Maitland and Mulligan Manual Therapies for Cervical Spine Disorders - Literature review Example

?Maitland and Mulligan Manual Therapies for Cervical Spine Disorders Spinal dysfunction, is a common case seen in physiotherapy clinics (Adams, 2002). The condition can affect any part of the spine, including cervical spine. Patients with cervical spine problems like cervical spondylosis, torticollis, cervicogenic headaches and chronic cervical disease suffer from chronic pain which can be distressing (Middleditch and Oliver, 2005). Physiotherapy is one of the important aspects of management of cervical dysfunction and manual therapy techniques are the most frequently used physiotherapy strategies to treat cervical dysfunction (Kay et al, 2005). Both passive mobilization of cervical spine and cervical manipulation are used frequently, although the former is used more frequently (Magarey et al, 2004). Manual therapy heals the patient through movement. There are 2 different techniques which can be employed for manual therapy. They are Maitland technique and Mulligan technique. The principles of both the techniques are different. Maitland approach of manual therapy is holistic and is individualized to a patient rather than just the part of the patient that is injured (Maitland, 2002). On the other hand, Mulligan techniques are specific towards the injured part and work by correcting the misalignment of the joints (Mulligan 1993). Both the techniques aim at relieving pain and improving movements (Smith, 1995). There is not much literature pertaining to randomized studies which compare and contrast the applications and outcomes of these techniques in cervical spine disorders. The methodological quality of many clinical trials which have used manipulation and mobilization of the spine to treat cervical spine ailments like cervicogenic headaches is low. This is evident in the literature review by Fernandez-de-las-Penas et al (2006) in which the researchers evaluated the methodological quality of various randomized controlled trials that were published with regard to manual therapies of diseases of the cervical spine. The researchers, based on the reports from the studies opined that there is a dire need for high quality randomized trials for assessment of manual therapy interventions in such diseases causing headaches. In this research article, literature review and critical analysis of the application of these manual therapies on patients with cervical spine disorders will be done for evidence based management of cervical spine dysfunction patients. Both Maitland and Mulligan are modern day manual therapies. Maitland's techniques of manual therapy basically apply accessory and oscillatory movements to the spinal joints for treatment of pain and stiffness of the joints (Hengeveld and Banks, 2005). The aim of the techniques are to cause restoration of motions of glide, spin and roll between the surfaces of the joints. There are basically five grades of of techniques based on the amplitude. In grade-1, the the amplitude is small and is suitable for highly irritable conditions. The movements are performed below the resistance range. Grade-1 relieves pain by manipulating the neural structures. It helps in taking up of the slack in the collagen when there is no load on the connective tissue (Threlkeld, 1992). In grade-2, the amplitude is higher than that in grade-1, but the amplitude is below the resistance level. Both these grades are useful to apply when the dysfunction is in early stages, i.e., there is pain on palpation, but there is no limitation in the movement. In grade-3 and 4, the amplitude is large and within resistance range. It is used for improvement in the range of motion. In grade-4, the amplitude is small, but is done for chronic irritability. In grade-5, high velocity thrust is applied for the purpose of manipulation. Other than these, even stretching exercises for a part of management through Maitland techniques, especially if there is muscle spasm (Maitland, 2002). The treatments are mainly through application of various accessory and physiological movements and hence are mainly passive in nature. Maitland advocates some pre-manipulation guidelines like sustained end-of-range rotation of cervical spine for manual therapy treatments of cervical spine for the purpose of prevention of post-manipulation complications like stroke, paralysis and even death (Mitchell et al, 2004). In a study conducted by Mitchelle et al (2004), the researchers investigated the effects of rotation of the cervical spine on the blood flow of the vertebral artery. From the results of the study, it was evident that vertebrobasilar insufficiency test is very essential prior to initiation of cervical rotation manual therapy because of the increased risk of development of insufficiency in some patients and identification of such patients prior to initiation of manual therapy helps in avoiding therapy in such patients. The test examines the effects of mechanical stress during cervical spine movements on the vertebral arteries. The principle techniques of Mulligan are SNAGS and NAGS for cervical spine dysfunction (Wilson, 2001). In sustained natural apophyseal accessory glides or SNAGS, the patient attempts to move the painful joints actively through out the range of motion. An accessory glide is overlayed parallel with the plane of treatment. In natural apophyseal accessory glides or NAGS, the patient is passive (Mulligan, 1993). Treatment in both the techniques is pain-free. While in Maitland, the treatments are non-weight bearing and; in Mulligan, they are mostly weight bearing. Also, in Maitland, only one treatment is given per session, unlike in Mulligan where multiple treatments are administered and self treatments are possible. According to the UK evidence report submitted by Bronfort et al (2010), manual therapies like Maitland and Mulligan are very effective in the treatment of various spine related ailments like cervicogenic headaches. These reports are based on certain randomised controlled trials. Treatments pertaining to Maitland begin with complete subjective assessment of the patient for the purpose of determination of the cause of pain and also to ascertain the most appropriate technique for application (Hing, 2003). This is very important in conditions like acute torticollis, which needs to be differentiated from other similar conditions like cervical sprain and cervical spondylosis (Sprague, 1983). The main goal of treatment in acute torticollis is to relieve pain and cause restoration of movement of the neck. Maitland applies slight flexion for relief of pain (Maitland et al, 2001). Speed of mobilization of the cervical spine is adjusted in such a manner that the treatments are pain free. Thus, in most cases low-velocity mobilizations are deployed for treatment (Di Fabio, 1999). Mulligan, on the other hand, takes a different approach for acute torticollis. After the initial subjective assessment, Mulligan makes the patient perform the movements of rotation of the neck and asks him to stop when he feels the pain. Once pain is felt, the therapists interferes and applies overpressure against the pain in a gentle manner and makes the pain bearable to the patient. Through this technique, certain oscillations occur between the vertebral facets in a gentle manner. these gradually increase and restore the range of movement of the patient (Mulligan, 1999). Another cervical dysfunction for which manual therapies can be applied is cervical headache. In this condition, the pathology mainly lies within various structures of the cervical spine like the muscles of the spine, the facets and the joints and also the neural structures (Brukner & Khan 2007). Cervical, or cervicogenic headaches are actually referred pains due to pathology in the above mentioned structures (Fleming, 2007). The aim of treatment in cervicogenic headaches is to relieve pain. In Maitland approach of therapy, the therapist assesses the limitation and the range of the movement of the cervical spine by compression and ascertains the joint in which movement is limited. Based on this assessment, mobilization techniques are applied for resolution of pain. Though in many patients pain subsides on application of Maitland therapy, recurrence is a major problem in cervicogenic headaches. Recurrent sessions of therapy is likely to decrease the intensity of pain and the severity and duration of suffering (Maitland et al 2001). On the other hand, Mulligan treats cervical headache through SNAGS in a seated position and weight bearing is applied until the patient develops pain and discomfort (Hearn, 2002; Reid et al, 2008). Mulligan stops treatment when pain appears during physiological and accessory movements. SNAG has been used frequently to treat cervicogenic headaches. The main components of SNAG are physiological and accessory movements and they exert biomechanical effects. According to Hearn and Rivett (2002), application of SNAG to ipsilateral side of pain successfully treats restricted cervical rotation that causes severe pain. The technique first distracts the zygapophyseal joint that is present on the ipsilateral side of pain and then compresses the joint. Hearn and Rivett (2002) opine that "Manual therapy slightly distracts the uncovertebral cleft, would be superior to a technique which distracts the articular surfaces with both accessory and physiological movement components and hence the reported clinical efficacy of cervical SNAGs cannot be explained purely on the basis of the resultant biomechanical effects in the cervical spine." SNAGS is also applied by the patient himself and this is known as self-SNAGS and this treatment is mainly applied for C1-C2 dysfunction for improvement in rotation. A self SNAG trap is applied for this purpose (Hall, 2007). Gross et al (2010) conducted a systematic review to analyze the effects of manual therapy in patients with cervical problems with and without cervicogenic head ache. From the results of the study it was evident that Maitland techniques were useful in reducing pain related to cervical spine problems. Hall et al (2007) reported in their study that Mulligan's self SNAG technique is useful for treating cervicogenic headache. The study was a prospective observational study. Similar reports were delivered by Reid et al (2008), in which the researchers conducted a randomized controlled trial to compare SNAGs with placebo. According to the authors of the study, "the SNAG treatment had an immediate clinically and statistically significant sustained effect in reducing dizziness, cervical pain and disability caused by cervical dysfunction." Thus, it can be concluded that both Mulligan and Maitland are effective manual therapy techniques in the treatment of cervical spine ailments like torticollis and cervicogenic head ache, but literature pertaining to their effectiveness and method of functioning is limited and uncertain. There is no evidence to suggest that one technique is superior over the other and hence choice of treatment must be based on the individual needs of the patient. More research is warranted in the form of comparative randomized controlled trial to ascertain the efficacy of these treatment and to establish as to which technique is most applicable for patients suffering from cervical spine disorders. References Adams, M. Bogduk, N. Burton, K. Dolan, P. (2002). The Biomechanics of Back Pain. China: Churchill Livingstone. Bronfort, G., Haas, M., Evans, R., Leininger, B., Triano, J. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat., 25, 18:3. Di Fabio, R.P. (1992). Efficacy of Manual Therapy. Physical Therapy, 72 (12), 853-864. Fernandez-de-las-Penas, C., Alonso-Blanco, C., San-Roman, J., Miangolarra-Page, J.C. (2006). Methodological quality of randomized controlled trials of spinal manipulation and mobilization in tension-type headache, migraine, and cervicogenic headache. J Orthop Sports Phys Ther., 36(3), 160-9. Gross, A., Miller, J., D'Sylva, J., et al. (2010). Manipulation or mobilisation for neck pain. 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