The Maitland Concept

"The Maitland Concept of Manipulative Physiotherapy [as it became to be known], emphasises a specific way of thinking, continuous evaluation and assessment and the art of manipulative physiotherapy (“know when, how and which techniques to perform, and adapt these to the individual Patient”) and a total commitment to the patient."[3]

The application of the Maitland concept can be on the peripheral or spinal joints, both require technical explanation and differ in technical terms and effects, however the main theoretical approach is similar to both[4].

The concept is named after its pioneer Geoffrey Maitland who was seen as a pioneer of musculoskeletal physiotherapy, along with several of his colleagues[5][2]. 

Key Terms

• Accessory Movement - Accessory or joint play movements are joint movements which cannot be performed by the individual. These movements include roll, spin and slide which accompany physiological movements of a joint. The accessory movements are examined passively to assess range and symptom response in the open pack position of a joint. Understanding this idea of accessory movements and their dysfunction is essential to applying the Maitland concept clinically[4].

• Physiological Movement - The movements which can be achieved and performed actively by a person and can be analysed for quality and symptom response[4].

• Injuring Movement - Making the pain/symptoms 'come on' by moving the joint in a particular direction during the clinical assessment[4].

• Overpressure - Each joint has a passive range of movement which exceeds its available active range. To achieve this range a stretch is applied to the end of normal passive movement. This range nearly always has a degree of discomfort and assessment of dislocation or subluxation should be acquired during the subjective assessment[4].

Initial Assessment

The Maitland concept is a fantastic tool for approaching an initial assessment as it can be used to form a logical and deduced hypothesis about the nature of the origins of the movement disorder or pain. It is worth considering using mobilisations in your assessment process and reading the Initial Assessment section in Maitlands book Peripheral Manipulation.

As with any treatment decision a competent and effective assessment is crucial to any patient interaction. The Subjective Assessment is necessary for determining whether or not mobilisations are suitable for this patient or if they are contraindicated by looking for red flags such as cancer, recent fracture, open wound or active bleeding, infective arthritis, joint fusion and more[6]. 

The Objective Assessment is an area which the versatile nature of mobilisations becomes clear. Additionally to being a treatment method they are available to the therapist to assess a patients joints and tissues by analysing their extensibility, pain reproduction, bony blocks or abnormal end feels.

Principles of Techniques

Decisions Which Need to be Made[4]

1. The Direction - of the mobilisation needs to be clinically reasoned by the therapist and needs to be appropriate for the diagnosis made. Not all directions will be effective for any dysfunction.

2. The Desired Effect - what effect of the mobilisation is the therapist wanting? Relieve pain or stretch stiffness?

3. The Starting Position - of the patient and the therapist to make the treatment effective and comfortable. This also involves thinking about how the forces from the therapists hands will be placed to have a localised effect.

4. The Method of Application - The position, range, amplitude, rhythm and duration of the technique.

5. The Expected Response - Should the patient be pain-free, have an increased range or have reduced soreness?

6. How Might the Technique be Progressed - Duration, frequency or rhythm? 

How to Choose the Direction

To make sure you settle on appropriate mobilisations it is important to get the type of glide, the direction and speed correct.

Different Types of Mobilisation: How Many Glides?

Each joint has a different movement arc in a different direction to other joints and therefore care needs to be taken when choosing which direction to manipulate; this is where the Concave Convex Rule comes into use, but for now consider the number of possible glides a clinician may use:

1. A-P (Anteroposterior)

2. P-A (Posteroanterior)

3. Longitudinal Caudad

4. Longitudinal Cephalad 

5. Joint Distraction

6. Medial Glide

7. Lateral Glide

Due to anatomical position and other physical limitations not all peripheral or spinal joints can be subjected to all of the types of glide. Here are examples of mobilisations of joints of the body:

• Elbow Mobilizations

• Wrist/Hand Mobilizations

• Hip Mobilizations

• Knee Mobilizations

• Ankle and Foot Mobilisations

• Spinal_Manipulation

• Shoulder Mobilizations and  Manipulation

• Cervicothoracic Manipulation

Concave Convex Rule: Up, down, Left or Right?

Choosing the direction of the mobilisation is integral to ensuring you are having the desired clinical outcome. This is where a knowledge of Arthrokinematics is important. In summary:

There are two important things to remember:

• When a convex surface (i.e Humeral Head) moves on a stable concave surface (i.e Glenoid Fossa) the sliding of the convex articulating surface occurs in the opposite direction to the motion of the bony lever (i.e the Humerus)[7].

The opposite can be said for 

• When a concave surface (i.e Tibia; talocrural joint) is moving on a stable convex surface (i.e Talus) sliding occurs in the same direction of the bony level[7]. 

Examples:

To improve shoulder flexion you would perform an A-P mobilisation due to the way the convex humerus articulates with the concave glenoid fossa.

Link to further reading

How to Choose the Grade: How Far into Range and Quickly or Slowly?

Grade I – small amplitude movement at the beginning of the available range of movement

Grade II – large amplitude movement at within the available range of movement

Grade III – large amplitude movement that moves into stiffness or muscle spasm

Grade IV – small amplitude movement stretching into stiffness or muscle spasm

**A 5th grade is possible but further training will be required to perform safely**

In many places, you are obliged to obtain a written consent from your patient before applying grade 5 manipulation .

The grading scale has been separated into two due to their clinical indications:[4]

• Lower grades (I + II) are used to reduce pain and irritability (use VAS + SIN scores).

• Higher grades(III + IV) are used to stretch the joint capsule and passive tissues which support and stabilise the joint so increase range of movement.

The rate of mobilisation should be thought of as an oscillation in a rhythmical fashion at[10]:

• 2Hz - 120 movements per minute

• For 30 seconds - 1 minute

Therapeutic Effect: How and Why Does This Work; Mechanisms of Action

There are a number of complex systems which interact to produce the pain-relieving effects of mobilisations, subsequently there is not a single theory into its mechanism. Therefore this article will outline the basics and evidence for the claims and further links will be added for additional more in-depth information. 

Pain Gate Theory

The pain gate theory (PGT) was first proposed in 1965 by Melzack and Wall[11], and is a commonly used explanation of pain transmission. Thinking of pain theory in this way is very simplified and may not be suitable in some contexts, however when discussing pain with patients this description can be very useful.

In order to understand the PGT, the sensory nerves need to be explained. At its most simple explanation there are 3 types of sensory nerves involved of transmission of stimuli[12][13]:

1. α-Beta fibres - Large diameter and myelinated - touch and pressure - Fast (50m/s)

2. α-Delta fibres - Small diameter and myelinated - temperature and pain (well localised, sharp/prickly) - Medium (15m/s)

3. C fibres - Small diameter and un-myelinated - pain (dull, poorly localised, persistent) - Slow (1m/s)

The size of the fibres is an important consideration as the bigger a nerve is the quicker the conduction, additionally conduction speed is also increased by the presence of a myelin sheath, subsequently large myelinated nerves are very efficient at conduction. This means that α-Beta fibres are the quickest of the 3 types followed by α-Delta fibres and finally C fibres[14]. 

The interplay between these nerves is important but it is not the whole story, as you can see only two of these nerves are pain receptors α-Delta fibres are purely sensory in terms of touch. All of these nerves synapse onto projection cells which travel up the spinothalamic tract of the CNS to the brain where they go via the thalamus to the somatosensory cortex, the limbic system and other areas[15]. In the spinal cord there are also inhibitory interneurons which act as the 'gate keeper'. When there is no sensation from the nerves the inhibitory interneurons stop signals travelling up the spinal cord as there is no important information needing to reach the brain so the gate is 'closed'[11]. When the smaller fibres are stimulated the inhibitory interneurons do not act, so the gate is 'open' and pain is sensed. When the larger α-Delta fibres are stimulated they reach the inhibitory interneurons faster and, as larger fibres inhibit the interneuron from working, 'close' the gate. This is why after you have stubbed your toe, or bumped your head, rubbing it helps as you are stimulating the α-Delta fibres which close the gate[11].

For an alternate explanation: Pain Gate Theory Article Science Daily Physiotherapy Journal Article: Pain Theory & Physiotherapy

Taken from https://www.physio-pedia.com/Maitland%27s_Mobilisations on the 23/09/2020

Introduction

Brian R. Mulligan qualified as a physiotherapist in 1954 and gained his diploma in Manipulative Therapy in 1974. He has been the author of numerous articles published in New Zealand Journal of Physiotherapy. He is also the author of two books:[1]

1. "Manual Therapy "NAGS","SNAGS", "MWMS",etc' (2003) for Physiotherapists.

2. 'Self Treatment for the Back, Neck and Limbs' for Public.

Description

• NAGS- Natural Apophyseal Glides.

• SNAGS - Sustained Natural Apophyseal Glides.

• MWMS- Mobilization with Movements.

• The concept of Mobilizations with movement (MWM) of the extremities and SNAGS (sustained natural apophyseal glides) of the spine were first coined by Brian R. Mulligan [2]

Mobilization with movement (MWM) is the concurrent application of sustained accessory mobilization applied by a therapist and an active physiological movement to end range applied by the patient. Passive end-of-range overpressure, or stretching, is then delivered without pain as a barrier.[3]

Concept of Positional Fault

• Mulligan proposed that injuries or sprains might result in a minor "positional fault" to a joint causing restrictions in physiological movement.

• The techniques have been developed to overcome joint `tracking' problems or `positional faults', i.e. joints with subtle biomechanical changes.

• Normal joints have been designed in such a way that the 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 [4]

• Normal proprioceptive feedback maintains this balance. Alteration in any or all of the above factors would alter the joint position or tracking during movement and would provoke symptoms of pain, stiffness or weakness in the patient. It is common sense then that a therapist would attempt to re-align the joint surfaces in the least provocative way[4]

Principles of Treatment

1. A passive accessory joint mobilization is applied following the principles of Kaltenborn. This accessory glide must itself be pain free.

2. During assessment the therapist will identify one or more comparable signs as described by Maitland. These signs may be; a loss of joint movement, pain associated with movement, or pain associated with specific functional activities

3. The therapist must continuously monitor the patients reaction to ensure no pain is recreated. The therapist investigates various combinations of parallel or perpendicular glides to find the correct treatment plane and grade of accessory movement.

4. While sustaining the accessory glide, the patient is requested to perform the comparable sign. The comparable sign should now be significantly improved

5. Failure to improve the comparable sign would indicate that the therapist has not found the correct treatment plane, grade of mobilization, spinal segment or that the technique is not indicated.

6. The previously restricted and/or painful motion or activity is repeated by the patient while the therapist continues to maintain the appropriate accessory glide.

While applying "MWMS" as an assessment, the therapist should look for PILL response to use the same as a Treatment .[5]

• P- Pain free.

• I- Instant result.

• LL- Long Lasting.

 If there is No PILL response, that technique should not be advocated. The second principle is CROCKS[5]

• C- Contra-indications (No PILL response is a contraindication)

• R - Repetitions (Only three reps on the day one)

• O- Over pressure

• C- Communications

• K - Knowledge (of treatment planes and pathologies)

• S- Sustain the mobilization throughout the movement.

Techniques

SNAGs

• SNAGs stand for Sustained Natural Apophyseal Glides.

• SNAGs can be applied to all the spinal joints, the rib cage and the sacroiliac joint.

• The therapist applies the appropriate accessory zygapophyseal glide while the patient performs the symptomatic movement.

• This must result in full range pain free movement.

• SNAGs are most successful when symptoms are provoked by a movement and are not multilevel.

• They are not the choice in conditions that are highly irritable.

• Although SNAGs are usually performed in weight bearing positions they can be adapted for use in non weight bearing positions.

Headache SNAG

If a patient is suffering from a headache of upper cervical origin then one of the mobilisations or the traction to be described should, as it is being applied, stop the pain. Mulligan assumes that if a headache stops with a manual technique involving the upper cervical spine then, this must be diagnostically significant as to the site of the lesion causing the problem and the fact that there is a mechanical component.

Technique

• Position of Patient: sitting

• Position of therapist: stands beside the patient, while his\her head is cradled between your body and your right forearm (when you stand at his\her right side)
  Application:

  • Start by placing your right index, middle and ring fingers at the base of the occiput. The middle phalanx of the same hand and the little finger lie over the spinous process of C2. Then place the lateral border of the left thenar eminence on top of your right little finger.

  • Gentle pressure is now applied in a ventral direction on the spinous process of C2 while the skull remains still due to the control of your right forearm. (The really gentle moving force to do this comes from your left arm via the thenar eminence over the little finger on the spine of C2).

  • The pressure applied by the index finger moves the lower vertebra forward under the first until the slack is taken up, then the first vertebra moves forward under the base of the skull. This is quickly taken forward until end range is felt and this position is maintained for at least 10 seconds. If indicated the headache will relieve, repeat the HEADACHE SNAG six to ten times. Some patients have a more favourable response when the position is sustained for a much longer time- up to a minute. 

Important, when applying the “ Headache SNAG” the good manual therapist will imperceptibly alter the direction of the glide to effect a change. Small adjustments in direction may be necessary as the true facet plane directions vary between individuals.[6]

NAGs

• NAGs stand for 'Natural Apophyseal Glides”.

• NAGs are used for the cervical and upper thoracic spine.

• They consist of oscillatory mobilizations instead of sustained glide like SNAGs, and it can be applied to the facet joints between 2nd cervical and 3rd thoracic vertebrae.

• NAGs are mid-range to end range facet joint mobilizations applied antero-superiorly along the treatment planes of the joint selected.

• Useful for grossly restricted spinal movement.

• NAGs for the treatment of choice in highly irritable conditions

Peripheral MWM [7]

• Once the aggravating movement has been identified, an appropriate glide is chosen. 

• The decision to use weight-bearing or Non-weight bearing movement depends upon the severity, irritability and nature of the condition.

• Once the glide has been chosen it must be sustained throughout the physiological movement until the joint returns to its original starting position

• Mobilizations performed are always into resistance but without pain

• Immediate relief of pain and improvement in ROM are expected.

• If this is not achieved, vary the glide parameters

AP mobilization with rotation for the GHJ

Spinal Mobilization with Limb Movement (SMWLMs) [4]

• Here a transverse pressure is applied to the side of the relevant spinous process as the patient concurrently moves the limb through the previously restricted range of movement.

• The assumption here is that the restriction of movement is of spinal origin of course.

• This does not necessarily imply neural compromise since spinal movement must occur when a limb moves beyond a certain point.

• Thus the technique addresses a spinal structural/ mechanical restriction, but this may have neural implications too.

MWM for the lumbar spine, sitting

• Extension- Superior anterior force on spinous process, assist with extension with hand on anterior shoulder.

• Flexion- Push superiorly with hook of the pisiform and assist flexion with hand on thoracic back.

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MWM for the lumbar spine

• Extension, supine

  • Two hands around the lumbar spine, compress hands (AP and PA force) patient extends back, assisting by pushing up with his hands. *Extension, standing

  • Stabilize with belt, place hand lateral to the lumbar spine, resist patients extension and apply PA force.

Taken from https://www.physio-pedia.com/Mulligan_Concept#20barrier. on the 23/09/2020

GHJ Flexion 

Inferior glenohumeral ligament, Posterior capsule, opposing muscles 

GHJ Extension

Superior glenohumeral ligament, Anterior capsule, opposing muscles 

GHJ Abduction

Greater tuberosity on glenoid fossa, tightness of inferior joint capsule, tightness of costoclav and interclav ligaments, muscular 

GHJ Adduction 

Trunk, tightness of superior joint capsule

GHJ Med Rot 

Posterior capsule 

GHJ Lat Rot 

Coracohumeral ligament, 3 glenohumeral ligaments, capsule 

Elbow flexion

Soft tissue approximation, coronoid process against coronoid fossa, radial head against radial fossa, Posterior capsule, Triceps

Elbow extension

Olecranon process against olec. fossa, Tight elbow flexors, Anterior joint capsule

Wrist Ulnar / radial deviation

Collateral Ligaments

Factors that limit Hip Flexion 

Soft tissue apposition of anterior thigh and abdomen.

Posterior hip joint capsule.

Gluteus maximus muscle. 

Factors that limit Hip Extension 

Anterior hip joint capsule.

Tension of iliofemoral, ischiofemoral, and pubofemoral ligaments, the Iliopsoas muscles (Psoas Major and Iliacus). 

Factors that limit Hip Abduction 

Pubofemoral ligament, hip adductor muscles, inferior joint capsule. 

Factors that limit Hip Adduction 

Soft tissue apposition between thighs, iliotibial tract, superior joint capsule, ischiofemoral ligament and superior band of iliofemoral ligament, hip adductor muscles. 

Factors that limit Hip Medial Rotation 

Ischiofemoral ligament, posterior joint capsule, lateral rotator muscles.

Factors that limit Hip Lateral Rotation 

Iliofemoral and pubofemoral ligaments, anterior joint capsule, medial rotator muscles. 

Factors that limit Knee Flexion 

Soft tissue apposition of posterior calf and thigh, quad muscles. 

Factors that limit Knee Extension 

Parts of both cruciate ligaments, medial and lateral collateral ligaments, oblique popliteal ligament 

Factors that limit Ankle Plantarflexion 

Anterior joint capsule, anterior talofibular ligament, ankle dorsiflexors (e.g. tibialis anterior) contact between talus and tibia (posterior aspects).

Factors that limit Ankle Dorsiflexion 

Posterior Joint Capsule, ligaments: deltoid, calcaneofibular and posterior talofibular, ankle plantar flexors (e.g. gastrocnemius) contact between talus and tibia (anterior aspects). 

Factors that limit Ankle Inversion 

Lateral collateral ligament of ankle joint, ankle evertor muscles, talocalcaneal ligaments, lateral joint capsule.

Factors that limit Ankle version 

Contact between talus and calcaneus, medial joint capsule, medial collateral ligament of ankle and medial talocalcaneal ligament, ankle invertors (e.g. tibialis posterior)