The efficacy of physiotherapy: A literature review with reference to the Maitland and Mulligan paradigms in the mobilization of a joint:

 

Maitland and Mulligan present different but not mutually exclusive sets of widely employed manual therapy techniques for treating pain and stiffness in human joints. Whilst the literature reports extensively on the efficacy of their respective techniques (Rothstein: Exelby 1995, 1996; Wilson) Maitland appears the more influential propagating a wider and more comprehensive range of techniques within a conceptual framework of clinical reasoning and protocol for patient examination and treatment. He offers his techniques as a base from which others may develop their own variations that best match the patient, their condition and the experience of the therapist (Maitland 2002, 1998). The approach is holistic relating the condition to the individual patient as a person rather than an injured part. Scientific rationale for manual therapy, as far as it exists, is sympathetic to the theory of healing through movement. This is not at odds with the Maitland concept. Mulligan, however, argues his techniques work by correcting joint misalignment, a theory that appears to have fallen out of favour (Twomey 1992). Mulligan does not detail philosophy, examination or procedural protocol deferring to Maitland in these areas (Mulligan 1993).  In discussing these paradigms this paper will attempt to unravel what kind of patients get better with what treatment and why. It will explore arguments for more universal standardization of techniques that could provide better evidence of correlations between treatment and results. Although the use of the techniques advanced by Maitland and Mulligan appear to have strong correlation with relieving pain and restricted movement it is not conclusively known why they do so.  This paper will therefore explore and assess some of the rationale and evidence. 

 

Maitland’s techniques involve the application of passive and accessory oscillatory movements to spinal and vertebral joints to treat pain and stiffness of a mechanical nature. The techniques aim to restore motions of spin, glide and roll between joint surfaces and are graded according to their amplitude..  Grade I is a small amplitude movement performed below the range of resistance and is suitable for treating highly irritable conditions. Use of Grade I enables the slack in collagen to be taken up when connective tissue is not under load and can relieve pain by working on neural structures (Threlkeld). A Grade II mobilization is wider in amplitude but still below resistance. Use of Grade I and II are appropriate when palpation elicits pain before restriction of movement.  Grade III and IV are used when resistance to movement is encountered before pain. A Grade III is a large amplitude movement performed within resistance and generally used to improve range of motion.  Grade IV is a small amplitude movement performed within resistance used for chronic aches of low irritability. Grade V is a high velocity thrust used in manipulation. Maitland also prescribes stretching techniques to deal with muscle spasm (Maitland, 2002, 1998).

 

Accessory movements are used when initially treating pain. When the patient is capable of 60% of normal range of movement unencumbered by pain then physiological mobilizations should be employed in pursuing the eventual establishment of normal range of movement (Maitland 1998).  Oscillatory mobilization techniques of the kind advocated by Maitland can reduce pain by stimulating natural pain killing endorphins but unless the cause of pain is removed, the relief will be temporary. In the case of muscle spasm, however, oscillatory mobilization techniques may break the pain cycle. Pain resulting from injury or spasm is transmitted along unmylinated ‘C’ nerve fibres that transmit impulses slowly. Oscillatory movements stimulate mechano-receptors associated with the mylinated alpha beta and alpha delta fibres. Mylinated fibres transmit impulses more quickly because impulses can jump between the nodes of ranvier embedded in the mylinated sheath. Consequently the faster impulses stimulated by manual oscillatory movement reach the receptors in the brain before the pain impulses transmitted by the ‘C’ fibres (Carpenter). The impulses stimulated by interferential techniques, including mobilization, thereby block off the pain impulses and break the pain cycle. Muscle spasm thereby ceases releasing the grip on soft tissue that may have caused nerve impingement or other distortions of alignment (Low and Reed 1990).

 

Maitland offers extensive protocol for the subjective and objective examinations and the recording of treatment. The therapist decides on what grade to use following an interview with the patient that Maitland refers to as the ‘subjective examination’. Here the therapist guides the patient in describing symptoms with the aim of ascertaining their history, location and behavior. The subjective examination facilitates the development of a working hypothesis the ‘objective examination’ either confirms or rejects. The objective examination is a physical examination of the patient involving the testing of accessory and physiological movements in order to locate pain or movement restriction. The therapist records movements that replicate or relieve the symptoms of the patient and uses them as a basis for treatment.  The effectiveness of treatment is measured against an objective marker immediately after treatment and before administering further treatment. Successful treatment techniques are progressed by increasing grades or repetitions. Techniques that do not appear to work are discarded in favour of others. Maitland also offers methods of differential diagnosis such as the slump test or straight leg-raising test in order to refine diagnosis. These techniques are performed with the patient relaxed, usually lying down and non-weight bearing (Maitland 1998, 2002).

 

Application of Maitland techniques to the vertebrae is along an anterior-posterior axis or transverse irrespective of the angle of the joint. Peripheral joints are similarly treated with Maitland techniques on planes appropriate to the condition, usually on the plane where there is pain or restriction. These may be anterior- posterior, transverse or longitudinal. Maitland argues that the comparable pain response “is nearly always found with the unphysiological movement rather than the physiological movement”.  Conversely, Mulligan applies movement in sympathy with physiological movement. Mulligan is guided towards restoration of correct physiological tracking by the absence of pain. His techniques are designed to deal with problems of restricted or painful movement but are not highly irritable.  These techniques are therefore used for conditions that are not acute when the biomechanics of the joint may be altered without inducing pain.  The appropriateness of the technique is judged against Maitland’s criteria of severity, irritation and nature of the condition. Mulligan does not prescribe grades of movement or oscillatory movements. He prescribes taking the joint through its full range of movement and this entails taking it into resistance. The therapist superimposes an accessory movement onto the patient’s active physiological movement with the aim of over-riding the obstruction and reestablishing correct alignment. The accessory movement takes the joint through what would be the normal physiological movement of the joint. The pre-injury joint tracking is reestablished reasserting the ‘joint memory’ or prior conditioning of the healthy joint.

 

Mulligan’s principle techniques are NAGS, SNAGS and MWMs (Mulligan 1993). NAGS are natural apophyseal accessory glides applied to the cervical spine with the patient passive. SNAGS are sustained natural apophyseal accessory glides whereby the patient attempts to actively move a painful or stiff joint through its range of motion whilst the therapist overlays an accessory glide parallel with the treatment plane. MWMs are mobilizations with movement and are applied to the peripheral joints. The underlying principle to MWMs is derived from Kaltenborn (1989 in Exelby 1995) who argued that joint surfaces are not fully congruent, physiological movements are a combination of rotation and glide, and glide is essential to pain free movement. Glide occurs in the direction of bone lever movement where its articulating surface is concave and in the opposite direction when convex. The treatment plane lies at a ninety-degree angle to the concave articulating surface of the bone and treatment is applied parallel to the treatment plane. The anterior-posterior and posterior-anterior movements used in Maitland’s techniques follow the same planes in peripheral joints. However, in treating the spine Maitland will follow the planes of the intervertebral body joints whilst Mulligan techniques follow the plane of the zygapophyseal joints. Exelby (1995) argues that the zygapopheseal joints guide the spine and so improving their glide by applying NAGs and SNAGs will improve the range of spinal movement. Applying treatment on the plane of the intervertebral body joints results in compression on the zygapopheseal joints and will not promote glide.

 

As pain is the principle signal of a mal-aligned joint working with pain is by definition incorrect because it suggests continued mal-alignment. Pain is a sign that treatment is not working and an indication that the technique should be changed. Relief of pain resulting from mechanical amendment is both the objective and the signal that the objective has been achieved. Pain is likely to induce muscle spasm detracting movement from the treatment plane thereby preventing realignment. The response of the patient to treatment must therefore be continually monitored. Once correct pain free gliding has been reestablished it must be maintained in functional activity.  The techniques are therefore performed with the patient weight bearing - sitting if symptoms are reproduced sitting, or standing when symptoms are only evident when standing. This is because successful remedial biomechanical action done with the patient lying down is likely to be reversed when the patient stands up.

 

The rationale behind Mulligan’s techniques is that joints have evolved in a manner that facilitates free but controlled movement whilst minimizing compressive forces generated by movement. This balance is maintained by normal proprioceptive feedback. Alteration of the balance and positioning of structures in and around the joint that may occur from strain or injury can alter joint tracking resulting in pain or restriction of movement. It is postulated that these techniques  “sedate an agitated, facilitated nervous system, particularly the dorsal horn, by bombarding it with the painless normality it has always been patterned to receive. Normal afferent discharge provokes a reciprocal normal efferent discharge to the structures controlling joint movement” (Wilson)’. An agitated central nervous system may cause soft tissue pain even after the tissues have recovered from strain.  Mechano- receptors over react to sudden stretching of connective tissue in an acute injury and continue to fire for longer than the protective mechanism warrants. The alterations in muscle tone then misalign the joint that, in turn, transmits proprioceptive stimulae to the already excited central nervous system thereby perpetuating its own malfunction. Manual therapy may re-establish a normal lower level of proprioceptive stimulation or ‘mobilisation induced analgesia’ (Zusman 1985,1994 in Wilson).

 

Mulligan’s techniques are claimed to improve signs and symptoms and do so more rapidly than other treatments alone (Kochar et al; Hall), but the reasons for this are not clear (Exelby 1995). Twomey (1992) cites literature by Haldeman, Paris and Zusman suggesting spinal manual therapy is unlikely to work by correcting joint alignment. Evidence for the justification of manual therapy of all persuasions is not overwhelming. Di Fabio identified only 14 studies suggesting clear evidence to justify the use of manual therapy in the treatment of back pain and little published research concerning the use of manual therapy on peripheral joints. A substantial amount of literature concerning the rationale for the use of manual therapy highlights the value of movement in maintaining health and strength of collagenous, muscular and bony tissues (Smith 1995 a and b; Twomey 1992, Threlkeld 1992, Evans 1980). Emphasis is placed on the need for joint movement and the application of stress on which these tissues thrive. The corollary to this is that these tissues react adversely to immobilization (Hendricks). One line of reasoning is the use of manual techniques applied to connective tissue to guide remodeling and repair of new collagen fibers following injury. Manual mobilizations impose tensile forces that encourage alignment of collagen and decreases randomized and interlinking collagen formation. More uniform alignment of collagen gives greater strength and extensibility to connective tissue (Threlkeld p 900).  However, whilst the literature supports the theory of improved healing and remodeling through mobilization, Threlkeld argues there is no research evidence to prove the case (Threlkeld 1992, p900).

 

Scientific rationale may be viewed as theory derived from anatomy, biomechanics and neuro-physiology. Unfortunately, the literature reflects a less than satisfactory underpinning of scientific rationale for manual therapy  (Farrell & Jensen p845, Twomey). Maitland addressed this question by decreeing,  “none of us can afford to neglect the anatomical and physiological components of manipulative therapy, and it is essential that the clinician should try to bridge the gap between the practice and theory of how, when and why treatment should be administered and why it is successful” (Glasgow & Twomey 1985 in Farrell et al).  Maitland subsequently published a model for clinical reasoning. The model is analogous to a semi-permeable brick wall the respective sides of which represent theory and practice. Knowledge and information can and should flow to and from each side of the wall but the therapist must keep the concepts distinct.  Knowledge of pathology and scientific rationale may illuminate the facts of the case but must not corrupt them. The ‘clinical’ side of the wall represents the area where facts may be marshaled for inductive reasoning in the process of building a generalized theory of the condition of the patient. The ‘facts’ on this side of the wall are induced by the therapist following empirical observation of the patient. The subjective element of the examination of the patient is dependent on the sensory perception of the patient. The quality of interpretation by the therapist of both subjective and objective examination is dependent on knowledge and experience. Facts acquired on the ‘clinical’ side of the wall therefore need to be tested against the objective scientific rationale and body of knowledge on the other side of the wall. It is from this body of knowledge that theories concerning pathology, diagnosis and prognosis may be deduced.  Scientific theories, however, should be continually tested against observable phenomena so clinical reasoning needs to reflect the dialogue of clinical findings against scientific knowledge that is continually being amended in the light of studies and case work. The brick wall must therefore be permeable.

 

In practice, a therapist using the Maitland concept applies a graded technique to test a hypothesis of the degrees of severity and irritability. The plan of treatment provides the testable proposition that, if verified, forms the basis for progression of treatment. If the treatment is unsuccessful the theory is refuted and another solution is sought, i.e. another grade or another technique. Maitland deserves credit for attempting to bring accountability to the practice of manual therapy by the systematic and objective recording of assessment and treatment of conditions. His use of grading provides a standardized methodology helpful to research and analysis. Using standardized markers to objectively measure results of treatment moves the discipline towards scientific methodology. However, the forces applied in the application of manual therapy are poorly documented and there is evidence of wide variation for given grades of amplitude.  Indeed,  “no generally available published studies have provided complete force versus time records for common mobilization or thrust techniques” (Threlkeld  1992, p 898). Threlkeld argues for a standardized catalogue of forces to be used to guide therapists and facilitate training and research. A review of studies of comparability of diagnostic palpation was published in 2002 (Huijbregts). This compared both the force of specified techniques across several therapists and single therapists on different occasions. The study found wide variations in both instances but the overall conclusion found the studies methodologically and statistically flawed. The grades Maitland prescribes are, of course, relative to the patient and the condition rather than absolute measurements of force. Prescribed force dosage formulas would need to incorporate variables of severity and irritability but these, in turn, can only be obtained empirically.

 

There is a danger that mechanistic scientific management of dosage advocated by Threlkeld could divert manual therapy from the use of acumen and intuition that flows from the interaction between patient and therapist.  The use of acumen is pragmatic and can facilitate innovative, adaptive and beneficial responses that scientific rationale may later validate. Whilst highly regulated examination and treatment protocol based on deductive reasoning may facilitate objective accountability and serve to protect patients against over-zealousness by a novice practitioner it should not inhibit more experienced therapists continuing to draw successfully from inductive reasoning and acumen.

 

In conclusion, both Maitland and Mulligan provide apparently effective mobilization techniques but the literature is uncertain about why they work. The techniques are complementary and may be used in conjunction with one another or separately. Both authors are flexible about application allowing therapists to choose techniques and modify them according to the condition and their expertise. Such pragmatism is essential as the jury appears to be out concerning rationality and efficacy of the respective set of techniques. It seems unlikely the verdict concerning theoretical rationale will fall in Mulligan’s favour although his techniques are, in practice, effective although their success is more likely to reflect the effects of movement than the effects of realignment.  Di Fabio argues that manual therapy as a discipline needs to formulate replicable studies of treatment to develop a body of evidence of its efficacy. Maitland offers a blueprint for clinical reasoning and a methodology with potential for accruing correlations of treatment and results. However, correlations of this nature are not evidence of the underlying reasons of why manual therapy works. The bulk of the evidence reported in the literature cited in this paper is from a decade ago when Physical Therapy published an edition dedicated to the available facts and evidence for the efficacy of manual therapy. The editorial conceded  “our professional endorsement of manual therapy is based on anecdotal observations and a shared faith, a belief that exists in the absence of evidence” (Rothstein) Progress may have been made since then but, if so, the literature is rather quiet about it.

 

 

 

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DAVID TIERNEY

5 January 2003

Word count: 2955.


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