Spinal Dysfunction: Maitland and Mulligan - Literature review Example

?SPINAL DYSFUNCTION (school) Word count: 1606 Spinal Dysfunction: Maitland and Mulligan Lower back pain is one of the most common health problems encountered by adults. Waxman, et.al., (2000, p. 2085) discusses that it has a 60% lifetime prevalence rate among adults; and a single episode of lower back pain can mark an episodic incidence, and the progress of the pain or dysfunction to chronic status. There are various causes of lumbar spine dysfunction, some 6-13% are associated with sports injuries (Trainor, et.al., 2002, p. 93). Among elderly patients, lumbar pain dysfunction often manifests as part of the aging process, osteoarthritis, and other degenerative disorders. Most of these patients undergo physiotherapy and other processes to manage their condition and ensure that they would not suffer a negative progression of their condition. In the UK, mobilization is the usual course of action in the management of lumbar pain dysfunction. “Manual traction or specific mobilization may be effective in relieving symptoms by decreasing mechanical stress on sensitized structures and encouraging physiologic responses to assist in reduction of edema and inflammatory reaction” (Herkowitz and Bell, p. 430). For authors and practitioners Maitland and Mulligan, they present management techniques for the management of spinal dysfunction, and in this instance, in the management of lumbar spinal dysfunction and associated lower back pain. Dysfunction is often seen as damage or constraints in the functioning of the spinal vertebral movement (Geraci, et.al., 2005, p. 6). These spinal dysfunctions may affect the cervical, thoracic, or lumbar portion of the spinal column. Lumbar spinal dysfunction which affects the psoas muscle often causes an individual to incline forward “and toward the side of the dysfunctional psoas” (Chaitow and DeLany, 2002, p. 83). This dysfunction can negatively impact on the movement of the affected patient; it can impact on his ability to carry out his daily activities (Trainor, et.al., 2002, p. 93). This paper shall critically evaluate the literature on the use of the Maitland and the Mulligan methods in the management of lumbar spinal dysfunction. In establishing the merits of either method, it is possible for practitioners to come up with better treatment and management methods for individuals suffering from this dysfunction. Mulligan’s approach to the management of lumbar spinal dysfunction has become an accepted and widely supported technique with many physiotherapists favouring this method over other options for treatment (Konstantinou, et.al., 2001, p. 206). This method of treatment has been known to immediately resolve functional issues and movements among joints, even after prolonged immobility and restriction (Mulligan, 2010, p. 5). Various clinical studies which establish the favourable application of this therapy have been published. In a paper by Exelby (2002, p. 69) sets forth that stimulating joint receptors through passive mobilization or manipulation would have an immediate impact on muscle activity. Spinal mobilization with leg movements in the lower limbs is often indicated in instances of straight leg raise, and it often helps relieve lower back pain as well as lower limb pain. This study was able to establish a strong support for the use of Mulligan approaches. In another study however, a more non-committal assessment of the Mulligan approach was set forth by Hall (2006, p. 95), where the authors set out to establish the immediate impact of the Mulligan traction straight leg raise technique (TSLR) on the range of straight leg exercise (SLR) among patient-respondents with lower back pain. The study revealed that there was a significant increase in the range of SLR of 11 degrees; such increase was credited to hip flexion, not hip rotation. In terms of pain relief, an assessment was made by Konstantinou, et.al., (2002, p. 206) where the authors set out to evaluate the current use of mobilization with movement for the management of lower back pain. The study revealed that most of the respondents used MWMs on a weekly basis and mostly for mechanical lower back pain. Most improvements were seen immediately after using MWMs with improvements seen in the range of movement and pain relief (Konstantinou, et.al., 2002, p. 206). Range of movement was improved by the Mulligan technique as revealed by the study of Exelby (2001, p. 69). Notably however, the authors also saw that minor discomfort still remained. This study however did not present the results of long-term follow-up; hence, it is difficult to assess the long-term efficacy of the treatment using Exelby’s study. Nevertheless, the value of the Mulligan approach in pain relief was made more apparent in yet another study. Backstrom (2002, p. 86) established how a 25% improvement in pain was apparent after MWM and full function was achieved 12 months after treatment. Backstrom’s methods however included other forms of therapy as well; it is therefore difficult to assess if the improvement in the patient’s condition is directly attributed to the use of the MWM. The passive mobilization which is applied under Maitland uses the examination of the non-contractile element of the spine, which includes the disc, capsule, and the ligaments. In contrast to the Mulligan approach, it discards muscle contraction in passive testing, thereby permitting the evaluation of segmental mobility (Kulig, et.al., 2004, p. 57). Other researches considered Magnetic Resonance Imaging studies to establish that Maitland’s posterior-anterior spinal mobilization causes instability and motion of a portion of the lumbar spine (Powers, et.al., 2003, p. 80). The impact of intervertebral movement changes with the force applied in the vertebrae. Studies also set forth that the Maitland PA spinal mobilization leads to the anterior glide of the vertebra with each other. In this case, the practitioners can detect the glide and set forth where the painful stiff motion segment is apparent (Raymond and Evans, 1997, p. 400). Various researches sought to establish the impact of Maitland’s techniques on lower back pain. In a paper by McCollam and Benson (1993) the immediate impact of Maitland’s technique on the range of movement in the lumbar spine was evaluated. In this study, the authors mobilized L3, L4, and L5 for a total of nine minutes. The study revealed that after the treatment, the treatment group experienced a significant gain in extension; in effect, 9 minutes of PA mobilization was able to significantly increase lumbar extension among patient respondents. This study was however carried out on asymptomatic respondents; it would therefore be difficult to evaluate the efficacy of the patients with limited range of motion attributed to lower back pain. In a paper by Chiradejnant, et.al., (2003, p. 233) sought to evaluate the impact of the mobilization technique in terms of reducing lower back pain. This study covered 140 subjects with patients assigned to the mobilization technique as chosen by the therapist and the other group receiving a randomly assigned mobilization technique. Better pain relief was seen with the application of the approach as recommended by Maitland. Maitland suggested that the large oscillation of mobilization method would cause better pain relief, as compared to the smaller oscillation of mobilization treatment (Chiradejnant, et.al., 2003, p. 233). The mobility of the lumbar spine in other planes, including the coronal plane was however not well assessed in this study. Much caution is therefore recommended in the application of these results to the general population. Goodsell and colleagues (2000, p. 332) set forth their study as a means of establishing the short term impact of lumbar posterioanterior mobilization among patients with LBP. Twenty six patients with nonspecific low-back pain experiencing pain on flexion or extension with pain settling after provocation were included in this study. In contrast to previous studies, no significant differences were seen between mobilization and control remedies in the application of posterioanterior response or even on the ROM. The authors did not however consider the volume of treatment which the patient received. The impact of treatment may therefore be different because of the amount or degree of treatment the patient respondents received. Support for the Maitland approach or PA mobilization was also seen in the study by Powers, et.al., (2008, p. 485) where a significant reduction in pain scores were seen. Admittedly however, the clinical meaningfulness of the changes in pain within-group was considered questionable. In the study by Krouwel, et.al., (2009, p. 7) an evaluation of the potential hypoalgesic impact of varying amplitudes of PA mobilizations on the lumbar spine based on pressure pain thresholds was carried out. The study saw a significant increase in pain thresholds following the PA mobilization; however, the study also revealed no significant difference in amplitude conditions. Since this is one of the first study to evaluate treatment dose, more studies in relation to these research methods are however needed in order to establish stronger support for these results. Mulligan’s theory manifested literature which is sometimes contradictory. Various studies within this literature however indicate strong support for the use of this technique in the management of lower back pain (Konstantintou, et.al., 2007; Mulligan, 2010). In contrast, more studies which investigated the application of Maitland’s PA mobilization technique were found (Powers, et.al., 2003, 2008; Raymond, et.al., 1997; Kulig, et.al., 2004)). Some of these studies, however, present with problems on their reliability (McCollam and Benson, 1993). Based on the current studies, recommendations for future research relate to a larger population and more blinded and randomized controlled studies (Chiradejnant, et.al., 2002). In effect, Maitland and Mulligan set forth both effective methods for mobilization and for addressing the issues of lumbar dysfunction. However, there is some issue based on the above literature on which method is fully applicable, in exclusion to the other. In effect, the application of both methods may serve complementary purposes; they may actually be used in coordination with each other especially as the authors are flexible in allowing therapists to choose and modify techniques in managing the dysfunction. Reference Backstrom K. (2002), Mobilization with movement as an adjunct intervention in a patient with complicated De Quervain’s tenosynovitis: a case report, Journal of Orthopaedic and Sports Physical Therapy, volume 32, number 3; pp. 86–97. Chaitow, L. & DeLany, J. (2002), Clinical Applications of Neuromuscular Techniques: The lower body, London: Elsevier Health Sciences. Chiradejnant, A., Latimer, J., Maher, C., and Stepkovitch, N. (2002), Does the choice of spinal level treated during a posteroanterior (PA) mobilisation affect treatment outcome?, Physiotherapy Theory and Practice, 18(4), pp.165-174. Exelby, L. (2001), The mulligan concept: its application in the management of spinal conditions. Manual Therapy, volume 7, number 2, pp. 64-70. Geraci, M., Brown, W., & Velasquez, J. (2005), Low back pain in adolescent athletes: diagnosis, rehabilitation, and prevention, Athletic Therapy Today, volume 10, number 5; pp. 6-16. Goodsell, M., & Lee, M. (2000), Short-term effects of lumbar posteroanterior mobilization in individuals with low-back pain, Journal of Manipulative and Physiological Therapeutics, 23(5), pp. 332-342 Haldeman, S. (1983), Spinal manipulative therapy, A status report, Clin Orthop, volume 179: pp. 62-70 Hall, T. (2006), Efficacy of the Mulligan traction straight leg raise technique on range of movement, Journal of Manual and Manipulative Therapy, volume 9, number 3; pp. 128-133. Herkowitz, H. & Bell, G. (2004), The lumbar spine, London: Lippincott Williams & Wilkins. Konstantinou, K., Foster, N., & Baxter, D. (2002), The use and reported effects of mobilization with movement techniques in low back pain management; a cross-sectional descriptive survey of physiotherapists in Britain, Manual Therapy, volume 7, number; pp. 206-214. Kulig, K., Landel, R., and Powers, C. (2004), Assessment of lumbar spine kinematics using dynamic MRI: a proposed mechanism of sagittal plane motion induced by manual posterior-to-anterior mobilization, Journal of Orthopaedic & Sports Physical Therapy, 34(2), pp. 57-64. McCollam, R. & Benson, C. (1993), Effects of Postero-Anterior Mobilization on Lumbar Extension and Flexion, Journal of Manual & Manipulative Therapy, 1(4), pp. 134-141(8) Mulligan, B. (1996), Mobilisations with movement (MWMS) for the hip joint to restore internal rotation and flexion, Journal of Manual and Manipulative Therapy, volume 4, number 1; pp. 35-36 Mulligan, B. (2010), Manual Therapy NAGS, SNAGS, MWMS etc. (6th Ed.), New Zealand: Plane View Services Ltd. Mulligan, B. (2010), About the Mulligan Concept, viewed 20 July 2011 from http://www.bmulligan.com/about/concept.html Powers, C., Beneck, J., Kulig, K., Landel, R., and Michael, F. (2008), Effects of a single session of posteriorto-anterior spinal mobilization and press-up xercise on pain response and lumbar spine extension in people with nonspecific low back pain, Physical Therapy, 88(4), pp. 485-493. Powers, C., Beneck, J., Kulig, K., Landel, R., and Michael, F. (2008), Effects of a single session of posteriorto-anterior spinal mobilization and press-up xercise on pain response and lumbar spine extension in people with nonspecific low back pain, Physical Therapy, 88(4), pp. 485-493. Raymond, L., and Evans, J. (1997), An in vivo study of the intervertebral movements produced by posterioanterior mobilization, Clinical Biomechanics, 12(6), pp. 400-408 Trainor, T. & Wiesel, S. (2002), Epidemiology of back pain in the athlete, Clinics in Sports Medicine, volume 21, number 1; pp. 93-103. Tierney, D. (2003), The efficacy of physiotherapy: A literature review with reference to the Maitland and Mulligan paradigms in the mobilization of a joint, viewed 20 July 2011 from http://gayyoga.gn.apc.org/Clinical%20essay.htm Waxman, R., Tennant, A., & Helliwell, P. (2000) Prospective follow-up study of low back pain in the community, Spine, volume 25, number 16; pp. 2085-90. Read More