therapist looking to gain a modern pain-free, patient driven and evidence informed manual therapy approach should consider the benefits of a Mulligan Concept  Course.

1. Tell our newsletter community about yourself 

While in high school I was encouraged by my anatomy teacher and track coach to consider a career in physical therapy, and after almost 30 years in the profession I have never regretted it!  Living an active lifestyle, whether through running, cycling, skiing, swimming, or hiking has always been extremely important to me. A career in physical therapy has provided me and my family with the opportunity to enjoy this kind of lifestyle and to help others do the same.

2.  How did you first become interested in the Mulligan Concept? 

I attended my 1st Mulligan Concept course in 2003, which was taught by Brian Folk. I had been a PT for 8 years and received the Orthopedic Certified Specialist designation but had yet to hear of the Mulligan Concept or mobilizations with movement. Brian had such an engaging way of teaching that I could not help but be intrigued. It would take several more years before I completed the entire series of Mulligan Concept courses and became a Certified Mulligan Practitioner, but I immediately put into practice what I learned at that first course and never forgot the impact it made in my orthopedic physical therapy practice.

3. Tell us about your journey to becoming an MCTA teaching member 

While serving as coordinator for continuing education at the large rehab clinic where I worked, I was able to bring the Mulligan Concept series in for 3 consecutive years. Leading up to the Advanced Course and CMP exam I led monthly study groups, which assisted several of our therapists becoming Certified Mulligan Practitioners. It was during this time I realized how passionate I felt about the concept and enjoyed teaching my colleagues. Over the next 5 years I assisted with Mulligan Concept courses with half a dozen different teachers in North America, which deepened my desire to become an MCTA teaching member. During that time, I also completed my fellowship training in Orthopedic Manual Physical Therapy, becoming a FAAOMPT.  Finally, after extensive, focused study and mentoring, I successfully passed my teacher's exam in 2024!

4. Why do you love teaching the Mulligan Concept?  

Manual therapy and active movement/exercise have always been key foundational components to my approach to physical therapy. While traditional manual orthopedic physical therapy keeps these distinct and separate, the Mulligan Concept brings them together in a readily usable assessment and treatment approach. I have seen first-hand the positive impact this patient-centric approach has made in the lives of my patients, and I love sharing with other clinicians how they can provide similar experiences for their patients.

5. Why should someone consider taking a Mulligan Concept Course?  

Every clinician who seeks to provide safe, evidence-informed care, performed in a pain-free manner, and that empowers the patient to become an active participant in their care should take a Mulligan Concept course.  While the courses include clinical reasoning backed by research, they are lab-based and emphasize development of your manual handling skills. After completion of a Mulligan Concept course, you can immediately put into clinical practice the principles of the concept and the techniques.

For the last 5 years, I have focused my practice on oncology. In school, we had always been told to avoid manual therapy with the cancer population. However,  I have found due to the gentle, pain-free nature of the Mulligan concept, it has become a great asset in improving mobility in this population.

When treating any patient with cancer, the physiotherapist always wants to complete a thorough history, including medication, types of treatments the patient has undergone, tumor type and classification, radiation treatments’ duration and locations, and especially the location of any metastatic lesions. All are critical in establishing treatment protocols. The physiotherapist becomes part of the oncology team, including the surgeon, oncologist, radiation oncologist, speech therapist, social worker, and nutritionist. Each has its specific job through the recovery process. Good, open communication between team members is key.

Once the joint /bone or surrounding tissues have been cleared of metastatic or cancer lesions, it is safe to apply gentle, pain-free techniques! I have been working closely with the head and neck population. Especially following radiation, patients develop fibrosis of the musculature which tends to draw the head and neck forward and can progress to “dropped head syndrome". If the posture is not addressed in a timely fashion, this condition can become dysfunctional very quickly.  I have found that gently performing NAGs to the lower cervical spine followed by gentle active ROM can dramatically improve patients’ ability to move.

Ideally, the NAGs are performed with the patient sitting, but I have modified the technique to be done supine. With this clinical variation, I can utilize gravity to allow the neck to come back to a neutral position.  By gently supporting the head on my forearms while the middle phalanx of my index finger hooks under the spine’s process, I can still apply the glide up toward the eyes.

For the lower cervical and upper thoracic spine, I find RNAGs too aggressive.  Accordingly, I modified to supine where I stabilize the upper segment with the middle phalanx of my index finger, but have the patient perform bilateral shoulder elevation. As the patient lifts their arms the therapist feels the vertebra dropping under his fingers, allowing the neck to move into gentle axial extension. These techniques are often coupled with myofascial work to the fibrotic musculature on the anterior aspect of the neck and active ROM.  Post-session I often see improved head control, with improved mobility.

The other area of dysfunction seen in our head and neck population is truisms. This condition can begin quickly after direct surgery on the jaw or as a result of post-radiation changes.  In some individuals truism tightness comes on gradually, due to teeth removal before surgery, eating a soft to liquid diet, or requiring a feeding tube for nutrition.  Some patients have lost the ability to speak. All of these these patients are challenging.  Again, if the therapist can start treatment and education early, teaching patients jaw exercises, some of the loss may be prevented.  But once a restriction is noted I use some of Mark Oliver’s techniques, along with trigger point work around the face and neck and hyoid region. I have found these to be invaluable with these patients.

So, don’t be afraid of oncology patients, be smart. Work with your team, to know what you're working with.  Gentle, pain-free treatments can be extremely beneficial to allow pain-free mobility.

Patricia Black PT, MS, MCTA, CLT

Below is an email I received from a practitioner after a recent Lower Quadrant Course. It is common to hear about success stories from participants, but they are rarely shared. Enjoy reading about this participant experience. I hope it reminds you about the importance of learning and applying MWM's to enhance your clinical practice.

Jarrod

My Experience with MWM's

Good morning, I was in your Lower Quadrant course in Virginia Beach a few weekends ago. I have used what I learned several times with good results. Thrilled to have this in my bag of tricks. I do want to tell you about one patient.

A 41 y/o male with low back pain for 20 years, and now is debilitating. Lots of extraneous medical issues. First injury, he stepped in a hole while running for military PFT. Then a huge motorcycle accident when he hit a car and flew over it with fx cervical vertebrae and ribs and collar bone. He had several doctors, several MRIs, injections, traction, PT, and stem cell injections. His main complaint was not being able to bend forward. He was so scared to even try for me. He said he would get spams that put him on the floor. I noted he had a right anterior pelvis, and maintained lordotic posture. I wasn’t able to fully correct his pelvic rotation.  I got his permission to try MWM’s. I really educated him about the techniques being pain-free. I held his right ASIS posteriorly with stabilizing at the sacrum. Took several hand placements to get pain-free. He could touch the floor with no pain. I got a big hug and we both teared up. He had been tossed around the medical system for so long and was clearly at his wit's end. He did not have positive expectations with PT.

I just wanted you to know, that I’m thankful for your course. I will see you in March for the Upper quadrant.

Stacy S, DPT, CMPTP, CDT

Knee Osteoarthritis (OA) is the second most prevalent musculoskeletal disorder in society at almost 29%. As the world gets older and the baby boom population continues to age (along with the rest of us), knee OA becomes more prevalent in the general population.  Thus, I wanted to highlight and expound on some important findings in the study “Long-term efficacy of mobilization with movement on pain and functional status in patients with knee osteoarthritis: a randomized clinical trial". (HERE)

This publication investigated pain and functional outcome differences between a control group receiving exercises (Exercises included pelvic bridging, resisted knee flexion and extension, mini squats, and heel raises) and hot packs.  The experimental group received MWM’s for the knee as well as the same treatment as the control group.

As an accredited Mulligan Concept Teacher Association member since 2014 and a Certified Mulligan Practitioner since 2007, I view MWMs as the greatest accelerant to my functional and manual treatments in my clinical population.  If my patient demonstrates a PILL response, I feel incredibly confident we are going to have a positive outcome much more quickly than waiting on standard care.  It’s an accelerant.  Getting to both my treatment goals and the patient’s goals much more quickly. Quicker than manipulation, any soft tissue technique, or solely exercise.

We can see that in the results of this publication.   Subjects with symptomatic knee osteoarthritis receiving two weeks of mobilization with movement in addition to usual care had significantly greater improvements than those receiving usual care alone. Beneficial effects were seen in disability, pain, function, and patient satisfaction and were sustained for six months. subjects receiving mobilization with movement together with usual care showed significantly greater improvements in self-reported function, pain, and patient satisfaction than those receiving usual care alone. This effect was apparent immediately after the intervention and was maintained even six months later. However, there were no significant differences between groups for functional mobility as measured with the timed up-and-go test and the 12-step test immediately after the intervention.

I wanted to further discuss this final interesting finding.  For the timed up-and-go test and 12-step test the difference between experimental and control groups was evident only after three months. Why? One explanation for this is that pain reduction achieved with mobilization with movement may not have been sufficient to achieve an immediate improvement in these functional activities. These more vigorous activities are not only impaired by pain but also by other factors such as muscle weakness. Muscle strength may have improved over time with repetition during the resumption of normal functional activities and could explain the improvement seen in the experimental group after three months.

Now we do know, from other published research, that exercise reduces pain, increases muscle strength, and improves control around the affected joint. Exercise also potentially has disease-modification effects by increasing the proteoglycan content of cartilage, increasing its thickness, and reducing the rate of joint space narrowing.

So why did the experimental group find MWM’s effective, at different times, in different ways?  Both immediate and then also with some delay.  Well, the real answer is, that we don’t know all the interplay of affects and contextual residue.  But what I do see in clinical practice, is the reports of patients feeling more confident, less afraid, and more willing to MOVE.  To engage in the daily trials with the mentality that I’m not broken by my arthritis. What if I can move with no pain, take those stairs, rise from that chair without excessive pushing with my arms, walk around the block, that more is less? More well-tolerated activity yields less pain.  And MWM’s inform my patients of that immediately.  They don’t have to just trust me, my education, my experience.  They can experience the results instantaneously…in real-time.

So as a clinician, I encourage you to just try MWM’s with your knee OA patients.  Just try to make that immediate difference.  Don’t wait.  Accelerate, with a manual therapy accelerant. Get ALL the benefits of exercise and movement without delay.  Without struggle. Without just hoping they improve with time.

Eric