Manual Therapy 19 (2014) 499e503
                                                                   Contents lists available at ScienceDirect
                                                                          Manual Therapy
                                                            journal homepage: www.elsevier.com/math
             Professional issue
             Mulligan Concept manual therapy: Standardizing annotation
                                                a,*                                        b                                             c
             Jillian Marie McDowell                , Gillian Margaret Johnson , Barbara Helen Hetherington
             aProhealth Physiotherapy, 124 Kelvin St, Invercargill 9810, New Zealand
             bCentre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand
             cUnit 3204, The Poynton, 142 Shakespeare Rd, Takapuna, Auckland 0622, New Zealand
             articleinfo                                      abstract
             Article history:                                 Quality technique documentation is integral to the practice of manual therapy, ensuring uniform
             Received 1 April 2013                            application and reproducibility of treatment. Manual therapy techniques are described by annotations
             Received in revised form                         utilizing a range of acronyms, abbreviations and universal terminology based on biomechanical and
             11 December 2013                                 anatomical concepts. The various combinations of therapist and patient generated forces utilized in a
             Accepted 21 December 2013                        variety of weight-bearing positions, which are synonymous with Mulligan Concept, challenge practi-
             Keywords:                                        tioners existing annotational skills. An annotation framework with recording rules adapted to the
             Annotation                                       Mulligan Concept is proposed in which the abbreviations incorporate established manual therapy tenets
             Clinical records                                 andaredetailedinthefollowingsequenceof;startingposition,side,joint/s, methodofapplication,glide/
             Manual therapy                                   s, Mulligan technique, movement (or function), whether an assistant is used, overpressure (and by
             Mulligan Concept                                 whom)andnumbersofrepetitionsortimeandsets.Therapistorpatientapplicationofoverpressureand
                                                              utilization of treatment belts or manual techniques must be recorded to capture the complete
                                                              description. The adoption of the Mulligan Concept annotation framework in this way for documentation
                                                              purposes will provide uniformity and clarity of information transfer for the future purposes of teaching,
                                                              clinical practice and audit for its practitioners.
                                                                                                                              
2014Elsevier Ltd. All rights reserved.
             1. Introduction                                                                 annotation applicable to Mulligan techniques, utilizing acronyms,
                                                                                             abbreviations and tenets common to established manual therapy
                 The Mulligan Concept of manual therapy is based on the                      approaches.Forthepurposeofthispapertheterm‘annotation’refers
             application of a sustained accessory joint mobilization, often in a             to the specific formula recording a manual therapy technique.
             weight-bearing position, which utilizes patient generated active or
             functional tasks through a specified range of joint movement                     2. Manual therapy annotation
             (Vicenzino et al., 2011). As the use of mobilization with movement
             (MWM)techniqueshasincreased,thenumberofstudiesanalyzing                            Manualtherapyannotationsmaybelikenedtoasequentialsetof
             the efficacy of Mulligan’s techniques has proliferated in the field of            operational instructions whereby details of all parameters (the task
             peripheral manual therapy (Paungmali et al., 2003; Collins et al.,              aswellasthepositionofthepatientduringtreatment,placementof
             2004; DeSantis and Hasson, 2006; Vicenzino et al., 2006; Penso,                 the therapist’s hand and amplitude, speed and directions of force
             2008; Teys et al., 2008; Amro et al., 2010; Teys et al., 2013). There           applied by the therapist) are recorded for exact technique repro-
             is also a correspondingincreaseofinvestigationsexaminingtheuse                  duction. These annotations are based on terminology derived from
             of MWM in spinal rehabilitation (Hall et al., 2007; Konstantinou                biomechanical and anatomical concepts, which are universally un-
             et al., 2007; Moutzouri et al., 2008; Richardson, 2009).                        derstoodbyphysiotherapistsfordescribingthelocationandtypesof
                 Accurate annotation of Mulligan Concept manual therapy is                   forces applied to the human body.
             essentialtoensurefuturequalitydisseminationofclinicalinformation                   Annotational methods currently utilized by physiotherapists in
             within patient records, research, education, governance and audit.              manual therapy practice are influenced by the nature of their
             This paper presents a documentation framework, based on existing                training backgrounds. Since Mennell wrote his first book on
                                                                                             mobilization in 1911 (Mennell,1911), therapists such as Kaltenborn
                                                                                             (Kaltenborn, 1970), Grieve (Grieve, 1975), Maitland (Maitland,
               * Corresponding author. Tel.: þ64 3 2189052; fax: þ64 3 2141950.              1978), McKenzie (McKenzie, 1981) and Edwards (Edwards, 1992)
                 E-mail addresses: jillianmmcdowell@gmail.com, jillian.mcdowell@xtra.co.nz   have utilized systems of acronyms, grades (oscillatory and sus-
             (J.M. McDowell).                                                                tained), symbols and assessment sheets pertinent to their
             1356-689X/$ e see front matter 
 2014 Elsevier Ltd. All rights reserved.
             http://dx.doi.org/10.1016/j.math.2013.12.006
         500                                             J.M. McDowell et al. / Manual Therapy 19 (2014) 499e503
         particularapproach.Severaluniquetechniqueacronymsdeveloped              wouldbedocumentedwithintheproposedannotationalframework
         by Mulligan (Mulligan,1989) are already commonplace within the          accordingly as “sup ly R Elb Lat gl MWM res grip 6sec(10)”.
         manual therapy literature and physiotherapy patient medical re-
         cords: these include the terms of sustained natural apophyseal          3.1. Mulligan specific annotation rules
         glides (SNAGS), natural apophyseal glides (NAGS), mobilizations
         with movement (MWM) and pain release phenomenon (PRP).                     Techniques with unique applications have annotation rules that
         While these acronyms have achieved wide spread acceptance as            mayalsosimplifyrecordingandtherearecertainpremisesspecificto
         written and verbal descriptive ‘short hand’ the quality of MWM          Mulligan techniques. For example, a cervical NAG can only be per-
         annotation has been found to be highly variable and the technique       formed in sitting but, for consistency across techniques that have
         tenets are inconsistently implemented and explained within the          multiple start positions, the positional parameter should always be
         research literature (Hing et al., 2008). Therefore consideration is     included. It would also appear pedantic to record whether a treat-
         warranted regarding the standardization of applicable common            ment belt was used for a lumbar SNAG if this was more common-
         technique annotations and abbreviations for physiotherapists            place than manual pelvic stabilization. Again however to maintain
         practising Mulligan Concept manual therapy.                             consistencyitshouldberecordedasinotherMWMsitmaybemore
                                                                                 commontoperformitmanually.Thefollowingoperationalrulesfor
         3. The Mulligan Concept annotational framework                          the annotational framework are outlined as follows:
            The Mulligan Concept of manual therapy challenges annotational         NAGSandSNAGSethetherapist’scontactpointsarecentralon
         skills due to the fact that multiple parameters must be recorded for       the spine unless notated otherwise. Documentation must stip-
         exact reproduction of each technique. MWMs utilize the dual role of        ulate whether the therapist’s contact position is on the right or
         both therapist force (accessory glides) and patient effort (active phys-   left of the spinal segment as a SNAG may be ipsilateral or
         iologicalorfunctionalmovement)andtechniquesareoftencarriedout              contralateral to the active movement.
         in a variety of weight-bearing positions, with treatment belts and,       Transverse SNAGS (formerly called positional SNAGS), spinal
         either additional therapist, assistant or patient applied overpressure.    mobilization with arm movement (SMWAM), and spinal mobi-
         ConsequentlytheseMWMtechniquesrequireadditionalannotational                lizationwithlegmovement(SMWLM)eiftheannotationstates
         detail in comparison to other manual therapy approaches.                   “LT1” this notates the therapist contact point: that is, the
            It is recommendedthatannotationsfortechniquesthatutilizethe             therapist applies pressure to the left of the T1 spinous process
         Mulligan Concept adopt the following parameters in sequential or-          and applies a transverse glide towards the right.
         der namely: start position (including weight bearing or non weight        If overpressure is applied then it should be recorded. Special no-
         bearing), side, joint/s, method of application (belt, harness, self-       tation should occur if it is performed by a third party or has a
         generated), glides applied, name of the Mulligan technique, movement       specialapplication:forexample,thepatient’spartneradministers
         (orfunction),whetheranassistantisused,overpressure(andbywhom),             the overpressure during a self-cervical rotation SNAG. Otherwise
         repetitions or time and sets. These mobilization parameters corre-         all overpressure should be considered patient generated.
         spond to five out of the six of manipulation characteristics already       If a technique has bothamanualandatreatmentbeltmethodof
         proposed by the American Academy of Manual Physical Therapists             application then the use of a belt should always be recorded.
         (Mintken et al., 2008) in their guidelines for describing a manipu-        When“belt”ismissingfromtheannotationthepractitionerwill
         lation technique. Five McKenzie parameters (side, repetition, direc-       assume it is a manual technique.
         tion, start position and overpressure) (McKenzie,1981)andfive out          If more than one corrective glide is applied (for example to the
         of six Maitland parameters (side, joint, technique, start position,        scapula for a scapulothoracic MWM) then the glides should be
         repetitions) (Maitland, 1978), are also utilized in the proposed           listed in the order of emphasis or magnitude of force. If more
         framework. The parameter of grade (IeV) is not included in the             inferior glide is needed than external rotation, medial glide and
         framework as it is not applicable to Mulligan MWM techniques.              compressionthenitshouldbelistedas“Infgl/ER/Medgl/Comp”.
            Althoughtheauthors’recognizethatcliniciansalreadyundertake              Forward slash lines separate multiple glides (in keeping with
         documentationofMulligantechniquesinpatientnotes,aconcernis                 Maitland’s combined movements (Maitland,1978)) and dashes
         raisedthatthelevelofdetailprovidedisoftenoverlysimplistic.Take             indicatecombinedglides(forexampleinthe“Post-supgl”ofthe
         for example a peripheral ‘MWM knee flexion lateral glide x6’ and            inferior tibiofibular joint, Appendix 2).
         spinal ‘SNAG L4 flexion x6’ annotation: there are seven technique          The clinical reasoning underpinning the Mulligan Concept rec-
         variations to consider whenperforming andrecordingalateralglide            ommends that only three repetitions of a technique be per-
         to increase knee flexion and 16 technique variations if all central,        formed if a patient’s condition is highly acute or irritable
         ipsilateral and contralateral L4 SNAG combinations are considered.         (Vicenzino et al., 2011). Accordingly, the number of repetitions
            The use of abbreviated annotations (Appendix 1) may save time           should be recorded as “3”. Once a condition is sub-acute or
         andassist clarity when Mulligan Concept practitioners share patient        chronic then six to ten repetitions may be used in three to five
         information. Paungmali et al. (2003) describe a technique for lateral      sets. Theannotation“6(3)”wouldindicatesixrepetitionswere
         epicondylalgia as follows: “the physical therapist used one hand to        performed three times with a rest between each set.
         stabilizethedistalendofthehumerusonthelateralsidejustproximal             Asapainreleasephenomenon(PRP)isasustainedtechniqueitisbest
         totheelbowjointlinewhileusingtheotherhandtoapplyalaterally                 recordedbydurationbutthetechniquealsomayhavesetsapplied;for
         directedglideoftheproximalulnarandradius.Thehandapplyingthe                example“20sec(3)”indicatingthatthree20scontractions,stretches
         lateral glide was situated just distal to the elbow joint line on the      or compressions were performed with a rest between each set.
         medialsideoftheulna.Theglidewaspainlesslyappliedandsustained              NAGS are applied at the rate of three per second and here each
         for approximately 6seconds while the participant performed the             second should be considered a set. Typically, 3e4s are per-
         pain-free gripping action. The gliding pressure was then maintained        formed per segment before retesting (personal communication
         until the participant completely released the grip. Ten repetitions of     Brian Mulligan). If “sit L C5 NAG x4sec” is recorded this should
         thetreatmenttechniquewereapplied,withapproximately15seconds                be interpreted as 12 glides to the C5 segment.
         restintervalsbetweenrepetitions”(p.376).Thecorrespondingfigure             RibMWMwithasinglepointofcontactovertheposteriorchest
         showed the patient in supine. The patient’s physiotherapy records          wall should be recorded using “costovertebral” (CV) in the
                                                                  J.M. McDowell et al. / Manual Therapy 19 (2014) 499e503                                             501
                 annotation. This abbreviation allows differentiation from the                parametersarereportedwithinasequentialframeworkasfollows:
                 double hand rib MWM where the rib is lifted anteriorly and                   starting position, side, joint/s, method of application, glide/s, Mul-
                 posteriorly, and recorded using “rib” in the annotation.                     ligan technique, movement or function, assistance, overpressure
               Self-treatments may be performed with a handgrip, fist, towel,                 (andsource)anddetailsofnumbersofrepetitionsortimeandsets.
                 or treatment belt with the method of application also included               Information regarding the therapist or patient application of
                 whenrecording home exercise prescriptions.                                   overpressure, the help of an assistant, or utilization of a treatment
                                                                                              belt are required to capture the complete description of these
                 Worked examples of key Mulligan techniques are displayed in                  techniques. Even if the exact order of these parameters is not
             Appendix2. If abbreviations are not accepted in the therapist’sarea              consistentwiththeannotationalframework,theinclusionofallthe
             ofpracticethenitisrecommendedthattheannotationsbewrittenin                       components is still considered the minimum requirement for
             long hand, although still in the same framework order of parameter               documentation of Mulligan Concept manual therapy techniques.
             descriptionspecifiedabove.Theauthorshavespecificallychosentext                     Standardizing annotation will ensure that future comparisons may
             abbreviations for the framework to facilitate the typing of electronic           be made between studies, reproducibility of techniques between
             patient notes without insertion of symbols, but the established                  practitioners is guaranteed, and accurate patient records exist for
             symbols developed by Maitland (Maitland, 1978) may be used                       audit purposes.
             interchangeably with accompanying text (Appendix 1).
                                                                                              Acknowledgements
             4. Summary
                                                                                                 The authors wish to acknowledge those members of the Mul-
                 To adequately annotate the treatment dimensions of the Mul-                  ligan Concept Teachers Association who provided feedback on the
             ligan Concept manual therapy techniques it is recommended that                   framework and the appendices.
             Appendix 1
             Abbreviations for use in Mulligan Concept annotations.
               Start position Side   Joints/anatomy              Glides (text)          Mulligan technique                         Movement           Repetitions/time/
                                                                                                                                                      sets
               pr ly¼Prone L¼left    ACJ¼acromioclavicular joint AP¼anteroposterior#    BLR¼bentleg raise                          Ab¼abductionF      sec¼seconds
                 lying       R¼right Ank¼ankle                   Ant¼anterior           HASNAG¼headachesustained natural           Ad¼adductionF      min¼minutes
               sit ¼Sitting          Calc¼calcaneum              Comp¼compressionF      apophyseal glide                           Dev¼deviation      ¼times
               sly¼Side              CV¼costovertebral joint     Dist¼distraction       MWM¼mobilisationwithMovement               DF¼dorsiflexionF    () ¼sets
                 lying               Cx¼cervical spine           gl¼glide               NAG¼NATURALapophysealglide                 DFIS¼dorsiflexion   Other
               st¼Standing           C3¼cervical spine 3rd       Inf¼inferior           Rev NAG¼reverse natural apophyseal glide   in standing        þA¼with
               sup                   vertebra                    Lat¼lateralF           Rev HA SNAG¼reverse headache sustained     EIL¼extension in   assistant
                 ly¼Supine           Elb¼elbow                   Med¼medialF            natural apophyseal glide                   lying❖             þ2A¼with2
                                     Fib¼fibula                                      *   SMWAM¼spinalmobilization with arm
               lying                 Fra¼forearm                 PA¼posteroanterior                                                El¼elevationF      assistants
               WB¼weight                                         Post¼posterior         movement                                   ER¼external        Bilat¼bilateral
                 bearing             Gastroc¼gastrocnemius       Prox¼proximal          SMWLM¼spinalmobilization with leg          rotation           OP¼overpressure
                                     GH¼glenohumeral             Sup¼superior           movement                                   Ev¼eversionF       Res¼resistance
                                     Kn¼knee                     / Separates multiple   SNAG¼sustained natural apophyseal glide    E¼extensionF       Unilat¼unilateral
                                     Inn¼innominate              individual glides      Tr SLR¼traction straight leg raise         F¼flexionF
                                     L5¼lumbarspine 5th          - Indicates combined   Trans SNAG¼transverse sustained natural    HBB¼handbehind
                                     vertebra                    glides                 apophyseal glide                           back
                                     MC¼metacarpal               Glides (symbol)F       Movementdirection (symbol)F                HF¼horizontal
                                     MCP¼metacarpophalangeal [¼anteroposterior          M¼lateral rotation                         flexionF
                                     joint                       /¼lateral glide right  N¼medialrotation                           HE¼horizontal
                                     MT¼metatarsal               )¼lateral glide left   Q¼lateral flexion left                      extensionF
                                     MTP¼metatarsophalangeal Y¼posteroanterior          l¼lateral flexion right                     IR¼internal
                                     joint                       4¼longitudinal                                                    rotation
                                     PFJ¼patellofemoral joint      ¼left posterior glide                                           Inv¼inversionF
                                     PIP¼proximal                ↴¼right posterior glide                                           LF¼lateral flexion
                                     interphalangeal joint                                                                         Opp¼opposition
                                     PS¼pubicsymphysis                                                                             PF¼plantarflexionF
                                     RUJ¼radio-ulnar joint                                                                         Pron¼pronation
                                     SCJ¼sternoclavicular joint                                                                    PKB¼proneknee
                                     Sh¼shoulder                                                                                   bend
                                     SIJ ¼sacroiliac joint                                                                         Rot¼rotation
                                     Sx¼sacrum                                                                                     SKB¼small knee
                                     Tx¼thoracic spine th                                                                          bend
                                     T4¼thoracic spine 4                                                                           Supin¼supination
                                     vertebra
                                     Tib¼tibia
                                     Wr¼wrist
             #
              Acceptable interchangeable terms for anteroposterior include dorsal and posterior (Kaltenborn, 1970; Maitland, 1978).
             *Acceptable interchangeable terms for postero-anterior include anterior and ventral (Kaltenborn, 1970; Maitland, 1978).
             FDenotesestablishedMaitlandabbreviationsandsymbols(Maitland,1978);whilstsupinationisrecordedas‘Sup’inMaitland’sabbreviationsithasbeenalteredheretoavoid
             confusion with superior glide ‘sup gl’ which is more commonly used than cephalad (ceph) and caudad (caud) in Mulligan Concept terminology.
             ❖Denotes established McKenzie acronym (McKenzie, 1981).
            502                                                        J.M. McDowell et al. / Manual Therapy 19 (2014) 499e503
            Appendix 2
                                                                                                      a
            Workedannotations for selected Mulligan Concept manual therapy techniques (abridged ).
              Starting        Side Joint/s          Method of            Glides                Mulligan           Movement/           Assisted Overpressure          Repetition/    Sets
              position                              application                                technique          function                     (source)              time
              sit                  C2-7                                                        NAG                                                                   3sec
              sit             R    C6-T4                                                       Rev NAG                                                               3sec
              sit                  C5                                                          SNAG               Rot L                        þOP                   6             (3)
              sit             L    T8                                                          SNAG               LF R                                               6             (3)
              sit             L    6th rib                                                     MWM                Inspiration                                        3
              sit             R    L4                                                          SNAG               E                                                  6             (3)
              sit                  C5               Self towel                                 SNAG               Rot R                        þOP(partner)          6
              sit                                   Self                                       Fist Tr                                                               10sec         (3)
              sit             R    C3/L C4                                                     SMWAM              RShAb                                              6             (3)
              sit             R    C5/L C6                                                     Trans SNAG         Rot R                                              6
              sit                  C2                                                          HASNAG                                                                10sec         (3)
              sit             L    Olecranon                             Medtilt               MWM                Res grip                                           6
              sit             L    Wr                                    Medgl                 MWM                F                            þOP                   6
              sit             L    Index PIP                             Lat gl/IR             MWM                F                            þOP                   6
              sit             R    Inf RUJ                               Ant-lat gl            MWM                Supin                        þOP                   6
              sit             R    ACJ                                   Inf gl/Post gl        MWM                F                                                  6
              sit             R    Scapulo                               Medgl/Inf gl/Comp/ MWM                   El                           þOP                   6
                                   thoracic                              ER
              sit             L    Thumb                                                       Stretch PRP        Finklestein                                        20sec         (3)
              st                   Lx               Self chair                                 Tr                                                                    10sec         (3)
              st              L    Hip              Belt                 Lat gl                MWM                IR                                                 6
              st              R    Sh               Belt                 Inf gl/E/Ad           MWM                HBB                          þOP                   6             (3)
              Rstep st        R    Tib/Fib          Belt                 Ant gl                MWM                DF                                                 6
              st L foot on    L    Inf Fib                               Post-sup gl           MWM                DF                                                 6
                chair
              sup ly          R                                                                BLR                                                                   3
              sup ly          L                                                                Gate                                                                  20sec         (3)
              sup ly          R                                                                Tr SLR                                                                3
              sup ly          L    Hip              Belt                 Lat gl                MWM                F                            þOP                   6
              sup ly          L    Kn                                    Med                   Squeeze            F/E                                                6
              sup ly          R    Ank                                   Ant gl-roll           MWM                PF                                                 6
              sup ly          L    Inf Fib                               Post-sup gl           MWM                Inv                          þOP(belt)             6
              sup ly          R    Elb              Belt                 Lat gl                MWM                Res grip                                           6
              pr ly           L    L2/R L3                                                     SMWLM              PKB                 þ2A                            3
              pr ly                L4                                                          SNAG               EIL                                                6
              4 Point kneel        L3               Self belt                                  SNAGLion                                                              6
              Rsly            L    L4                                                          SMWLM              SLR                 þA                             3
                              L    Kn                                    IR                    Tape
            Note: repetitions and sets listed in this table illustrate examples of annotations and are not linked to any recommended treatment prescriptions.
             a Full version available in the Online supplementary material.
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