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Bill Vicenzino Wayne Hing Darren Rivett Toby Hall
Edinburgh London New York Philadelphia St Louis Toronto

Churchill Livingstone
is an imprint of Elsevier
Elsevier Australia. ACN 001 002 357

(a division of Reed International Books Australia Pty Ltd)
Tower 1, 475 Victoria Avenue, Chatswood, NSW 2067
© 2011 Elsevier Australia
This publication is copyright. Except as expressly provided in the Copyright Act 1968
and the Copyright Amendment (Digital Agenda) Act 2000, no part of this publication
may be reproduced, stored in any retrieval system or transmitted by any means (including
electronic, mechanical, microcopying, photocopying, recording or otherwise) without prior
written permission from the publisher.
Every attempt has been made to trace and acknowledge copyright, but in some cases this
may not have been possible. The publisher apologises for any accidental infringement
and would welcome any information to redress the situation.
This publication has been carefully reviewed and checked to ensure that the content is as
accurate and current as possible at time of publication. We would recommend, however, that
the reader verify any procedures, treatments, drug dosages or legal content described in this
book. Neither the author, the contributors, nor the publisher assume any liability for injury
and/or damage to persons or property arising from any error in or omission from this publication.
National Library of Australia Cataloguing-in-Publication Data
______________________________________________________________________________
Title: Mobilisation with movement : the art and the science / Bill Vicenzino ... [et al.]
ISBN: 9780729538954 (pbk.)
Subjects: Physical therapy--Australia.
Movement therapy--Australia.
Physical therapy--Handbooks, manuals, etc
Movement therapy--Handbooks, manuals, etc
Other Authors/Contributors: Vicenzino, Bill.
Dewey Number: 615.82
______________________________________________________________________________
Publisher: Melinda McEvoy

Developmental Editors: Sam McCulloch and Rebecca Cornell
Publishing Services Manager: Helena Klijn
Project Coordinator: Geraldine Minto
Edited and indexed by Forsyth Publishing Services
Proofread by Gabrielle Challis
Cover and internal design by Lisa Petroff
Photography by Porfyri Photography
Illustrated by Lorenzo Lucia of Galaxy Studios
Typeset by TNQ Books and Journals Pvt. Ltd.
Printed by China Translation & Printing Services Ltd
CONTENTS
Foreword by Brian Mulligan vii Chapter 10 Temporomandibular joint dysfunction:
Foreword by Professor G Jull ix an open and shut case 123
Preface xi Chapter 11 Golfer’s back: resolution of
Authors xiii chronic thoracic spine pain 134
Contributors xiii Chapter 12 Mobilisation with Movement in the
Reviewers xiv management of swimmer’s
shoulder 143
Acknowledgments xv
Chapter 13 A recalcitrant case of aircraft
SECTION ONE M OBILISATION WITH MOVEMENT: engineer’s elbow 152
ITS APPLICATION 1 Chapter 14 A chronic case of thumb pain and
Chapter 1 Introduction 2 disability with MRI identified
positional fault 164
Chapter 2 Mobilisation with Movement: the art
and science of its application 9 Chapter 15 A chronic case of fear avoidant
low back pain 169
SECTION TWO EFFICACY 25 Chapter 16 Restoration of trunk extension
Chapter 3 A systematic review of the 23 years after iatrogenic injury 179
efficacy of MWM 26 Chapter 17 Hockey hip, a case of chronic
dysfunction 192
SECTION THREE M ECHANISMS AND Chapter 18 Thigh pain: a diagnostic
EFFECTS 65 dilemma 199
Chapter 4 Mulligan’s positional fault Chapter 19 Two single case studies of lateral
hypothesis: definitions, ankle sprain in young athletes 208
physiology and the evidence 66
Chapter 5 A new proposed model of the SECTION FIVE TROUBLESHOOTING 219
mechanisms of action of Chapter 20 Technique troubleshooting 220
Mobilisation with Movement 75
Chapter 6 Pain and sensory system Picture credits 223
impairments that may be amenable
Index 224
to Mobilisation with Movement 86
Chapter 7 Motor and sensorimotor deficits and
likely impact of Mobilisation with
Movement 93
SECTION FOUR CASE STUDIES 101

Preface to case studies 102
Chapter 8 A headache that’s more than
just a pain in the neck 103
Chapter 9 A diagnostic dilemma of dizziness 114
FOREWORD BY BRIAN MULLIGAN
The need for an appropriate textbook on my concepts O stands for overpressure. Basically, the mobilisation
has at last been met. Mobilisation with Movement component of MWM is really a sustained reposition-
(MWM) has been developing for nearly three decades ing of the joint surfaces. This, when indicated, enables
and the evidence base for its use is mounting. Justi- pain-free function to occur and, when restricted joints
fication for its use based on such evidence, clinical are treated, passive overpressure must be given. While
reasoning and reflection is within these pages making painless, maximum movement must be gained and this
this volume an excellent reference for the researcher, can only be attained by applying overpressure. With
teacher and clinician, and it will become a worthy stan- longstanding restrictions the movement gained on day
dard text on my concepts. one is usually all passive. If overpressure is not applied
What has enabled the successful teaching of the con- the results will not be long lasting.
cepts to date, without the much needed scientific back- C stands for communication and cooperation. You
ing, has been the fact that MWMs are only to be used as must explain in detail to the patient what you are about
a treatment when, on assessment, they have a ‘PILL’ to do. They must know to tell you immediately if there
effect. The acronym stands for pain-free, instant result is any discomfort. Without their feedback you will not
and long lasting. succeed.
Pain-free refers to both the mobilisation and move- K stands for knowledge. Manual therapists must
ment components. have an excellent knowledge of musculoskeletal medi-
Instant result means that at the time of delivery there cine. They must know their anatomy and it is critical
is an immediate pain-free improvement in function. that they know all joint configurations and, in particu-
This is not true of many manual therapy techniques lar, joint planes.
taught. S stands for many things. Sustain your mobilisation
Long lasting means that all or most of the improve- throughout the movement. Sustain the repositioning
ment gained is maintained. If the patient regresses until you return to the starting position.
between visits and there is no obvious correctable rea- Skill is required. Handling skills when dealing with
son for this, after three visits you can say that MWMs sensitive painful structures are important. You need a
are not indicated. sensibility in your fingertips to locate accurately and
On this basis MWMs should be used as an assess- firmly without squeezing. Sometimes a plastic sponge
ment tool by all those involved in the field of musculo- can be used for patient comfort. Handling skills deter-
skeletal therapy to ascertain if they are a valuable and mine how much force you use. With some structures
appropriate treatment tool. the movement taking place may be less than 1 mm.
Another important acronym we use when teach- Sense — commonsense and sometimes a sixth sense
ing MWMs is ‘CROCKS’, which deals with their are invaluable.
application. Subtle changes in direction are required when repo-
C stands for the contraindications to manual ther- sitioning joint surfaces to completely eliminate any
apy which, of course, will be known by all manual discomfort. This ties in with handling skills.
therapists. To now have this reference book, Mobilisation with
R stands for repetitions. With an extremity joint that Movement: the art and the science, is wonderful. I feel
has been dysfunctional for weeks or even longer, up humble and I am personally indebted to Bill Vicenzino,
to three sets of 10 MWMs can be used. With acute Wayne Hing, Darren Rivett and Toby Hall and all the
injuries, on day one, it is wise because of irritability individual contributors for the immense time and effort
to apply the techniques three to six times. With the that has gone into its creation. I cannot thank them
spine we have ‘the rule of three’. On day one only use enough.
MWMs three times. This is because some patients fol- Brian Mulligan 2010
lowing any form of manual therapy get a latent reac-
tion to their treatment. This is minimised by the rule
of three. Even when they get this reaction it is of short
duration and when it settles they are still much better
and further treatment can be given.
vii
FOREWORD BY
PROFESSOR GWENDOLEN JULL
The term Mobilisation with Movement, or MWM, is c onstructed and presented novel paradigms which
in common usage in the vocabulary of manual ther- stand to advance the understanding and applications of
apy practitioners worldwide. MWM is a method of MWM. To advance the field, they have developed a
manual therapy that is being increasingly incorporated well reasoned clinical paradigm for MWM (Chapter 2)
into management regimes for patients with musculo- and have introduced a model incorporating what they
skeletal disorders. The term is also synonymous with have named the Client Specific Impairment Measure
New Zealand physiotherapist Brian Mulligan, a gifted (CSIM) which acts as a key and central feature of the
and innovative clinician and manual therapist who has approach to patient assessment and management. This
developed the approach over several decades, with the model is well conceived, comprehensive and stands
assistance of his patients. Brian Mulligan has made a to guide the clinician’s clinical reasoning in patient
major contribution to the field of manual therapy. He assessment and management. Importantly, use of such
has generously shared his knowledge, clinical exper- a model can guide design of future research ranging
tise and experience. He has taught the MWM approach from, for example, Phase I to Phase III trials.
widely, nationally and internationally, and importantly It is easy for the enthusiast to laud uncritically
he has trained others to teach the approach. Brian Mul- a management approach and ‘spread the doctrine’. What
ligan has also published books and DVDs which detail is appreciated and valuable in this text, is the authors’
the indications and applications of techniques for clini- balanced approach between the science and the art and
cians and patients alike. their determination to advance the field. The available
The therapeutic approach to MWM has undoubt- evidence of benefit of MWM has been presented in
edly gained the attention of clinicians because of its an unbiased way using the rigorous methodology of a
effectiveness in the management of patients with mus- systematic review. While some preliminary evidence
culoskeletal pain and movement disorders. There has of benefit is emerging, the need for further high qual-
been some research investigating its efficacy and the ity trials is noted. In relation to mechanisms of action
hypotheses for its mechanisms of effect. However, to to explain the effects of MWM, the historical positional
date the MWM approach has had its seminal basis in fault hypothesis of MWM is critically reviewed. While
clinical observation of responsiveness to the clinically appreciating the available evidence, the authors forge
reasoned application of passive movement/position- ahead and present a new model for consideration of the
ing in combination with active movement. While the mechanisms of action of MWM to advance the field both
primacy of high level clinical reasoning and practical clinically and in research. Importantly and realistically,
skills can never be underestimated, there is a current there is an expansion of the hypothesis for MWM mech-
desire by clinicians, researchers and healthcare agen- anisms from a previously predominantly biomechanical
cies alike for delivery of practice which is also research one, to one which also incorporates the neurosciences
informed and evidence based. This text, Mobilisation (the sensory and motor systems) and the behavioural sci-
with Movement: the art and the science, embarks upon ences, and expert input into the field has been provided.
the process of providing the nexus between a seem- It is often difficult in a theoretical construct, such as
ingly successful clinical approach and its clinical sci- a book, to ‘bring to life’ the clinical reasoning and meth-
ence base. odologies of the approach together with the nuances of
The text’s authors, Bill Vicenzino, Wayne Hing, Toby patients, especially when dealing with the heterogene-
Hall and Darren Rivett are all highly regarded clini- ity in presentation of musculoskeletal disorders. The
cal researchers and teachers, well versed in the MWM authors have successfully addressed this challenge by
approach. They have all been involved in research into providing several well crafted chapters of patient cases
the efficacy and effectiveness of MWM and thus have presented by leading clinicians in the field, as well as
a strong and authoritative clinical and research base to the authors themselves. What is of enormous value
explore both the art and science of Brian Mulligan’s in these chapters for clinicians is the inclusion of the
approach. clinical reasoning process that is integrated with the
A treatment method has a risk of ‘non survival’ description of the technical aspects of patient manage-
without clinical and research paradigms that can be ment. In addition, the cases serve to display the wide
tested and advanced. The authors are to be congratu- application of the principles and practice of the MWM
lated on the scholarship evident in this text. They have approach in the musculoskeletal field.
ix
Foreword
As mentioned, the MWM approach has generated approach will grow and thrive for the benefit of future
considerable interest and enthusiasm in the field of patients and manual therapists. The authors are to be
manual therapy. From a clinical standpoint, it has, over congratulated on the eloquent way they have brought
the past two or more decades, provided an advance to the art and science of MWM together in this text with
the art of manual therapy and assisted many patients due scientific and clinical rigour. It will be appreciated
with painful musculoskeletal disorders. However, as is by clinicians and researchers alike.
commonly encountered, the clinical art of MWM is to Gwendolen Jull MPhty, PhD, FACP
date well in advance of its science and evidence base, Professor of Physiotherapy
which is essentially at the beginning of its journey. This The University of Queensland
text provides a vital basis on which the science can be Australia
developed further to ensure that the Mulligan MWM
x
PREFACE
We aimed to make this book a comprehensive and The book is essentially in five parts. The first part
unique exposition of the state of the scientific evidence introduces the concept of MWM and its principles of
for a relatively new form of manual therapy, Mobilisa- application. Part two provides a systematic review of
tion with Movement (MWM). When Brian Mulligan the evidence for its efficacy. The third part focuses on
first described MWM in 1984 the only evidence base possible underlying mechanisms of action, an exami-
was his expert opinion and a small number of his case nation of potential sensory and motor effects, and an
reports. In the intervening period the empirical evi- evaluation of Mulligan’s positional fault hypothesis.
dence has steadily grown to now include randomised Part four is comprised of twelve case reports in which
controlled trials and systematic reviews. Moreover, the the authors and other expert case contributors describe
biological understanding of MWM has evolved from the application (with underpinning clinical reasoning)
Mulligan’s self-admitted simplistic ‘positional fault of MWM for a wide range of musculoskeletal disor-
hypothesis’ to the testing of scientific hypotheses in ders of varying complexity. The reader will get most
sophisticated studies involving MRI and controlled value from these case reports if the preceding chap-
laboratory conditions. It is now timely to review and ters have been first digested, as the cases incorporate
present the evidence for all forms of MWM (including discussion and commentary integrating the scientific
sustained natural apophyseal glides of the spine) from evidence with the clinical guidelines in the context of
the past quarter of a century in one volume. the patient’s unique presentation. The book concludes
In addition to the science underpinning MWM, this with the fifth part; a troubleshooting section that aims
text also describes ‘the art’ inherent in its success- to guide practitioners in optimising their application of
ful implementation. Basic principles are outlined and MWM.
more advanced aspects of its clinical application are This book has been written for the clinician, teacher
developed and critiqued, including guidelines on dos- and post-graduate student interested in furthering their
age and troubleshooting. Most importantly, the practi- understanding and skill in MWM, and indeed manual
cal art of MWM is illustrated in a series of case studies therapy more broadly. It builds on but does not replace
in which real life clinical presentations elucidate the Mulligan’s texts as it is not intended to be a catalogue
clinical reasoning underlying its effective application, of techniques. We have also provided the undergradu-
including consideration of the evidence base, and pro- ate student with information that will benefit them in
vide detailed descriptions of selected techniques and their studies of manual therapy and evidence-based
home exercises. These cases help bridge the divide that management of musculoskeletal disorders.
typically separates the science and the art of various Professor Bill Vicenzino
approaches in manual therapy. Brisbane, Australia, 2010
Although the primary focus of the book is MWM, Associate Professor Wayne Hing
much of its content is applicable to manual therapy Auckland, New Zealand, 2010
in general. In particular, the chapters describing the Professor Darren Rivett
current understanding of potential mechanisms of Newcastle, Australia, 2010
action provide a summary of the contemporary theo- Dr Toby Hall
ries explaining the clinical benefits of manual therapy. Perth, Australia, 2010
Similarly, the case reports stand alone as a resource to
foster the development of skills in clinical reasoning
as they relate to the management of musculoskeletal
disorders.
xi
AUTHORS
Bill Vicenzino PhD, MSc, BPhty, Grad Dip Sports Phty Darren Rivett PhD, MAppSc (ManipPhty),
Professor of Sports Physiotherapy, BAppSc(Phty), Grad Dip Manip Ther
Head of Physiotherapy, School of Health and Professor of Physiotherapy, Head of School,
Rehabilitation Sciences, University of Queensland School of Health Sciences, Faculty of Health,
The University of Newcastle
Wayne Hing PhD, MSc(Hons), ADP(OMT), DipMT,
DipPhys, FNZCP Toby Hall PhD, MSc, Post Grad Dip Manip, FACP
Associate Professor, Head of Research, Specialist Musculoskeletal Physiotherapist,
School of Rehabilitation and Occupation Studies, Adjunct Senior Teaching Fellow (Curtin University),
Auckland University of Technology, New Zealand Senior Teaching Fellow, The University of Western
Australia, Director Manual Concepts
CONTRIBUTORS
Leanne Bisset PhD, MPhty (Sports Phty), MPhty Tracey O’Brien MPhty (Sports Phty), BPhty
(Musculoskeletal Phty), BPhty Former executive member SMA Qld Board of
APA Titled Sports Physiotherapist Directors (2000–2007), Associate lecturer in
APA Titled Musculoskeletal Physiotherapist Physiotherapy at the University of Queensland
Senior Lecturer, Griffith University
Mark Oliver MSc
Stephen Edmonston PhD, A/Prof. Private Practitioner
Director, Postgraduate Coursework Programs, School
of Physiotherapy, Curtin University of Technology Sue Reid MMedSc (Phty), Grad Dip Manip Phty,
BAppSc (Phty), BPharm
Paul Hodges PhD, MedDr (Neurosci), BPhty (Hons) Faculty of Health Science, The University of
Professor and NHMRC Principal Research Fellow Newcastle, Callaghan
Director, NHMRC Centre of Clinical Research
Excellence in Spinal Pain, Injury and Health Kim Robinson BSc, FACP
University of Queensland Specialist Musculoskeletal Physiotherapist
Adjunct Senior Teaching Fellow, Curtin University
C Hsieh MS, PT, DC, CA Senior Teaching Fellow, The University of Western
Private practice, Owner of John Hsieh Australia
Director Manual Concepts
M Hu
Associate Professor, School and Graduate Institute of Michele Sterling PhD, MPhty, BPhty, Grad Dip
Physical Therapy, National Taiwan University, Taipei, Manip Physio (distinction)
Taiwan, Republic of China Associate Director, Centre for National Research on
Disability and Rehabilitation Medicine (CONROD)
Kika Konstantinou MSc, MMACP, MCSP and Director Rehabilitation Research Program
Spinal Physiotherapy Specialist/Physiotherapy (CONROD)
Researcher, Primary Care Musculoskeletal Research Senior Lecturer, Division of Physiotherapy, School
Centre, Primary Care Sciences, Keele University of Health and Rehabilitation Sciences, University of
Queensland
Brian Mulligan FNZSP (Hon), Diploma M.T
Registered Physical Therapist
Developer of the concept of Mobilisation with
Movement
xiii
Reviewers
Pam Teys MPhty (Sports Phty), BPhty, Grad Cert CH Yang

Higher Ed Department of Physical Therapy,
School of Physiotherapy, Bond University Tzu-Chi University, Hualien, Taiwan, Republic of
China
C Yang
President, Calvin Yang MD Medical Imaging
REVIEWERS
Dr Nikki Petty Ken Niere
Principal Lecturer, Programme Leader Professional Senior Lecturer, School of Physiotherapy, LaTrobe
Doctorate in Health and Social Care University, Melbourne, Australia
Clinical Research Centre for Health Professions,
School of Health Professions
University of Brighton, UK
Dr Alison Rushton
Senior Lecturer in Physiotherapy, School of Health and
Population Sciences
College of Medical and Dental Sciences, University of
Birmingham, UK
xiv
ACKNOWLEDGMENTS
To my wife Dorothy and children Michelle, Louise Christine and Douglas, wife Liz, son Sam and daughter
and Selina. Amy for putting up with me during the writing process.
As testament to my father Romeo’s belief in the ben- The support of all my family truly means more to me
efits of study and also the support of Mary Vicenzino than anything else.
and Dorothy-May Ritchie. Toby Hall
Bill Vicenzino
Collectively, the authors acknowledge the valuable
Firstly to the centre of my world and love of my contributions of:
life, my little twins Matthew and Philippa. Also to my Brian Mulligan for overseeing the filming of the
parents and family who have always been there and techniques for the DVD and for performing many of
supported me through my journeys. Special mention them. He continues to be an inspiration for the correct
to my extended friends and colleagues of the Mulligan application of his MWM techniques.
Concept Teachers Association and in particular Brian Mark Oliver for performing the MWM techniques
Mulligan for your enormous contribution to my man- for the SIJ and TMJ, his areas of speciality.
ual therapy journey. Lastly a big thanks to the numer- The models who volunteered to participate in the
ous friends and work colleagues at AUT University filming for the DVD: Simon Beagley, Nadia Brandon-
and New Zealand physiotherapy fraternity who have Black, Wolly van den Hoorn, Christopher Newman,
shaped and steered my career. Ben Soon and Jeffrey Szeto.
Wayne Hing The models who volunteered to participate in the
photography sessions for the figures showing MWM
To my children Cameron and Karina, and to my men- techniques: Hans Giebeler, Honi Mansell, Katrina
tor in manual therapy and father Dr Howard Rivett. Mercer and Katherine Taylor.
Darren Rivett Assistance from the following was also greatly
appreciated: Renee Bigalow, Toni Bremner, Marion
Many people unknowingly helped steer my career, Duerr, Robin Haskins and Kerry Melifont.
which ultimately enabled me to contribute to this book. We are grateful for the specialist assistance provided
Notable are Bob Elvey, Kim Robinson, Brian Mulligan by Dr Natalie Collins in the conduct of the systematic
and Kate Sheehy, but there are many others. Thanks review and quality analyses in Chapter 3.
to you all. Special thanks go to my family: my parents
xv
SECTION ONE
Mobilisation with
Movement: its
application
Chapter 1
Introduction
Darren Rivett, Bill Vicenzino, Wayne Hing and Toby Hall
In the history of manual therapy revolutionary changes years studies testing this hypothesis using cutting-edge
in clinical practice have appeared from time to time. imaging and other research tools. It is timely that this
The individuals responsible for such impacting emerging science is linked to the clinical art of MWM;
changes have each contributed innovative and origi- that is, the evidence for MWM should be integrated
nal insights, and developed novel manual therapeu- with its clinical practice.
tic approaches and techniques. Maitland, McKenzie, Bogduk and Mercer[1] contend that any form of treat-
Kaltenborn, Paris, Jull and Elvey are just a few of the ment can be appraised against three distinct, comple-
leading practitioners who, utilising their sophisticated mentary axes of evidence: convention, biological basis
skills in clinical observation, palpation and reasoning, and empirical proof. A substantial part of this text will
opened new fields in manual therapy which effectively be concerned with the latter two forms of evidence;
shifted practice paradigms and transcended profes- that is, the biological mechanisms that may explain
sional boundaries. Indeed, their names have over the effects of MWM reported by practitioners and
time become synonymous with manual therapy itself. increasingly observed in empirical quantitative trials
Almost without exception, these outliers of manual of its efficacy. The remaining axis of convention, albeit
therapy exhibited self-deprecation and a continual the weakest type of evidence, is clearly supported by
drive to share their ideas, techniques and experiences the widespread uptake of MWM by manual thera-
with other practitioners. Brian Mulligan (Figure 1.1) pists, the increasing number of publications describ-
is a recent addition to this pantheon of leading man- ing the techniques including entry-level professional
ual therapy practitioners, with his unique ‘Mobilisa- texts (Petty, for example[2]), and the growing number
tion with Movement’ (MWM) concept significantly of Mulligan courses run annually across 25 countries
impacting on manual therapy practice worldwide over (see www.bmulligan.com for current courses), as well
the last two decades. as the incorporation of MWM into undergraduate and
In Chapter 2 we explain in detail the nuances of postgraduate university curricula. Moreover, there is
MWM, however, simply, MWM can be described as now a regular international conference on the Mulli-
a combination of a sustained passive accessory joint gan Concept and an international teachers’ association,
mobilisation with an active or functional movement. with a hierarchy of practitioner credentialing.
This book is a complete and comprehensive presenta- Before further discussing MWM and to truly under-
tion and exploration of the principles of application, stand the concept, it is arguably first necessary to
potential underpinning mechanisms and evidence base appreciate the history of the individual who initiated
for Mulligan’s MWM. Since the early 1990s when and developed this original form of manual therapy,
MWMs first come to prominence, there has been a Brian Mulligan himself.
rapid expansion in the number of techniques described
which can be used for differing clinical scenarios, and BRIAN MULLIGAN
a steady increase in the quantity and quality of support- The following historical recount is based on an inter-
ing research. Indeed, from Mulligan’s early descriptive view with Brian Mulligan.
case reports and videotaped patient treatments from Brian Mulligan began his career as a physiothera-
his clinic in New Zealand, scientific investigation pist after a chance conversation with a work colleague
into MWM has progressively advanced such that we early in 1951. A friend was about to take up physio-
now have high quality randomised controlled trials therapy studies in Dunedin on the South Island of New
being published in top ranked peer-reviewed interna- Zealand, when the conversation took place. This life-
tional journals (see Chapter 3). Similarly, from Mul- changing discussion regarding physiotherapy com-
ligan’s relatively simple ‘positional fault’ hypothesis pletely changed the course of Mulligan’s life and set in
as to the possible mechanistic basis for the clinically place a chain of events that had major implications for
observed effects of his techniques, there are in recent manual therapy.
2
1 • Introduction
similarly developing their interests in manual therapy.

Both Paris and McKenzie went to Europe to study with
Freddy Kaltenborn and returned to New Zealand to
teach this new approach in physiotherapy to Mulligan
and other physiotherapists. These were exciting times
for young ambitious physiotherapists, but there was
still a great deal of frustration with more to be learnt
about when to apply these new manual therapy tech-
niques in clinical practice.
The significance of these developments in phys-
iotherapy should be considered in the context of the
times. The Otago school and indeed almost all under-
graduate programs in physiotherapy in the 1950s did
not include any form of manual therapy. Treatments
largely consisted of exercise therapy and massage, as
well as modalities such as ultraviolet radiation. Fara-
dism, microwave and short-wave diathermy were also
Figure 1.1 Brian Mulligan, creator of Mobilisation common treatments. Ultrasound was a latter addi-
with Movement tion to the therapeutic armamentarium that required a
special licence in New Zealand. In those heady days,
manual therapy was a very new and exciting advance
Mulligan was in his early 20s in 1954 when he in physiotherapy.
graduated from the Otago School of Physiotherapy in Mulligan sought to expand his knowledge in manual
Dunedin. This was the same era that two other well therapy and was keen to learn about peripheral joint
known physiotherapists also graduated in Dunedin, mobilisation. In 1970 Mulligan was New Zealand’s
Robin McKenzie and Stanley Paris. Mulligan’s first representative at the World Confederation for Physical
job was at Wellington Hospital on the North Island of Therapy (WCPT) conference. Following this he trav-
New Zealand, but he quickly moved out of the public elled to Helsinki to attend a Kaltenborn peripheral joint
hospital system into private practice. His first private mobilisation course. It was the first time he had been
practice work was a two-week private clinic locum exposed to mobilisation techniques for the extremity
position for Robin McKenzie. At that time there were joints. Shortly after his return to New Zealand he was
only five private physiotherapy practices in Welling- asked to teach the new skills he had learnt to the local
ton. Mulligan enjoyed the experience immensely, and private practitioners’ group. He ran his first weekend
decided that this type of physiotherapy practice would course on Kaltenborn mobilisation techniques in 1970.
be his career path in the future. Accordingly, he started Shortly afterwards, in 1972, he was asked to teach a
his own private practice in Wellington and was very similar course in Perth and Sydney, in Australia. Mul-
well supported by the local referring medical practi- ligan then taught regularly in Australia, especially Mel-
tioners. bourne, where he visited for 15 consecutive years.
Mulligan was very active in the New Zealand Soci- In 1984 Mulligan had his first MWM success, which
ety of Physiotherapists (NZSP). He joined the NZSP completely changed his whole approach to manual
after graduation, becoming the secretary of the local therapy. The patient was someone he had been treat-
Wellington Branch at the end of his first year, and took ing for some time but could not alter the status of their
on the presidency soon after. He attended as many condition. The patient presented with a grossly swollen
meetings as he could in those early years to increase his finger with painfully limited flexion and extension fol-
clinical knowledge and to develop his skills in practice, lowing a sporting injury. Mulligan used contemporary
being acutely aware of the general lack of understand- treatment techniques of the day, which included ultra-
ing in managing patients with musculoskeletal prob- sound and traction as well as medial and lateral joint
lems at that time. glide mobilisations. Nothing appeared to significantly
In the late 1950s, Jennifer Hickling from London improve the patient’s condition.
gave seminars in New Zealand on Dr James Cyriax’s Mulligan again attempted a medial glide technique
approach to orthopaedic medicine, which included but the patient reported this as being painful. He then
spinal manipulation (high velocity thrust) and passive applied a lateral glide, which the patient stated did not
joint mobilisation techniques.[3] Mulligan attended hurt. In a moment of inspired lateral thinking, Mulli-
those seminars and was deeply impressed by Hick- gan asked the patient to try to flex the injured finger
ling’s knowledge and expertise. Mulligan’s interest while he sustained the pain-free lateral glide (Figure
in manual therapy was greatly stimulated by these 1.2). The technique was immediately successful and
seminars. About this time, Paris and McKenzie were restored the full range of pain-free movement to the
3
MOBILISATION WITH MOVEMENT: THE ART AND THE SCIENCE
joint in both flexion and extension. Further repeti- Mulligan wrote his first textbook on his concept
tions rendered the patient symptom-free after only one of manual therapy in 1989.[4] Every few years a new
treatment session. A telephone call several days later updated version was written as more and more tech-
revealed that the pain had not returned and the swelling niques were being developed. Currently the book is
had completely reduced following this single applica- in its sixth edition[5] and has sold more than 75 000
tion of MWM. For Mulligan, this was a Louis Pasteur copies worldwide. It has also been translated into 10
moment: ‘Chance favours the prepared mind’. languages, including Mandarin, Polish, Korean, Portu-
All MWMs that have since been developed arose guese and Spanish. A further publication followed in
from this single observation of a recalcitrant clini- 2003 based on self-treatment techniques entitled Self
cal problem. Mulligan thought a great deal about this treatments for the back, neck and limbs, and is currently
patient, and soon realised the whole concept of posi- in its second edition. Techniques from the Mulligan
tional faults and MWM. He was keen to apply the Concept are also now described in CDROM and DVD
same idea to all his patients with finger joint problems, products (see www.bmulligan.com for a description of
and then to other joints. Medial and lateral glides and these products). Mulligan started to teach his new tech-
rotations with movement were developed first in the niques in many other countries, starting with Australia
fingers, shortly followed by the wrist. The concept and the USA. From the beginning, an important focus
of MWM was rapidly evolving. Sustained Natural of these courses has been actual patient treatment dem-
Apophyseal Glides (SNAGs) were also being devel- onstrations to clearly show the benefits of the concept.
oped in the spine at the same time. Mulligan realised In 1990 Mulligan lectured at Curtin University of
that the effects of MWM in the peripheral joints were Technology in Perth, Western Australia. Three UK
similar to the effects of SNAGs in the spine. All these physiotherapists, Toby Hall, Linda Exelby and Sarah
techniques essentially involved sustained accessory Counsel were attending postgraduate courses at the
joint glides together with physiological movement. university at the time and were impressed by the
He rationalised that the techniques somehow restore approach Mulligan presented. These three physiother-
a positional fault which arose from either trauma or apists took Mulligan’s techniques back to the UK and
muscle imbalance. started teaching them to their colleagues. Such inter-
Momentum gathered quickly from this early incep- est was generated that this eventually led to invitations
tion of MWM. Mulligan was very excited by his for Mulligan to teach in the UK and Europe and to the
discovery and knew he had to share it with other development of the international Mulligan Concept
physiotherapists. He started to teach these new tech- Teachers Association (MCTA), which had its inaugu-
niques at courses in New Zealand through the manual ral meeting in Stevenage, UK in 1998. This teaching
therapy special interest group of the NZSP known as group was set up to standardise the teaching of the
the New Zealand Manipulative Therapists Association Mulligan Concept around the world. There are now
(NZMTA). At that time Mulligan was teaching a range more than 47 members of MCTA providing courses
of techniques from different concepts, including those for physiotherapists all over the world. In addition, due
of Geoff Maitland and Kaltenborn, but gradually his to the demand from clinicians in the USA, and even-
own techniques replaced these other concepts. His first tually elsewhere, who wished to be acknowledged as
Mulligan Concept course was held in 1986. competent Mulligan Concept practitioners, Certified
A B
Figure 1.2 (a) Manual application of a lateral glide MWM for a loss of flexion of the proximal inter-phalangeal
joint of the index finger
(b) Application of a lateral glide MWM for a loss of hip flexion using a treatment belt
4
1 • Introduction
Mulligan Practitioner (CMP) competency examina- may follow the convex–concave rule of joints[6] but in
tions were established. To date, there are over 300 cli- some cases in the opposite direction to the mechanism
nicians worldwide who have gained this certification. of injury movement. Sometimes a little trial and error
In recognition of his significant contribution to man- is needed to find the right direction. One distinction
ual therapy and the physiotherapy profession, Mulli- with SNAGs, which are effectively the ‘MWM of the
gan has received a number of awards. In chronological spine’, is that the gliding motion is always in the direc-
order of presentation these include: Life Membership tion of the facet joint plane. Mulligan generally recom-
of the NZMTA (1988); Honorary Teaching Fellow- mends three sets of 10 repetitions of MWM, or fewer if
ship from Curtin University of Technology (1991); the impaired task is pain-free on reassessment follow-
Honorary Fellowship of the NZSP (1996); Life Mem- ing the application of a set of MWM or if irritability or
bership of the New Zealand College of Physiotherapy acuteness is a factor in the spine when using SNAGs.
(1998); Life Membership of the NZSP (1999); Honor- There are many nuances to the successful application
ary Teaching Fellowship from the University of Otago of MWM and these are covered in depth in Chapter 2.
(2003); WCPT Award for International Services to the MWM can be easily integrated into the standard
Physiotherapy Profession (2007). The impact that the manual therapy physical examination to evaluate its
Mulligan Concept has had on clinical practice was potential as an intervention. A seamless integration
highlighted when Mulligan was named one of ‘The can be undertaken after examining the active/func-
Seven Most Influential Persons in Orthopaedic Man- tional movements, static muscles tests in some cases,
ual Therapy’ as the result of a poll of members of the and passive accessory movements. They can be readily
American Physical Therapy Association. trialled and implemented in the treatment. Reassess-
ment is generally just a matter of the practitioner tak-
MOBILISATION WITH MOVEMENT ing their hands off the patient and asking them to move
The fundamental components of the MWM techniques (without having to change position), and frequently
are still as they were when in 1984 Mulligan first observed the treatment and its reassessment can be applied in
immediate full restoration of pain-free movement after he weight-bearing positions for lower limb and lumbo–
sustained a lateral glide mobilisation to an inter-phalan- pelvic problems. Mulligan recommends discarding the
geal joint and asked the patient to actively flex that joint. technique immediately if no positive change is evident
Furthermore, he observed that it only took one session on initial reassessment.[7]
of this first MWM to bring about long lasting changes. The indications for MWM in both the physical
This was especially impressive because the finger joint examination and for treatment are essentially the same
had not responded to a range of contemporary physical as for other ‘hands-on’ manual therapy approaches,
therapies applied over several sessions. This immediate, as are the contraindications. This is discussed more
pain-free and long lasting response has become the key comprehensively in Chapter 2. Generally, mobilisation
principle guiding MWM application today. techniques, including MWM have been conceptualised
MWM can be defined as the application of a sus- as being indicated for mechanically induced joint pain
tained passive accessory force to a joint while the and joint stiffness limiting ROM. However, MWM has
patient actively performs a task that was previously also been proposed by Mulligan to effect what appear
identified as being problematic. A critical aspect of to be soft tissue conditions, such as lateral epicondylal-
MWM is the identification of a task that the patient gia of the elbow and lateral ankle ligament sprain, and
has difficulty completing, usually due to pain or joint indeed there is growing evidence to support his asser-
stiffness (see Chapter 2 for more detail). This task is tion (see Chapter 3). The various potential mechanisms
most frequently a movement or a muscle contraction by which MWM may exert its effects are considered in
performed to the onset of pain, or to the end of avail- Chapters 4, 5, 6 and 7.
able range of motion (ROM) or maximum muscle con- While innovative and original in nature, the MWM
traction. In this text, we will refer to this as the Client concept has parallels to other ‘traditional’ mainstream
Specific Impairment Measure (CSIM, see Chapter 2 for approaches to manual therapy that would facilitate
more detailed description). The passive accessory force ready adoption by the experienced manual therapist.
usually exerts a translatory or rotatory glide at the joint For example, the consideration of joint mechanics in
and as such must be applied close to the joint line to some MWM techniques is akin to the approach advo-
avoid undesirable movements. It may be applied manu- cated by Kaltenborn,[6] and the strong emphasis on
ally or sometimes via a treatment belt (Figure 1.2b). self-management using repeated movements would
The direction of the accessory movement that is used be familiar to McKenzie practitioners.[8] This is not
is the one that effects the greatest improvement in the surprising given that Mulligan was heavily influenced
CSIM. It is somewhat surprising that a lateral glide is early in his career by both these practitioners through
the most commonly cited successful technique used in direct mentoring. In common with both the Maitland[9]
peripheral joints, but if this direction is not effective and McKenzie approaches a change in pain response is
then other directions may be tested. Alternate glides used as an indication that the correct technique is being
5
applied, although rather than provoking or localising s ystematic review of such trials, where this is limited
pain the aim of MWM is its immediate and total elimi- or not available we must use the next best external evi-
nation. In contrast, there are no ‘grades’ of mobilisa- dence (see Chapter 3, Table 3.1 for the various levels
tion in MWM as there are in the Maitland approach and of evidence), whether it be a case report or from the
some other approaches,[10] and MWM combines both basic sciences. We therefore prefer the term ‘evidence-
passive and active elements rather than just focusing on informed practice’, and particularly use this in the
one (e.g. passive joint movement as per Kaltenborn) or case studies which comprise the latter part of the text,
the other. In regard to the latter, there is some similar- as the cases strive to illustrate how expert clinicians
ity to the combined movement approach described by apply the external research evidence for MWM within
Brian Edwards[11] in which pain-free joint positioning a clinical reasoning framework and without losing the
is used to enable end-range passive mobilisation. The uniqueness and individuality of the patient. The patient
other interesting parallel is the story about how Mul- is considered an active and equal partner in the clini-
ligan ‘discovered’ MWM, not dissimilar to the account cal problem-solving exercise, as they bring their own
given by McKenzie as to how he chanced upon the beliefs, understandings, expectations and experiences
therapeutic value of lumbar spine extension for low to the unfolding clinical journey. In addition, consis-
back pain.[8] These outliers of the manual therapy tent with the biopsychosocial model of healthcare, the
world appear to share an ability to creatively clinically patient is required to actively engage in their treatment
reason or think outside the box. and management, as opposed to just passively receiv-
ing the ‘laying on of hands’ implicit in many traditional
MWM AND CLINICAL REASONING manual therapy approaches.
Some approaches to manual therapy have been criti- The MWM concept arguably promotes patient-cen-
cised for fostering ‘recipe book’ clinical practice. That tred clinical reasoning in several ways:
is, rather than promoting skilled clinical reasoning in • Collaborative clinical reasoning in treatment, as pro-
autonomous practitioners, some approaches could be mulgated by Jones and Rivett[12] is central to MWM.
considered to relegate the role of the manual therapist First, the patient needs to understand that the tech-
to that of a technician, required simply to deliver a pre- nique is completely pain-free and that they must
determined course of therapeutic action. A cursory view report any pain immediately to the therapist. Second,
of the MWM concept might similarly suggest it simply in most MWM applications, the patient is required to
requires the clinician to routinely follow several basic perform an active movement or functional task that
rules (e.g. the treatment plane rule, convex–concave is problematic and for which treatment was sought
rule) and therefore is at odds with the development of (e.g. a painful or limited movement). Third, many
skilled clinical reasoning. However, on closer inspection MWM techniques involve the patient applying over-
it is clear that MWM actually incorporates many of the pressure at the end of range, and indeed Mulligan[7]
desirable aspects of contemporary, exemplary clinical considers this component critical in effecting an
reasoning. In particular, these relate to a patient-centred optimal response. Finally, and perhaps most impor-
approach to healthcare and promotion of the ongoing tantly in this context, some MWMs can be adapted
development of the practitioner’s clinical skills. for home exercise as self-MWMs or by using tape
to simulate the accessory movement (or mobilisa-
MWM promotes patient-centred tion) component of the technique. Of course, all of
reasoning the above elements of MWM necessitate that the
patient understands the principles of MWM and is
Jones and Rivett[12] have advanced a model of clini- willing to actively participate in their own manage-
cal reasoning in manual therapy that places the patient ment; thereby rendering the patient a central and
firmly at the centre of the clinical encounter and the necessary factor in successful MWM treatment. The
associated clinical reasoning processes. Their model importance of collaboration and patient cooperation
is consistent with the patient-centred approach to evi- to the success of MWM is highlighted in an acronym
dence-based medicine advocated by Sackett et al.[13, 14] favoured by Mulligan (personal communication,
Evidence-based medicine has been defined by Sack- 2009) in his teaching – CROCKS:
ett et al (p.71)[14] as ‘the conscientious, explicit, and ▪ Contraindications to manual therapy as for any
judicious use of current best evidence in making deci- manual therapy techniques
sions about the care of individual patients’. These ▪ Repetitions of the technique are required, but with
authors further stress that evidence-based medicine is care on initial application and in acute injuries for
an integration of the practitioner’s clinical expertise which three to six repetitions are recommended
with both the best external clinical research evidence ▪ Overpressure to ensure optimal ongoing improve-
and the patient’s preferences in making decisions ments
about their care. While for treatment the ‘gold stan- ▪ Communication and cooperation is essential
dard’ for evidence is the randomised clinical trial or a for safe and effective MWM application with
6
1 • Introduction
p ractitioners informing patients of expected relation to MWM recognises the unique clinical pre-
effects and for patients informing practitioners of sentation of the individual patient.
any discomfort or pain • Arguably, MWM provides a means by which vari-
▪ Knowledge of musculoskeletal medicine, biome- ous types of clinical reasoning hypotheses[12] can be
chanics and anatomy tested, aside from the obvious one of management
▪ Sustain the glide for the entire duration of the rep- and treatment. Most notably, the degree of response
etition. S also stands for skill in the manual han- to MWM can potentially expedite and refine the clin-
dling of the physical application of the MWM, ical prognosis.
sensibility of the sensing fingertips to accurately
locate MWM forces and to detect movement, sub- MWM promotes knowledge organisation
tle changes in glide direction are often required, A well-organised knowledge base has been identified as
and common sense. one of the hallmarks of clinical expertise. It is not just
• The practitioner can facilitate patient compliance the degree of knowledge in its three main types — prop-
with treatment, especially the self-management com- ositional (essentially basic and applied science), non-
ponent, by demonstrating to the patient that applica- propositional (including practical and other professional
tion of MWM can produce an immediate pain-free skills) and personal (an individual’s life experiences)
response in their ‘worst’ movement or activity. — that is important in clinical reasoning, but how these
Moreover, such a powerful response has significant understandings and skills are stored and held together
potential to change any negative beliefs or expecta- using clinical patterns.[12] A well-organised knowledge
tions that the patient may have brought to the clinical base will facilitate the application of advanced clinical
encounter. Another of the acronyms that Mulligan reasoning processes, particularly that of pattern recog-
(personal communication, 2009) uses when teaching nition which has been shown to be more accurate than
MWM is PILL, indicating the desired response from hypothetico–deductive processes in manual therapy
the technique’s application: diagnosis and is typically used by experts.[16]
▪ Pain-free application of the mobilisation and It can be argued that the MWM concept promotes
movement components knowledge organisation by:
▪ Instant result at the time of application • Stimulating research and a growing evidence base
▪ Long Lasting effects beyond the technique’s which can be used to help guide and inform clini-
application. cal reasoning. As later chapters demonstrate, there
• Effective communication is pivotal to the effective is a burgeoning evidence base, both biological and
application of MWM. The patient must immediately empirical for MWM.
communicate the onset of any pain with either the • Highlighting and integrating key physical exami-
‘Mobilisation’ or the ‘Movement’ component, or nation findings, most notably passive accessory
else the technique will be rendered ineffectual. Simi- movement findings (the ‘Mobilisation’) with the
larly, the therapist must clearly communicate what is ‘comparable’ active/functional movement findings
expected of the patient, as outlined in the previous (the ‘Movement’).
point. Effective communication is also unambigu- • Facilitating clinical pattern acquisition through the
ously the foundation of effective collaborative clini- immediate response to the application of MWM.
cal reasoning. Effectively this constitutes feedback to the therapist
• Central to the MWM concept is that each patient on the accuracy of the related clinical decision(s) and
is an individual and their clinical presentation is helps to reinforce the association of key clinical find-
unique, although they may share some common fea- ings with correct clinical actions.
tures with others. This consideration of individuality • Fostering the development of metacognitive skills
and uniqueness is consistent with the ‘mature organ- through the need to continually adapt the applica-
ism model’[15] which proposes that each patient’s ill- tion of MWM on the basis of the patient’s initial and
ness or pain experience is influenced by their own changing responses. Metacognitive skills are higher
life experiences and immediate contextual circum- order thinking skills of self-monitoring and reflec-
stances, and therefore their clinical presentation can- tive appraisal of one’s own reasoning, and are a well-
not be exactly the same as that of another patient. recognised characteristic of clinical expertise.[12]
The ‘Movement’ component of MWM requires that While the Mulligan Concept as it relates to MWM
a movement or functional activity be identified that may promote the development of skills in clinical rea-
is most painful or limited for that individual, and soning, there is a risk that an unquestioning inflexibil-
which has a significant impact on their daily life. ity of thinking may set in if vigilance is not maintained.
This movement is also used in reassessment as a The writings of Mulligan should be used as a guide to
‘comparable sign’ (i.e. a clinical sign that relates the application of MWM with the techniques adapted
to their functional limitation and pain) as described for the needs of a particular patient, and not treated as
by Maitland et al.[9] Similarly, the use of a CSIM in gospel from which heated debates arise over differing
7
interpretations and trivial technical issues. The history do so with an open but healthily sceptical mind. The
of manual therapy is replete with examples where a case studies comprising the bulk of the chapters will
far-sighted pioneer has been feted like a guru by his provide the novice reader with the confidence to take
followers, who with the fervour of religious zealots the concept of MWM into their clinic, and the experi-
then proceed to construct a framework that stifles cre- enced clinician with the opportunity to develop their
ativity and the further evolution of the protagonist’s clinical reasoning skill by comparing their reasoning to
approach,[17] and which misdirects future practitioners that of other Mulligan Concept practitioners.
and advocates of the approach away from the origina-
tor’s fundamental underpinning concepts. References
1 Bogduk N, Mercer S. Selection and application of treat-
AIMS AND STRUCTURE OF THIS BOOK ment. In: Refshauge KM, Gass EM (eds) Musculoskele-
The primary aim of this book is to present a comprehen- tal Physiotherapy: Clinical Science and Evidence-Based
sive and contemporary discourse on Mulligan’s MWM Practice. Oxford: Butterworth-Heinemann 1995.
2 Petty N. Neuromusculoskeletal Examination and Assess-
management approach for musculoskeletal pain, injury ment. Edinburgh: Churchill Livingstone 2005.
and disability. In particular, it strives to integrate the 3 Cyriax J. Cyriax’s Illustrated Manual of Orthopaedic
evidence base for MWM into clinical practice, with Medicine (2nd edn). Oxford: Butterworth-Heinemann
an emphasis on explicating the underpinning clinical 1993.
reasoning. 4 Mulligan B. Manual Therapy — ‘NAGS’, ‘SNAGS’,
This book will cover the spectrum of the MWM ‘PRPS’ etc. Wellington: Plane View Services 1989.
treatment approach from: (a) the evidence base for its 5 Mulligan B. Manual Therapy - ‘NAGS’, ‘SNAGS’,
clinical efficacy, clinical and laboratory based effects, ‘MWMS’ etc. (6th edn). Wellington: Plane View Ser-
and underlying mechanisms; (b) best evidence guide- vices 2010.
lines for MWM treatment selection and application; 6 Kaltenborn F. Manual Mobilisation of the Extremity
Joints. Basic Examination and Treatment Techniques.
and (c) the current state of play with regard to Mul- Norway: Olaf Norlis Bokhandel 1989.
ligan’s ‘positional fault’ hypothesis, as well as other 7 Mulligan B. Manual Therapy - ‘NAGS’, ‘SNAGS’,
impairments/deficits in the pain, sensory, sensorimo- ‘MWMS’ etc. (5th edn). Wellington: Plane View Services
tor and motor systems that may well be plausibly 2003.
addressed by the MWM approach; through to (d) a 8 McKenzie R, May S. The Lumbar Spine Mechanical
series of case studies (Chapters 8 to 19) that demon- Diagnosis and Therapy (2nd edn). New Zealand: Spinal
strate how the former considerations can be utilised Publications 2003.
in the clinical reasoning process. The latter will also 9 Maitland GD, Hengeveld E, Banks K, English K.
demonstrate the framework within which the practitio- Maitland’s Vertebral Manipulation (6th edn). Oxford:
ner is able to design and implement customised MWM Butterworth-Heinemann 2001.
10 Boyling J, Jull G. Grieve’s Modern Manual Therapy:
techniques for the individual patient, as illustrated The Vertebral Column (3rd edn). Edinburgh: Churchill
by some prominent Mulligan Concept practitioners. Livingstone 2004.
By presenting these cases within a clinical reasoning 11 Edwards B. Manual of Combined Movements: Their
framework it is further intended to demonstrate that the Use in the Examination and Treatment of Mechani-
use of MWM is very much dependent on the individ- cal Vertebral Column Disorders. Edinburgh: Churchill
ual patient’s presentation and requires a sophisticated Livingstone 1992.
level of thinking by the practitioner. These are not 12 Jones M, Rivett D. Introduction to clinical reasoning.
‘recipe book’ treatments. Key MWM techniques, par- In: Jones M, Rivett D (eds) Clinical Reasoning for
ticularly those for which evidence is supportive, will Manual Therapists. Edinburgh: Butterworth-Heinemann
be described in detail and depicted. In the event that 2004:3–24.
13 Sackett D, Straus S, Richardson W, Rosenberg W,
a practitioner confronts issues in putting into practice Haynes R. Evidence-based Medicine: How to P ractice
the MWM techniques, we have included a technique and Teach EBM (2nd edn). Edinburgh: Churchill
troubleshooting section (Chapter 20), which is geared Livingstone 2000.
towards practitioners self-reflecting and appraising 14 Sackett DL, Rosenberg WM, Gray JA, Haynes RB,
their performances in order to develop strategies and Richardson WS. Evidence-based Medicine: What it is
solutions to these issues. and what it isn’t. BMJ. 1996;312:71–2.
This book will be of benefit for students of manual 15 Gifford L. Pain, the tissues and the nervous system: a
therapy and for the various health professionals work- conceptual model. Physiotherapy 1998;84:27–36.
ing clinically in this field, and it should provide a valu- 16 Miller P. Pattern Recognition is a Clinical Reasoning
able resource for instructors and researchers. It is not Process in Musculoskeletal Physiotherapy (Masters
Thesis). Newcastle: The University of Newcastle,
intended to replace the technical books of Mulligan, Australia 2009.
but rather is complementary. To make the most of this 17 Rivett D. Manual therapy cults (editorial). Manual
book, the reader should strive to first understand the Therapy 1999;4:125–6.
principles and evidence underpinning MWM, and to
8
Chapter 2
Mobilisation with Movement: the art and science of
its application
Bill Vicenzino, Wayne Hing, Toby Hall and Darren Rivett
In this chapter we set out to define and operationally client-centred and meaningful to the individual client,
describe Mobilisation with Movement (MWM) tech- so consequently we have termed it the Client Specific
nique in terms of its parameters and how these may Impairment Measure (CSIM). To reiterate this point in
be manipulated in order to achieve clinically beneficial a slightly different manner, establishing the CSIM is
outcomes. the first criterion that needs to be met. If a CSIM can-
MWM is essentially the application of a specific vec- not be found then a MWM cannot be used.
tor of force to a joint (mobilisation or the first ‘M’ in
MWM), which is sustained while the client performs a The patient’s problem
previously impaired physical task. The key to successful The CSIM is a physical task or functional activity that
use of MWM is the skilful and efficient application of the practitioner is able to evaluate and that is com-
this mobilisation force so as to painlessly achieve imme- parable to the patient’s presenting problem, which
diate and long lasting relief of pain.[1] We propose that in many ways is similar to Maitland’s[2] comparable
the mobilisation element of MWM can be adequately sign. That is, the key element of a CSIM is that it
described through the parameters of amount, direction needs to reflect the patient’s main concern(s). The
and volume of applied force, as well as the location and CSIM assessed in the clinic may be the task itself;
mode of application of the force. The knowledgeable, for example, placing the hand behind the back to tuck
judicious and skilful manipulation of these parameters a shirt in for a shoulder problem or walking down a
provides the practitioner with the capability whereby to step for a knee problem. That is, a physical activity or
optimise the opportunity for success with MWM. task that is easily reproducible in the clinic is likely
Notwithstanding the importance of understanding to be directly incorporated in a MWM, whereas the
these mobilisation parameters, it is critical to realise one that is not readily reproducible in the clinic will
that the key feature of a MWM application is the move- need to be approached in a slightly different way. To
ment or the second ‘M’ in MWM. We have called this illustrate this, consider an example of a male patient
the Client Specific Impairment Measure (CSIM). Spe- who indicates that his main problem is throwing
cifically, the key to understanding how to apply MWM a ball. Clearly it is difficult to do a manual therapy
successfully is in understanding the role of the CSIM technique on a shoulder while the patient is throwing
in guiding the practitioner on a range of treatment a ball, so in this case the practitioner would conduct a
selection issues; for example, in determining the opti- physical examination to find physical signs of impair-
mum force parameters. Before detailing the mobilisa- ments that are reproducible in the clinic and for which
tion force parameters of MWM, this chapter will first it is conceivable to apply a MWM. In this example,
define in detail the movement element of MWM and this may well be shoulder rotation at 90° of elevation
along with other chapters demonstrate that it is argu- in the scapula plane. That is, the more complex or
ably the most critical element. demanding tasks may need to be broken down into
This chapter is set out in two parts: the first part some of their critical constituent parts in the clinical
is about the CSIM or movement element of MWM context.
whereas the second part is about the mobilisation ele- In some cases, the CSIM may be a task that is repro-
ment of MWM. ducible in the clinic but is not readily amenable to the
application of a MWM. For example, a patient may
PART 1 CSIM: THE MOVEMENT ELEMENT have a severe pain problem with deep squatting or
OF MWM walking down stairs. In this case it may not be desir-
able to reproduce the deep squat or down stairs walk-
A MWM can only be applied if there is a meaningful ing too many times, so alternatively, the practitioner
clinical measure of the physical task with which the can break down these tasks into less stressful and pre-
client is having problems. The measure needs to be sumably with less painful component parts. So in the
9
case of a deep squat perhaps non-weight-bearing knee at the onset of the pain (Table 2.1). It follows that the
flexion is limited and less painful than weight-bearing, quantification of the CSIM is the amount of physical
which could be a starting point for the treatment. If activity/task that is possible leading to the onset of pain
non-weight-bearing knee flexion is only mildly painful, and not the amount/severity of pain elicited. For exam-
then perhaps 4-point kneeling or partial weight-bearing ple, in the event that the physical problem is a pain-
with a foot up on a step or small stool would be a rea- ful movement, the patient would indicate when they
sonable and appropriate starting point. In summary, first feel pain during the movement and this could be
selection of a CSIM, while reflecting the patient’s main measured with a goniometer, inclinometer, tape mea-
problem, should also allow a safe MWM to be applied sure or some other reference point (e.g. a point on the
without risk of exacerbating a severe pain problem in wall). In the event that a painful muscle contraction
fully loaded joints. is the CSIM, it can be measured with a dynamometer,
To arrive at an appropriate CSIM, the practitioner so that the amount of force generated that leads to the
first identifies, through the interview, a comparable first perception of pain is used to quantify the patient’s
sign or physical task/activity that is problematic (usu- problem (e.g. grip testing in tennis elbow as illustrated
ally painful) to the patient. In doing so, the practitioner in the case study described in Chapter 13). All these
should make sure to document the extent to which the measurements are standard and routine in musculosk-
physical task interferes with the patient’s day-to-day eletal healthcare practice.
function, as well as the severity and irritability of the Using the pain onset as the endpoint of the test (pain
condition.[2] Then in the physical examination the prac- threshold) works best in non-irritable presentations
titioner will quantify the CSIM. This quantification and is critical in minimising exacerbation of pain or
will be somewhat variable depending on the presenting ‘treatment soreness’ after the session. It should be used
problem; that is, it will be different for a painful condi- with great care in irritable presentations for which it
tion versus a stiffness or weakness problem. becomes more important to allow time after perfor-
mance of the CSIM in order to assess for any latent
Quantifying the CSIM in painful exacerbation of pain.
conditions
CSIM quantification where pain is at end of
In the case of someone presenting with pain as the range or at full strength contraction
problem it is essential that the endpoint of the CSIM
is the onset of pain (otherwise called a pain threshold The only case in which the foregoing guide may not
endpoint). That is, the physical task, which could be apply and where pain is the presenting problem is when
either a movement or muscle contraction, is ceased a patient demonstrates full range of motion (ROM) or
Table 2.1 Defining impairments in terms of endpoint, how measured and target(s) for MWM
Impairment Endpoint Measurement or quantity MWM target(s)
Pain-limited motion1 Pain onset Degrees of motion2 Motion (not pain)
Painful arc Pain onset and offset3 Degrees of motion Arc of motion and motion
at onset (not pain)
Pain at full end of range End of normal range of motion Pain (NRS or VAS)4 Pain (not range of motion)
Limited range of motion with Range of motion Degrees of motion Motion
no pain5
Force generation less than Pain onset Force output Force generation6 not pain
normal due to pain
Painful contraction without Normal force output Pain (NRS or VAS) Pain not force generation
strength deficit
Weakness without pain Force output Force output Force generation
1 The motion could be of joints, muscle or nerve. This applies for all motion functions in this table.
2 In some instances it may not be degrees, but rather a linear distance achieved (e.g. hand behind back using millimetres
along the back, bending forward using linear measurement of reach with fingers to the floor).
3 The pain experienced at pain onset should not increase with further movement so as to prevent further movement.
4 VAS (visual analogue scale), NRS (numerical rating scale).
5 This may also include perceptions of stretch and discomfort that the patient does not describe as being painful per se.
6 In order to have a reproducible measure, the force generation is usually isometric, but this only refers to when pain is
involved and when pain is the endpoint.
10
2 • Mobilisation with Movement: the art and science of its application
normal muscle strength (usually compared to the other 120° (100%) before pain onset could be viewed as a
side) at pain onset. In such cases the CSIM can only be substantial improvement. Improvements in the order
measured by the level/severity of pain elicited as mea- of 50–100% are often cited as targets to be reached in
sured on a pain visual analogue scale (VAS) or numeri- this regard (e.g. McConnell’s glide and tilt taping of
cal rating scale (NRS) (Table 2.1). the patellofemoral joint, which is very much akin to a
MWM should improve the patient’s pain by 50%[5]),
CSIM quantification where pain is not the but no hard supportive evidence for MWM exists. Suf-
problem (e.g. weakness, stiffness) fice to say that the larger the initial effect, logically
the greater the likelihood of success in managing the
The preceding refers to a patient who has pain on case with MWM and that pursuing the use of a MWM
physical activity where pain exacerbation following in a treatment program is a valid course of action.
a provocative treatment session may be a substantial Interestingly, others have shown between session
disincentive to continue with the treatment plan. How- changes are predicted from within session changes.[6, 7]
ever, those who are seeking help for a limitation in the For example, Tuttle[7] showed that for cervical spine
performance of a task where there is no pain — for manipulation the within session gains in ROM, pain
example, the person presenting with tight muscles, stiff intensity and pain centralisation were highly predic-
joint, or muscle weakness — can be managed with ref- tive of between session changes in these measures, of
erence to discomfort and gains in ROM or muscle force the order of 71–83% predictive. This may be regarded
generated. The traction straight leg raise and ankle dor- as lending support to the notion of using a CSIM as a
siflexion MWMs (see Chapter 5, Figure 5.3) are exam- guide to clinical decisions on selection of a MWM, or
ples of techniques that have been reported to improve other manual therapy treatment.
ROM where pain is not the main problem.[3, 4] It is important to understand the concept of a ceiling
effect in determining how much of an improvement is
How to use a CSIM when applying sufficiently substantial. For example, if the ROM defi-
MWM cit between sides is in the order of 10% (or 16° in the
case in the previous paragraph) then regaining that
The critical aspect of a CSIM is that it will guide the small amount of range in a pain-free manner is also
MWM application not only immediately during the a substantial effect. Thus the presenting condition and
application of the MWM, but also it will guide modi- the associated potential available improvement also
fications of MWM on subsequent applications of a impacts on what is deemed to be substantial.
course of treatment. That is, it will be used to judge Vicenzino and Wright[8] showed a desired response
the effectiveness of the applied MWM within a session profile during a MWM application in a case study (Fig-
and between sessions of a course of treatment. The way ure 2.1). The patient was a 39-year-old female with
in which the CSIM guides the application of a MWM chronic tennis elbow who had failed to respond to typi-
will differ slightly in its implementation when the con- cal treatment (deep tissue massage, transverse friction
dition is a predominantly painful condition than when massage, electrotherapy). Application of a lateral glide
the condition is primarily one of stiffness (or weak- MWM for tennis elbow produced substantial changes
ness), for example. in pain-free grip force during its application in the
This section will outline the use of the CSIM in dif- order of 3–4 times baseline measurement (Figure 2.1
ferent generic patient presentations, such as, when (i)). That is, while the practitioner is actually applying
a patient presents with a painful condition limiting the MWM there should be a substantial change from
motion or muscle contraction, or where the patient the baseline CSIM measurement. The improvement in
presents with pain at end of range or full force muscle the CSIM immediately following the MWM applica-
contraction where it is not the limiting factor, as well as tion should also be substantial relative to the pre-treat-
briefly in cases where pain is not present or minimally ment measurement of the CSIM, as represented at (ii)
present, such as in a stiff limited joint. in Figure 2.1.
The foregoing has dealt with the CSIM during
When the MWM is being used in a painful and immediately after the application of the MWM.
condition There is preliminary evidence that the CSIM may
also prove to be useful in predicting the success or
In terms of the CSIM, the pain-free and immedi- otherwise of a course of MWM treatment before it
ate effect that is required for an effective MWM is is even applied. There is only one study that we are
interpreted through a substantial and instantaneous aware of that addresses the issue of predictors of suc-
improvement in the quantity being measured at the cess with MWM. In this recent study, a preliminary
point of pain onset (Table 2.1). For example, if the clinical prediction rule (CPR) was developed from a
ROM was 60° to pain onset out of a possible 160° post-hoc analysis of 64 patients with tennis elbow who
motion at a joint, then an improvement from 60° to were treated with an average of five sessions of MWM
11
300
AFFECTED UNAFFECTED
250
Pain-free grip force (N)
200
150
100
(i) (ii) (iii)

50
Baseline
0
A1 A2 B1-1 B1-2 B1-3 B2-1 B2-2 B2-3 B3-1 B3-2 B3-3 B4-1 B4-2 B4-3 C1 C2
Measurement Period
Figure 2.1 Pain-free grip force measurements taken at 8 sessions divided into baseline phase
(A) treatment phase (B) and post-treatment phase (C)
The circles represent the unaffected side and the diamonds the affected side. On the affected side, the triplicate measurements
in each treatment phase (B1 to B4) represent pre- (-1), during (-2) and post-MWM (-3) measurements. Key points of interest are
the grip force during MWM application (i) and post-application (ii), both compared to pre-application for that same session, as
well as the pre-application grip force in subsequent sessions (iii) compared to baseline (A and B1-1). In this figure, B4-1 is the
first session at which the pre-MWM grip force is substantially higher than the baseline (iii), which we propose is a sign of an
adequate volume of MWM being applied by the practitioner and patient, taping and exercise. Figure adapted with permission
from Vicenzino & Wright 1995.[8]
and exercise over 3 weeks.[9] One of the univariate (and possibly the change in CSIM) in an initial MWM
predictor variables identified in this analysis was a application in increasing the confidence with which a
>25% improvement in pain-free grip force (CSIM) practitioner can choose an effective MWM treatment.
during the application of an elbow lateral glide MWM An important aspect of MWM is the application of
compared to pre-MWM application. However, this overpressure to the CSIM at the endpoint of the move-
was not retained in the final multivariate CPR model, ment, but only if pain-free. This overpressure has been
and it only represented a small effect size (positive strongly emphasised by Mulligan[1] and is regarded as
likelihood ratio [LR] of 1.5 [95% CI 0.78 to 2.9]), necessary in order to optimise the effectiveness of the
which translates to a small increase in probability of treatment. Either the patient or the therapist can apply
improvement from 79% to 85%. overpressure. Certain techniques require the patient
Interestingly, in the final CPR model, the pre-treat- to apply the overpressure because the practitioner has
ment CSIM (pain-free grip force) was a major determi- both hands otherwise engaged in the MWM. In these
nant of improvement in tennis elbow at 3 weeks. That circumstances the patient needs to have the process
is, the probability of improvement with this treatment explained to them prior to the application of the MWM
improved to 93% (LR 3.7 [95% CI 1.0 to 13.6]) when and have the capacity to understand and perform the
two of the following were present in a patient: (a) a overpressure. Additionally, specific techniques that
high pain-free grip force on the affected side (>112N); have an active weight-bearing (e.g. see Chapter 16)
(b) a low pain-free grip force on the unaffected side or include a gravitational effect (e.g. see Chapter 15),
(<336N); and (c) being younger than 49 years.[9] These thus effectively an overpressure component, require
preliminary findings need to be further explored both no manual application of overpressure and are often
clinically and through research. Nevertheless, the valuable techniques for a patient to perform as a self-
results do provide some support for the role of a CSIM MWM.
12
In overview, a fundamental rule of MWM for the sustainability of the effect over time. These fac-
painful conditions is that there needs to be a sub- tors can be considered the input parameters/variables
stantial positive change in the CSIM in terms of an of the mobilisation (or first ‘M’) part of the MWM
increased ROM or muscle force production to the (Figure 2.2).
onset of pain (Table 2.1) at the time of its application There are two reference points for these parameters
and immediately afterwards. The important matter (Figure 2.2). One is in reference to the description of
in this regard is the quantity of either the ROM or the input parameters, such as the amount (N) and direc-
force production obtained at the first perception of tion (degrees) of force. The other reference point is the
pain on the CSIM. CSIM and in particular how the parameters impact on
the CSIM, which is ascertained through changes in
For the MWM where there is pain at end of output. The interrelationship between these two refer-
range or on full strength contraction ence points is highlighted in a proposed algorithm out-
lined in Figure 2.3.
Instead of quantifying the ROM or force generated, in
this situation the patient reports their perception of pain Direction of force application
using VAS or NRS and the MWM should substantially The direction of force application is predicated on
reduce the pain to no pain or very little pain for it to be the best possible outcome of the CSIM at the time
of any use in treatment (Table 2.1). of application and initially afterwards, within that
treatment session. The direction of force application
When the MWM is being used in cases where refers to the direction of the accessory or passive
pain is not the problem physiological motion that the practitioner is seeking
to exert at the joint. For example, accessory motions
The CSIM would be used in much the same way as for may encompass medial, lateral, anterior and poste-
when pain is present, but the endpoint of the CSIM is a rior translations, traction and rotational joint forces,
quantity such as ROM or force generated (Table 2.1). with the latter constituting physiological motions at
some joints. It is uncommon that flexion/extension
Summary of Part 1 or abduction/adduction will be used as the mobilisa-
The CSIM is fundamentally the most critical element tion force. Any of these passively applied forces will
of the MWM because it connects the treatment effect be sustained while the patient undergoes a CSIM. It
to the patient’s specific problem. In doing so, it guides is interesting to note that of all the 25 MWM tech-
the application of the MWM in terms of the practitio- niques for peripheral joints specifically described
ner’s selection, modification and progression of the by Mulligan in his book (fourth edition), the lateral
various parameters of a technique. In this regard it is glide is mentioned 11 times (44% of all mobilisa-
vitally important that the practitioner understands the tions described) and appears to be the most favoured
concept of a CSIM and its endpoint for different clini- direction of choice. Transverse plane glides (56%) are
cal presentations (e.g. pain-limited function). The fol- more commonly recommended than glides in the sag-
lowing part of this chapter focuses on the applied force ittal plane (28%), which seems to be a characteristic
or the mobilisation element of MWM. feature of MWM that somewhat differentiates it from
other manual therapy approaches. While this should
PART 2: THE MOBILISATION ELEMENT OF only be seen as a record of Mulligan’s clinical obser-
MWM vations over the course of his practice, it still provides
novice practitioners with an expert opinion (from the
The parameters of the applied force vector, which is innovator of the techniques) regarding a starting point
the mobilisation element of MWM, will be discussed to their applications of MWM in individual patients,
herein under the separate categories of the direc- especially since there appear to be no other scientifi-
tion of force application, the amount of force being cally based guidelines for the direction of force appli-
applied, the possible interrelationship between direc- cation in MWM.
tion and amount of force, the locality of the force Apart from the recommended direction of force
application, the manner in which the force is applied application for a particular MWM described by Mul-
(e.g. manually, tape, treatment belt) and the overall ligan, the practitioner may also employ some other
volume. The overall volume is the sum total of all basic guidelines to select the initial mobilisation to
repetitions of the MWM applied by the practitioner use when first applying a MWM, such as the con-
and patient. We propose that manipulation of the cave–convex rule[10] or simply opposing the direc-
mobilisation force parameters, such as the amount, tion of the mechanism of injury. In applying any
direction and locality of the applied force, impacts joint glide the practitioner should also be aware of
directly on the immediacy of effect. Whereas varying the concept of the ‘treatment plane’, which is defined
the volume is considered to have more to do with as the plane that lies perpendicular to a line drawn
13
Mobilisation with Movement Pain threshold

• Increased ROM3
ROM • OP in full ROM
± pain-limited Not pain-limited (e.g. stiff)
• ROM endpoint to CSIM
Location of contact
• Increased ROM3
• Joint (local or distant to symptoms)
Input parameters
Output criteria2
• OP ± maximum muscle contraction
• Contact point on bone
Pain at end of range
Applied Force • Reduced pain
• Direction (gross, subtle) CSIM 1
• Level (amount of force)

• Overpressure (OP)
• How applied (manual, belt, tape)
Force generation
Pain threshold
• Isometric • Increased force3
• Isotonic/isokinetic Not pain-limited (e.g. weak)
• Increased force3
• Superimpose sustained contraction
Volume Volume parameters are more about sustaining the gains made on individual MWM
• Repetitions (e.g. 6-10)
techniques after their application whereas Location and Applied Force are manipulated
• Sets (1 initially)
with the express aim of improving CSIM during MWM application.
• Repetition: Rest (1: 0 to 1)
1. Client Specific Impairment Measure (CSIM) is the ‘Movement’ element of the MWM:
• Load must be consistent before and during MWM (e.g. same limb or body weight load, same weight lifted)
• Initial tempo of 1:0:1 in most instances (i.e. equal time getting to endpoint and return to start with no sustain at endpoint)
• Other less common CSIM may be single leg stance, joint position error or time to pain onset with isometric sustained force
2. One quantifiable endpoint must be identified (e.g. ROM to pain threshold (onset of pain), time to onset of pain in case of a
repetitive/hold task) and this applies to each repetition of a MWM
3. Substantial improvement, usually cited as between 50-100% improvement from pre-MWM quantity
Figure 2.2 Overview of a schematic definition of MWM in which the central feature is the CSIM or the
‘movement’ element of MWM and its output criteria (right column)
The input parameters of the ‘mobilisation’ element of MWM are listed in the left column. Pain threshold refers to measuring
some quantity of the task other than pain, such as ROM or force generated when the patient first feels the onset of pain. That
is, pain is not the variable, but rather the ROM or force generation are the key output criteria. Where pain is not the main limiting
feature of the patient’s problem then measures of pain, ROM, and force generated become the possible output criteria. From
these criteria, decisions can be made to modulate the input parameters (location and force in the left column, and volume in
the middle row above footnotes) of the mobilisation (first ‘M’ in MWM). Implicit in this flow chart is the iterative nature of MWM
applications.
from the axis of rotation of the convex member to glide direction to attain a better outcome, which may
the centre of the concave member of a joint.[11] An be achieved by fine-tuning the inclination of the lat-
example of the treatment plane is shown in Figure eral glide so that it is now slightly posteriorly inclined
2.4. It is believed that to be effective, all MWM will (~10° posterior to the frontal plane; see Figure 2.4(b)
be either applied parallel or perpendicular to this to visualise this, for an example). If this was a success-
treatment plane. ful refinement the squat would then be substantially
There are two important aspects to the direction of improved and the patient may be able to fully squat
force application: the gross (in foregoing paragraphs) with the application of the MWM. However, if there
and the subtle. For example, visualise that a practi- was no change on initial application of the lateral glide
tioner has applied a lateral glide of the tibiofemoral then the practitioner should consider changing the
joint in order to improve a pain-limited squat (limited gross direction of the force (e.g. perform a medial or
to one-third squat). On first performing the glide the posterior glide, or medial rotation), which would also
patient is able to go somewhat further but not by any be the case if the subtle changes in direction were inef-
substantial amount (e.g. one-third squat pre-MWM to fective.
half squat with the MWM applied). In order to seek a As MWM is a reasonably recent innovation there
larger effect, the practitioner may wish to modify the are limited detailed data in the literature regarding the
14
1
SESSIONS: ALL ALL AFTER FIRST
SESSION 1 BASELINE COMPARED TO: DURING MWM IMMEDIATE POST-MWM NEW BASELINE2
CSIM SUBSTANTIALLY IMPROVED: NO YES YES3 NO
MOBILISATION PARAMETERS TO VARY: 4

LOCATION ISQ or CHANGE ISQ
FORCE LEVEL INC ISQ
FORCE DIRECTION CHANGE ISQ
MWM VOLUME:
REPETITIONS 1 6-10
SETS 1 1 INC
SELF -TREATMENT - - YES5 YES
TAPING - - YES5 YES
IF NO CHANGE AFTER 4 WHEN 100% IMPROVED OR NO

CESSATION POINT: FURTHER IMPROVEMENTS POSSIBLE
ATTEMPTS
1. After completing a set of MWM repetitions always do a through range movement with the MWM applied, gradually easing out to the
end of range pain-free. Failure to do this commonly results in an exacerbation of pain when the patient first moves after the MWM.
2. If patient does not report 100% recovery (to the extent that is possible for their condition) with the application of only one type of
MWM technique (usually applied over several sessions) then consideration needs to be given to new MWM techniques being additionally
applied, possibly at other locations also (e.g. spine for peripheral problem, or adjacent joint).
3. Care should be exercised at the first session as it is commonly reported that a rebound effect (worsening in ensuing 24-48 hours) may
occur if Volume is too great.
4. In all MWMs with ROM as an endpoint criterion, overpressure is applied. This overpressure may be passive as in pain-limited ROM or it
may be a maximal contraction in cases of stiffness or weakness limited ROM.
5. This is not always the case following first sessions, but depends on how successful the MWM was, how well the patient can learn the self-
treatment and if tape was possible to apply. After the first session, if the patient is very much better (which occurs in some) then self-
treatment and tape may not be required.
Figure 2.3 An overview of a proposed decision matrix that can be incorporated in the clinical reasoning pro-
cess for the application and progression of MWM in one session and across a number of sessions
For within session decisions on application and progression, the clinical reasoning process largely relies on the response during
and immediately post-MWM application compared to that session’s pre-application CSIM, whereas for ensuing sessions the
pre-application CSIM is compared to the first session’s baseline (pre-application) CSIM. Whether or not the CSIM is substantially
improved or not will dictate whether changes will be made to the parameters of the MWM and the exact nature of those changes
if required. Parameters such as location, level and direction of force are modulated to effect changes during application, whereas
volume parameters are usually manipulated to maintain or improve on the post-MWM CSIM, either within or between sessions.
As a general guide, a successful MWM session appears to usually involve 1 to 3 sets of 10 repetitions but the exact volume for
any individual can only be determined with certainty by using the post-application CSIM response.
contribution of the direction of the force application old female with a 7-month history of base of thumb
to improving the CSIM. In a study of 25 patients with pain following a fall, Hsieh et al[13] reported that
tennis elbow, Abbot et al[12] showed that 19 patients only the MWM that used a supination glide of the
responded with greater pain-free grip force when proximal phalanx effected a pain-free full range
the lateral glide MWM was applied in a pure lateral of flexion of the first metacarpophalangeal joint,
(n = 9) or slightly (~5°) posterior of lateral direction whereas MWMs with either a medial or lateral glide
(n = 10), as opposed to slightly anterior or caudal component did not improve flexion (see Chapter 14).
of lateral (n = 6). In a single case study of a 79-year Teys et al[14] assessed the effect of a shoulder MWM
15
in 24 patients with pain-limited shoulder elevation Amount of force application

and reported that the MWM with a posterior glide The initial change in CSIM is determined to some
of the humerus produced a significantly greater extent by the amount of force that is applied during the
improvement in shoulder elevation (~10%) than a MWM. There is preliminary evidence that there may
sham anterior glide MWM of the humerus. Interest- well be a threshold of force application that governs
ingly, there is some evidence for shoulder manipula- the outcome in the CSIM. McLean et al[16] evaluated
tions (not MWM) that suggests that the direction of the effect of four incremental force level applications
the manipulation of the humeral head significantly on pain-free grip force in six tennis elbow patients
impacts on the gains in ROM and pain reduction (Figure 2.5). They used a flexible force mat to measure
after treatment.[15] the force applied by the practitioner during the manual
The gross direction of force application during a application of a lateral glide MWM of the elbow. The
MWM and the subtle variations thereof, which have practitioner estimated three force levels (a third, half
been long advocated by Mulligan, appear to be critical and two-thirds of his maximum force application) and
in the successful application of a MWM. Practitioners applied these and the maximum force application in
should consider varying this parameter in improving a random sequence. The data showed that there was
outcomes. a substantially greater pain-free grip force production
Po
glid steri
e d or-a
ire nte
cti ri n
on or ctio
ation dire
f rot de
Axis o dial gli
ne ral-me
en t pla Late
tm
Trea
Centre of tibial plateau
rior
ith poste
Lateral w o n g li d e
inclinati
A
B
Figure 2.4 Treatment plane
(a) The treatment plane defined with reference to an example at the tibiofemoral joint. The treatment plane is perpendicular to a
line drawn from the centre of rotation of the femoral condyles (convex member) to the centre of the tibial plateau (concave mem-
ber). Glides and rotations that occur in this plane are thought to be the most mechanically effective.
(b) Demonstrates fine-tuning of a lateral glide with a slight posterior inclination with the filled in circle representing the contact
point and the arrow the direction. Note how the contact point and application will be modified when fine-tuning the direction. (Ben
Soon drew these images)
16
at the higher two levels of force (approximately 30% Relationship between direction of force
greater) than at the lower level (37 N). Interestingly, and amount of force applied
there was very little difference between maximum
(mean force 113 N) and two-thirds maximum (75 N) In setting up a MWM technique, practitioners should
force application on pain-free grip force production. To satisfy themselves that they sense that accessory joint
our knowledge this is the only study to have evaluated play has occurred from the application of the accessory
the impact of varying the amount of force application joint glide prior to the patient trying the CSIM. This is
on MWM effects. Even though it is a small prelimi- an immediate feedback that a practitioner seeks at the
nary study it does alert the practitioner to be aware of moment of the application of a joint mobilisation and
the need to ensure that adequate force is being applied provides the earliest affirmation that a joint mobilisation
with MWM, such that if the effect on the CSIM is not technique will have a chance of being effective. The fol-
substantial with MWM application, the practitioner lowing is a conceptual framework (Figure 2.6) that will
should consider if they have applied sufficient force. help illustrate how a practitioner may optimise effecting
This may occur where the patient is relatively large accessory joint play during the application of a MWM.
or has very stiff connective tissues and the practitio- In the previous sections of this chapter we described
ner is relatively small (small hands) or lacks sufficient separately the direction and the amount of applied force
strength, in which case the use of treatment belts may as being important in optimising the effect of a MWM
assist the practitioner in delivering a therapeutically technique. However, the amount of force applied is
effective force level (e.g. see Figures 1.2b, 5.3, 13.4 likely not independent of the orientation/direction of
and 17.2). Alternatively, if the effect on the CSIM is the glide. The successful manual therapy practitioner
substantial then the practitioner could consider if less will need to appreciate the interdependent relationship
force would still achieve this effect. Feasibly less between direction and amount of force applied in a
force reduces the risk of any side-effect of the treat- MWM technique. Above we previously described the
ment affecting the soft tissues. Along these lines, it is treatment plane geometrically, but its practical clini-
prudent to always commence a MWM with a lower cal utility for practitioners is in conceiving the treat-
level of force, especially soon after injury or in cases ment plane as that plane in which the applied MWM
of high pain intensity. That is, the least force required glide effects most joint motion with least applied
to achieve the desired effect on the CSIM should be force. A schematic representation of this can be seen
the aim. (See the following section for a conceptual in Figure 2.6 in which force is hypothesised to expo-
framework on this.) nentially increase as the practitioner applies the force
increasingly out of the treatment plane. An additional
dimension can be seen by the integration of the force
threshold curve reported by McLean et al[16] (Figure
35 2.5), such that for any orientation/direction of the glide
there is likely a different outcome in CSIM that is
25 dependent on the amount of applied force.
113 N
75 N Location of applied force
15 The location of applied force for MWM is not unlike
that for other manual therapy applications in that there
is a notion that the therapeutic effects are optimal
% PFGS
5 when the force is applied at the most appropriate loca-

tion. Similarly, good general joint handling skills are
-5
56 N required in the application of MWM to optimise the
effects; for example, using manual contact points near
the joint line. Some of the other aspects that need to be
-15 considered in order to appropriately apply a MWM are:
37 N • localisation/identification of the joint to be mobil-
ised, for example, should the neck or shoulder be
-25 treated for proximal arm pain, or should an individual
100 66 50 33
bone, such as the scaphoid, be targeted as opposed to
Force Levels (% maximum ) several carpal bones at the wrist being targeted as a
functional wrist articulation
Figure 2.5 A higher-order Bèzier curve approximat- • deciding which bone is to be stabilised and which is
ing the relationship between applied manual force of to be moved
a MWM and the percentage change in pain-free grip • the direction of the applied glide as this will dictate
strength (% PFGS). Adapted from McLean et al.[16] the contact points
17
• the amount of tenderness at the contact point may then on the basis of ongoing clinical re-examination
necessitate a slightly different contact point be used, and reasoning (e.g. see Jones et al[17] and Chapters
although a foam pad can also sometimes be useful in 8–19). As a general rule in orthopaedics the joints
reducing contact point tenderness above and below the one at which the patient is report-
• how fine or gross should the contact point be. ing problems should be considered in examination and
As for many approaches in musculoskeletal health- as a possible location for treatment to be applied. In
care, the practitioner clinically reasons the resolu- manipulative therapy, it is common practice to also
tion of these aspects following an examination of the consider the spine as the possible origin of peripherally
patient prior to first delivering a MWM treatment and located symptoms. For example, in managing someone
with tennis elbow with MWM, the practitioner needs
to consider not only the elbow, but also the neck as a
potential site from which pain has been referred and
Applied at which a MWM may need to be applied to achieve
Force (N) complete resolution of the patient’s problem. Once a
joint and general direction of mobilisation is chosen,
Key the MWM is applied once and then on the basis of the
Maximum force applied by practitioner response in CSIM (as per the algorithm in Figure 2.3).
Optimal change in outcome If there is not a substantial improvement in the CSIM
(66% of maximum force) then further refinement of the location may need to
occur in order to continue performing the MWM or in
No change in outcome
order to optimise it further. Alteration of the location of
(50% of maximum force)
contact may also need to occur on the basis of a change
Negative change in outcome in mobilisation direction (see Figure 2.4b), with the
(33% of maximum force) extent to which it will change varying, depending on if
it is a gross or fine change in direction.
Most of the foregoing is based on clinical reasoning
and a biologically plausible but indirect rationale. Not-
withstanding this, there are some preliminary reports
that support the notion that localisation of a manual
technique is important in terms of its induced effects.
One such report studied the effect of a lateral glide
MWM for tennis elbow,[18] which is similar to that
reported in Chapter 13. The lateral glide MWM was
compared to a sham intervention in 24 patients. The
sham intervention consisted of a firm pressure to the
elbow that mimicked the force applied by the MWM,
but with contact points on both the medial and lateral
In the Treatment Plane Out of the Treatment Plane ulna, radius and humerus, which is different to the spe-
cific contact points in a lateral glide MWM (i.e. ulna
Glide Orientation / Direction
on medial side, humerus on lateral side). The specifi-
Figure 2.6 Four curves showing a hypothetical rela- cally applied lateral glide MWM produced effects that
tionship between the amount of force in Newtons were in the order of five times larger than the sham
applied by the practitioner, and the accessory glide treatment.
orientation of the mobilisation (from within the treat- In terms of spinal MWM (SNAG), locating the exact
ment plane to out of the treatment plane) or at least the most appropriate spinal segment to apply
Applied force increases exponentially the further out of the the MWM force is usually deemed to be important if
treatment plane the practitioner directs the technique, such
not essential. We are not aware of any research that
that practitioners should trial (‘tweak’) the glide orientation/
direction to find the one for which least force is required. has directly studied this aspect of MWM, but there are
Additionally, for any given application of a MWM, the applied several investigations that have looked into other pos-
force–outcome relationship (see Figure 2.5) also varies in a tero–anterior (PA) mobilisation techniques.[19–21] Chi-
characteristic way, hence the superimposition of 6 force-out- radejnant et al[19] evaluated the specificity of applying
come higher-order Bèzier-like curves, which show that for any accessory glide mobilisations (central and unilateral
given treatment application the practitioner should be aware PA, transverse) to the upper and lower lumbar spine of
that there is likely a range of force levels with differential
outcomes on the CSIM (from negative to optimal outcome).
140 patients with low back pain by two manipulative
That is, practitioners will find that there is an accessory glide therapists. While these investigators reported that the
direction that will deliver an optimum outcome without over- effect on patient outcomes was no better for the thera-
loading the joint or being ineffectual. pist-selected spinal level than if randomly selected, they
18
did find that there was a greater analgesic effect gained We interpret this as supporting the contention that the
from the application of the mobilisations to the lower volume of the applied MWM is not relevant to its ini-
lumbar spinal levels (L4–L5). This appears to support tial effect.
the view that the area of pain and its qualities/charac- From our clinical experience and the collation of
teristics, which are obtained through patient interview the above data we hypothesise that the volume of the
rather than by manual examination, play an important MWM treatment pertains more to the sustainability of
role in selecting the region of the spine that should be the effect (i.e. over two or more sessions) rather than
targeted by the MWM. In applying this clinically, after the initial effect, which appears to be better modulated
the interview, from which the practitioner has ascer- through manipulation of magnitude, direction and
tained a region of the spine that is likely the best to location of force application parameters. That is, the
target (i.e. narrowed down the range of possibilities to manipulation of the volume parameter should be seen
2 or 3 motion segments), it appears reasonable that an more in light of a mode of progressing MWM treat-
iterative approach as outlined in Figure 2.3 is employed ments in order to sustain an effect rather than exacting
to determine the most effective MWM to apply (loca- a larger magnitude of effect (Figure 2.3).
tion being one of the variables that can be manipulated We propose that the manner in which the practitio-
in this regard). That is, the MWM technique itself can ner manipulates volume (repetition and sets) is deter-
be used to fine-tune the localisation of the segment to mined by taking into account primarily the change
which the force is most effectively applied. in CSIM from pre- to post-application of the MWM
(Figure 2.3). For example, the case described in Fig-
HOW MUCH MWM IS REQUIRED? ure 2.1 shows that initially after application of the
lateral glide MWM there was a substantial change
The amount of MWM that is applied may be conceptu- (improvement to 150N) compared to the pre-MWM
alised as a volume, which is defined as the sum total of pain-free grip force of 50N (unaffected side ~200N),
all MWM applications that a patient experiences. The which we suggest is an indication to the practitioner
volume of MWM consists of the MWM that is per- that sufficient MWM volume was administered at that
formed by the practitioner as well as that which the session (Figure 2.3). However, let us assume that a set
patient does in self-treatment. This is reasonably easy of 6–10 repetitions had made a substantial improve-
to quantify by multiplying the number of repetitions ment in the CSIM during the application of the MWM,
per set by the number of sets of a specific MWM com- but that this was not maintained immediately after the
pleted over a period of time. The application of tape is application of the MWM; for example, lets say it was
also considered another way of extending the amount/ 75N after MWM application. In this situation it would
volume of MWM experienced by the patient, but it is
relatively less quantifiable and in most cases is only
worn for a day or two per application.
In contrast to the studies of the initial effects of level 60
and direction of force application on the CSIM, pre-
% change from baseline
liminary as they may be, there is no study yet of the 50

initial effect of manipulating volume in a MWM.[22]
In order to get a sense of the relationship between the 40
amount or volume of a MWM delivered and its ini-
tial effect, we conducted an analysis of all relevant 30
papers,[4, 14, 18, 23–28] by selecting from the results of the
comprehensive search strategy in Chapter 3 only those 20
papers that reported: (1) a study of initial effects; (2)
sufficient data to calculate a percent change score; and 10
(3) enough information to allow a volume (number of
total repetitions) of the MWM to be determined. The 0
0 5 10 15 20 25 30 35
data from this analysis is collated in Figure 2.7. What
Figure 2.7 highlights is that there appears to be no Volume
relationship between volume and the initial effect of a Figure 2.7 Initial effect (y-axis) by volume (x-axis;
MWM (R2 = 0.063) when we collapse data from tennis total number of repetitions performed) plot for MWM
elbow[18, 25–27, 29], ankle[4, 23, 24, 28] and shoulder[14] stud- for tennis elbow (diamond; pain-free grip force)
ies as well as include both force and ROM data (and [18, 25–27, 29], ankle (circle; ankle range of motion)
represent point estimates of effect as a percent change [4, 23, 24, 28] and shoulder disorders (square; shoulder
from baseline). The highest degree of association was range of motion) [14], highlighting a lack of associa-
observed when we examined only the force data for tion between the amount of MWM applied in a ses-
tennis elbow (R2 = 0.12), but this was still very small. sion and the immediate effect size
19
appear reasonable to apply more MWM or, in other first session. For example, this can be seen in Figure
words, increase volume by repeating the MWM for 2.1 (iii) in which there was a sizeable elevation (~50–
another two or three sets in order to seek to sustain 100%) in pain-free grip force from the baseline mea-
the effect. A recent review highlighted that there has sure of the first to that of the fourth session. Notable
been no systematic evaluation of the most appropriate in this case study is the lack of change in the baseline
volume of MWM, but that 86% of papers published CSIM in the second and third sessions. Guided by
on case studies and clinical trials of MWM roughly this response the practitioner gradually increased the
followed Mulligan’s initial recommendation of three volume of the MWM treatment by adding in MWM
sets of 10 repetitions, with some studies using one set self-treatment and elbow taping (see Chapter 13 for
and others four.[22] The implementation of a MWM techniques). Essentially, if the baseline CSIM at sub-
self-treatment program along with the addition of a sequent sessions is not substantially improved, then
MWM taping technique should also be considered in the volume of the MWM should be progressed by
this regard. increasing the repetitions and sets performed, but
There is one caveat on increasing the volume in remember this only applies if the MWM produces
the manner described — that it is not uncommon for substantial changes during and immediately after a
patients to experience a rebound effect within the 24– MWM application. Additional consideration should
48 hours after their first session, especially in those be given to adding patient MWM self-treatment and
with a severe or irritable disorder, but also in those taping. Typically 4–6 sessions are required to grad-
who have a remarkably substantial improvement in ually ramp up the volume of MWM, but this will
that first session. This is an often repeated caution- vary from patient to patient. Failure to improve the
ary message.[1] An example is seen at measurement baseline CSIM over such a treatment period could
period B2-1 in Figure 2.8 [8] which shows a rebound be taken to indicate that the MWM should not be
to pre-treatment baseline values in the pain visual continued.
analogue scale (VAS) during the 48 hours after the In comparing the ensuing sessions’ baseline to
first application of MWM. At the second session (B2) the first baseline CSIM, it is important to keep in
the patient expressed her unhappiness at continuing mind other factors that are not within the MWM
with treatment if this was to be a common outcome treatment program. For example, overall physical
following treatment and required quite a deal of reas- activity levels or any unintentional events (such as
surance to continue with this treatment. In this case an unexpected increase in pain-provoking tasks),
it was fortunate that the patient did actually return as well as patient compliance with and adherence
to express such a sentiment; she could have eas- to effective self-treatment. These would need to be
ily not bothered. Withdrawing from the treatment considered on an individual case-by-case basis and
would have been counterproductive in this instance they may also impinge upon the decision to continue
as the patient subsequently demonstrated an excel- with MWM treatment or to modify it by addressing
lent response to the MWM program of treatment, the various other parameters, as well as modulating
underpinning the importance of being somewhat cau- volume.
tious and not overly ambitious in the first session. It
is prudent for the practitioner to warn the patient of SELF-TREATMENT ISSUES
the possibility of an exacerbation and to reassure the
patient that, should this occur, it is only transient. Another element of MWM application that is required
Whilst it is important to consider the possibility of for the majority of patients (i.e. those who are not com-
a flare up after the first treatment session, it is more pletely recovered after a session or two with the practi-
important to ensure that the patient receives an ade- tioner, see Figure 2.3) is self-treatment in order to ensure
quate volume of MWM at follow-up sessions, which complete ongoing resolution of their condition. As out-
in the majority of cases requires considerably more lined above, the volume of MWM experienced by the
than 6–10 repetitions. patient is likely to be a large driver of the sustainabil-
While change in the CSIM after the treatment ity of the MWM effects and, as such, repetition of the
application can be used as a guide to determining the MWM will often require the patient to self-treat, which
required volume of MWM, comparison of the base- will necessitate their cooperation. The patient needs to
line CSIM with that over ensuing sessions can also cooperate in several ways, the most fundamental being
be used to monitor the sustainability of the effects an ability to effectively apply the MWM and then to
gained from the MWM, in addition to the effect of diligently repeat the application at a volume that has
any self-treatments and taping that has been insti- been determined in collaboration with the practitioner.
tuted. We propose that it is reasonable to determine The patient’s ability to effectively apply the self-
that an adequate volume of MWM has been reached treatment MWM can be assessed in the same way as
when the baseline CSIM for a given treatment ses- the practitioner has been directed herein and in the pre-
sion changes substantially from the baseline of the vious chapter; that is, by using the CSIM to quantify
20
10
Pain Function
9
8
Visual Analogue Scale (cm)
0
A1 A2 B1-1 B1-2 B2-1 B2-2 B3-1 B3-2 B4-1 B4-2 C1 C2
Measurement Periods
Figure 2.8 Example of a rebound effect (hollow triangle and dashed line at B2-1) within 48 hours of treat-
ment
Visual analogue scale (VAS) for pain (triangle, where 10 is worst pain and 0 is no pain) and function (circle, where 10 is normal
function and 0 is ‘arm in sling’) for a single case of tennis elbow. B represents a 2-week period in which 4 treatment sessions
were delivered (number immediately after B is the treatment session number) with the last number in the B phase representing
either pre-MWM (-1) or post-MWM (-2). A and C are no treatment (representing baseline) and post-treatment phases, respectively.
Figure adapted with permission from Vicenzino & Wright 1995.[8]
the effect of the self-MWM. While it may not be fea- Compliance and adherence to the self-treatment set
sible or realistic for the patient to reproduce the same by the practitioner is essential in ensuring the success
magnitude of the effect that the practitioner is able to of MWM. This is not unique to MWM but there are
bring about, it is futile to have a patient repeating a some unique features of MWM that can be used to
self-administered MWM that does not effectively facilitate high levels of compliance and adherence.
change the CSIM in any meaningful way. One of the unique features is that the MWM has a
Strapping tape that is applied in a manner that seeks built-in feedback mechanism (i.e. performance on the
to replicate the manually applied MWM (i.e. applied in CSIM) through which the patient and practitioner can
a similar direction to the mobilisation) is another strat- judge the compliance of the patient in performing an
egy that is frequently employed to extend the therapeu- effective self-application of the specific MWM. The
tic effect of the practitioner delivered MWM. Taping immediacy of feedback on performance of the MWM
relies on the patient being able to tolerate the adhesive with respect to the CSIM and the substantial size of the
without allergic reaction as much as it relies on its skil- effect are both very strong drivers of ‘buy in’ by the
ful application, which in most instances is best accom- patient and are critical to seeding a positive attitude in
plished by a practitioner and not the patient. Similar complying with the self-MWM approach. Adherence
to the self-administered MWM, the tape should have to a self-MWM protocol can be encouraged by struc-
some demonstrable effect on the CSIM if it is to be turing the clinical encounter in such a way that the
used as part of the treatment plan. patient becomes implicitly aware of the importance of
21
the self-treatment. For example, at follow-up sessions the CSIM endpoint is the onset of pain (pain
after the self-MWM has been given to the patient, threshold). That is, the CSIM will measure either
the very first thing that should be examined by the ROM of a joint or amount of force output of a
practitioner is the patient’s ability to perform the muscle to the onset of pain – not pain on a rating
self-MWM. Typically this would involve the patient scale.
performing the baseline CSIM test followed by the • The parameters of the applied manual force, such
self-MWM. The practitioner would then have two key as location, force level and direction of force, can
bits of information that will establish the basis for that be modified to improve the outcome as quantified
treatment session: one being a comparison to the base- by the CSIM and should be used in an iterative
line measurement for the first session and the other manner in the selection of the most effective
being an indication of the patient’s ability to effec- MWM.
tively repeat the self-MWM which was taught in the • The volume or amount of a MWM applied,
previous session. inclusive of that applied by the practitioner in the
clinic and that self-administered by the patient,
INTEGRATION WITH OTHER TREATMENTS will usually need to be modified (often increased)
in order to:
AND FUNCTION
• sustain beyond the treatment session the
As is the case with many other physical treatments, effects on the CSIM of a successful MWM
gained within a treatment session
once the patient is experiencing improved capacity
to move, be it due to relief of pain, increase in ROM, • gain a substantial improvement in the pre-treat-
improvement in strength or combinations thereof, it ment CSIM at subsequent sessions.
is frequently beneficial to include other treatments, • While it is currently difficult to provide
often in the form of exercises (e.g. strengthen- evidence-based data on the volume required
ing, endurance, functional, etc). This integration of for a successful MWM treatment program, it
is generally recognised that several sets of 10
MWM with other forms of treatment can be under-
repetitions are required in the clinic to gain long
taken in much the same manner as described for the lasting effects.
application of a MWM, by an iterative approach of
• If on attempting to apply a MWM it is
assessment/re-assessment and intervention to guide unsuccessful, no more than four attempts at trying
the latter. to make the MWM work should be entertained.
An unsuccessful MWM in this case being defined
SUMMARY as a lack of substantial improvement in the CSIM
at the time of application. This definition assumes
In this chapter we operationally defined MWM in that the MWM is not making the condition worse;
terms of a set of parameters and provided the reader if it was the MWM would be immediately ceased.
with some guidelines on how these parameters may
be manipulated in order to optimise treatment effects.
We emphasised that the practitioner will usually be
able to ascertain if, when, what type and how much References
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elucidated upon herein, some of which have some vices 1999.
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Maitland’s Vertebral Manipulation (7th edn). Sydney:
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KEY POINTS low back pain. Journal of Manual and Manipulative
• The Client Specific Impairment Measure (CSIM) is Therapy. 2006 Jul 22;14(2):95–100.
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• Clear identification and specification of the CSIM of two Mulligan mobilisation with movement treat-
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• It is critical to the success of the MWM that in
Sports Medicine Australia; 2001. Online. Available: http
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contraction of a muscle or muscle group) that
(accessed 21 April 2010).
22
5 Crossley K, Cowan SM, Bennell KL, McConnell J. 19 Chiradejnant A, Maher CG, Latimer J, Stepkovitch
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evidence? Manual Therapy. 2000;5(3):142–50. selected’ mobilisation techniques for the treatment of
6 Hahne AJ, Keating JL, Wilson SC. Do within-session low back pain: a randomised controlled trial. Australian
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Australian Journal of Physiotherapy. 2004 Jan 1; Does the choice of spinal level treated during postero-
50(1):17–23. anterior (PA) mobilisation affect treatment …. Physio-
7 Tuttle N. Do changes within a manual therapy treatment therapy Theory and Practice. 2002;18:165–74.
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8 Vicenzino B, Wright A. Effects of a novel manipulative ment of the cervical spine following manual therapy
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9 Vicenzino B, Smith D, Cleland J, Bisset L. Development sation with Movement: A review of the tenets and
of a clinical prediction rule to identify initial responders prescription of MWMs. New Zealand Journal of Physio-
to mobilisation with movement and exercise for lateral therapy. 2008;36(3): 144–64.
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math.2008.08.004. Mulligan’s mobilization with movement technique on
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Joints, Basic Examination and Treatment Techniques. Therapy. 2004 May;9(2):77–82.
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12 Abbott JH, Patla CE, Jensen RH. The initial effects of algesia and sympathoexcitatory effects of mobilisation
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13 Hsieh CY, Vicenzino B, Yang CH, Hu MH, Yang C. Naloxone fails to antagonise initial hypoalgesic effect
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14 Teys P, Bisset L, Vicenzino B. The initial effects of a induced by elbow manipulation in chronic lateral epi-
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15 Johnson AJ, Godges JJ, Zimmerman G, Ounanian changes in posterior talar glide and dorsiflexion of the
LL. The effect of anterior versus posterior glide joint ankle after mobilization with movement in individuals
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23

SECTION TWO
Efficacy
Chapter 3
A systematic review of the efficacy of MWM
Leanne Bisset, Wayne Hing and Bill Vicenzino
INTRODUCTION The aim of this chapter is to synthesise the evidence

The ability of Mobilisation with Movement (MWM) for the efficacy of MWM techniques. It achieves this
techniques in generating hypoalgesic effects, increas- through a systematic review of the literature about the
ing joint range of motion (ROM), enhancing muscle effects of MWM techniques on clinically relevant out-
function, as well as more specifically, treating par- comes for musculoskeletal conditions. There is a focus
ticular pathologies or post-trauma treatment has been on defining and providing information on the levels of
reported in a number of studies of varying quality.[1–6] evidence, quality issues and how this is reflected in the
Studies applying MWM techniques to the shoulder, literature on MWM techniques. This chapter does not
elbow and ankle have shown them to be effective in deal with potential mechanism(s) of action of MWM
reducing pain and increasing joint ROM immediately effects, nor of the effects of MWM, which are dealt
during and after their application, though the main with in Chapters 4–7, but rather this chapter deals with
focus has been to the upper limb joints.[1, 6, 7] Despite the clinical efficacy of MWM.
a number of studies reporting the clinical effects of
MWM, we are not aware of any systematic reviews METHODS
that have summarised the evidence for this technique’s
clinical efficacy. Search strategy
In order for practitioners to make informed deci- One reviewer searched the full set of the follow-
sions about whether a treatment for a particular condi- ing databases to 21 October 2009, without language
tion is truly effective, all the available evidence must restrictions, using the recommended Cochrane Library
be evaluated and summarised. There is variety in the search strategy: MEDLINE, CINAHL, Web of Science,
quality of evidence presented in the literature and it is SPORTdiscus, and Physiotherapy Evidence Database
therefore important to be informed as to the level of (PEDro).[13] The Cochrane Controlled Trial Register
evidence achieved by a particular study or review.[8] was searched for RCTs on MWM, and references from
A randomised controlled trial (RCT) represents a high retrieved articles and systematic reviews were also
level of evidence, as does a meta-analysis or a sys- screened. The refined key terms included Mobilisation
tematic review, but it is not to say that lower levels with Movement* OR mobilization with movement*
of evidence, such as an observational study or a case OR MWM*; manual therapy AND (mobilisation* OR
report, are not also important and included in system- mobilization*); mulligan; mulligan mobilisation* OR
atic reviews where insufficient RCTs have been pub- mulligan mobilization*. In addition, cross referencing
lished.[9–11] For example, nascent physical therapies was undertaken through communication with experts
are often initially described through case reports and in the field.
case studies, prior to undergoing preliminary evalua-
tion through case series or controlled trials of initial Selection
effects before any RCT is undertaken. However, for For this systematic review we included all studies
a therapist to be confident that a particular treatment that met the following conditions: participants with
approach, such as MWM, will be effective in the man- a diagnosis of a musculoskeletal condition, as con-
agement of their individual patient, the highest levels firmed by a clinical diagnosis and/or other investiga-
of evidence are required. Equally, if the evidence for tions (e.g. radiographic), and who were treated with
a particular treatment depends only on a few obser- a MWM technique. Studies that included other treat-
vational studies, it should not be seen as having been ments in addition to MWM were also included as the
proven to be effective. The level of evidence supplied multi-modal approach is standard in contemporary
by a particular study or review can be rated using the physiotherapy. A MWM technique was defined as
Oxford Centre for Evidence-based Medicine Levels of any passive joint mobilisation that was applied and
Evidence (see Table 3.1; Phillips et al[12]). sustained during a passive or active movement of
26
3 • A systematic review of the efficacy of MWM
Table 3.1 Levels of evidence, adapted[12] Quality assessment

All articles included in this review were ranked accord-
Level Therapy/prevention, aetiology/harm ing to the Oxford Centre for Evidence-based Medicine
1a SR (with homogeneity*) of RCTs Levels of Evidence.[12] As non-randomised trials were
1b Individual RCT (with narrow Confidence Interval)
also included, the Quality Index[14] was used to evalu-
ate the quality of the studies. The Quality Index is a
1c All or none§ checklist that can assess the methodological quality not
2a SR (with homogeneity*) of cohort studies only of randomised controlled trials but also non-ran-
2b Individual cohort study (including low quality RCT; domised studies (Appendix 3.1). This checklist has pre-
e.g., <80% follow-up) viously been shown to provide a profile of an individual
2c ‘Outcomes’ Research; Ecological studies paper, alerting reviewers to its particular methodologi-
cal strengths and weaknesses. On average, the Quality
3a SR (with homogeneity*) of case-control studies
Index has been shown to have high internal consistency
3b Individual case-control study (Kuder-Richardson 20: 0.89), test-retest (r 0.88) and
4 Case-series (and poor quality cohort and case- inter-rater (r 0.75) reliability.[14] The Quality Index con-
control studies§§) sists of five categories including reporting (/10), external
5 Expert opinion without explicit critical appraisal, validity (/3), internal validity (bias) (/7), internal validity
or based on physiology, bench research or ‘first (confounding or selection bias) (/6) and power (/1), total-
principles’ ling 27 criteria. Two experienced raters (LB and NC)
RCTs = randomised controlled trials; SR = systematic rated all papers independently and blind to each other.
review. Both raters were also blind to the name of the authors,
* homogeneity = a systematic review that is free institution and journal, as these identifying features were
of worrisome heterogeneity in the directions and removed prior to rating.[15] Disagreement on any criterion
degrees of results between individual studies. Studies
displaying worrisome heterogeneity should be tagged
was re-assessed by both reviewers and any disagreement
with a ‘-’ at the end of their designated level. that was unresolved by general consensus was taken to a
§ Met when all patients died before the Rx became third reviewer (BV), who was independent to the initial
available, but some now survive on it; or when some deliberations, and a final consensus was reached.
patients died before the Rx became available, but Each criterion was accompanied by a strict descrip-
none now die on it. tive list and was rated either ‘yes’, ‘no’ or ‘unable to
§§ Poor quality cohort study = one that failed to clearly
determine’ to minimise ambiguity. Each criterion was
define comparison groups and/or failed to measure
exposures and outcomes in the same (preferably then given a score: yes = 1 point, no = 0 point, unable to
blinded), objective way in both exposed and non- determine = 0 point; except for criterion 5, which scored
exposed individuals and/or failed to identify or a maximum of 2 points (Appendix 3.1). A total score for
appropriately control known confounders and/or the methodological quality of each study was calculated
failed to carry out a sufficiently long and complete by summing up the number of positive criteria (maxi-
follow-up of patients. Poor quality case-control study mum score of 28). The last item in this tool, regarding
= one that failed to clearly define comparison groups
and/or failed to measure exposures and outcomes
the power of a study, was modified due to its complex-
in the same (preferably blinded), objective way in ity.[16] While all studies were included in this review,
both cases and controls and/or failed to identify or data pooling for further meta-analyses were limited to
appropriately control known confounders. studies rating 50% or more (>14/28) in order to ensure
adequate methodological quality and reliable interpre-
tation of results. It has been previously shown that the
inclusion of poorer quality studies in a meta-analysis
may alter the estimate of benefit and therefore may alter
the joint or contraction of muscles. By definition, the the interpretation of the effect of an intervention.[17]
studies also required the use of one clinically relevant
outcome measure, such as pain, grip strength or range Inter-rater reliability
of movement, however studies with no data were still Inter-rater reliability was evaluated by reporting the per-
included in the review process. Non-randomised tri- centage of initial agreement and the Kappa statistics, both
als were also included as there are very few RCTs for overall agreement as well as for each criterion.[18]
published on this emergent therapy.
Abstracts of papers identified by the search strat- Data management and statistical
egy were screened for inclusion by one reviewer analysis
(LB). If there was any indecision, the full text was
retrieved and reviewed by three reviewers (LB, WH, Key data such as participant characteristics, descrip-
BV). A full copy of all identified articles was then tion of the treatments given, outcome measures used
retrieved. and results were extracted from all articles. Summary
27
data, where available, was extracted and if the stud- 28 points (criterion number 5 awarded a maximum of
ies were clinically homogeneous, then a meta-analysis 2 points).
was performed using RevMan 5.0[19] to provide an Following rating by reviewers, 17 studies (Table 3.3)
overall effect estimate for each comparison. If the scored above the a-priori minimum quality score of
study compared at least two groups, the between group 50% (i.e. 14 out of 28 points) to be included in further
Standardised Mean Difference (SMD) with 95% confi- meta-analyses, where possible. The most common fea-
dence intervals (CI) (SMD; 95% CI) and Relative Risk tures of the studies that rated less than 50% were the
(RR; 95% CI) were calculated on a random effects lack of a control group, lack of randomisation and lack
model. A positive SMD represents an effect in favour of blinding. All of the poorer quality studies were single
of the intervention, with values greater than 0.8 con- case studies, except for five studies: Manchanda and
sidered a large clinical effect, 0.5 a moderate effect and Grover[23] and Naik et al[24] were RCTs, Kochar and
0.2 a weak effect.[20, 21] To rate clinical significance Dogra[25] was a quasi-randomised trial and Abbott[7]
for the RR, we followed Smidt et al[22] and set it at and Merlin et al[26] used a single group pre- post-test
0.7 as favouring the placebo/control group and 1.5 as design (Table 3.3 — quality rating results).
favouring the intervention. Where possible, the mean As illustrated in Table 3.4, cross-over RCTs in which
change scores and standard deviations of the change participants acted as their own control achieved the
scores were used to calculate the SMD. If this was not highest mean score for methodological quality (aver-
possible, and provided the baseline scores were not age score = 19.9/28), closely followed by full RCTs
significantly different, the SMD and 95% CI were cal- and then single group pre- post-test design. The quasi-
culated from the post-intervention mean and standard randomised study,[25] single case studies and case
deviation scores. All data entry and conversion was reports rated below 14/28 on the quality rating scale,
performed by one investigator (LB) and then checked except for Creighton et al.[27] Even though the study
by another (BV). Confidence interval that contained 0 by Creighton et al[27] used a non-experimental design
represented a null effect. and did not specifically label the intervention as a
If valid data was lacking or the studies were too MWM, it scored 50% (14/28) and met the inclusion
clinically or statistically heterogeneous, then the meta- criteria of an applied joint glide in conjunction with a
analysis was not performed and only an analysis of the movement or exercise, and was therefore included in
quality of the studies was performed. Various levels of this review.
evidence to the effectiveness of MWM were assigned The sub-category of reporting was the only one that
using the Oxford Centre for Evidence-based Medicine averaged greater than 50%, with significant weak-
Levels of Evidence [12] (Table 3.1). nesses across all studies in reporting on the external
Where studies failed to include a comparison group, validity sub-scale (Table 3.4). The majority of studies
the effect size (post-intervention mean – pre-interven- also reported poorly on the internal validity (confound-
tion mean/standard deviation mean) for the individual ing) sub-scale, with the mean score of 1.9 (SD 1.6) out
group was calculated. of a possible 6 points across all studies.
Figure 3.2 illustrates the relationship between meth-
RESULTS odological quality and estimated effect size of the
The systematic review process of identifying, refining MWM intervention. It is evident that studies of lesser
and final selection of studies into this review is illus- quality reported larger effects than studies of higher
trated in Figure 3.1. A total of 38 papers were rated quality. Importantly, 15/21 studies that rated below
using the Quality Index. 50% on the Quality Index did not report sufficient data
to allow estimation of an effect size.
Inter-rater reliability
Out of a total of 1026 criteria rated, there were 57 Outcome measures
(5.6%) initial disagreements between raters with a Pain scores were reported in the majority of studies
Kappa statistic of 0.894. The median (lower to upper using either a continuous visual analogue scale (VAS)
quartile) for inter-rater agreement for each criterion or an ordinal points system (Table 3.5). Joint ROM was
was 0.903 (0.729 to 0.9695) (Table 3.2). After a con- reported in several studies (ROM; 18 studies; 47%) as
sensus meeting between the two reviewers (LB and was pain-free grip strength (PFGS; 8 studies; 21%).
NC), seven (<1%) decisions could not be resolved and Table 3.5 lists the outcome measures used across the
the third reviewer (BV) was called upon to make the included studies. Thirty-two studies reported at least
final decision. one short-term outcome assessment (< 6 weeks), whilst
only two studies [28, 29] included a long-term follow-
Methodological quality up (> 6 months) of the primary outcome measures.
Methodological quality, as rated by the Downs and Fourteen studies only looked at the immediate post-
Black Quality Index,[14] ranged from 2 to 24 out of a intervention effects of the primary outcome measure,
maximum of 27 rateable criteria, and a maximum of with nine studies not reporting any outcome data.
28
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gods; or to ask those things which are not beneficial, begging evils
for themselves under the appearance of good things.
Whence, as is right, there being only one good God, that some
good things be given from Him alone, and that some remain, we and
the angels pray. But not similarly. For it is not the same thing to pray
that the gift remain, and to endeavour to obtain it for the first time.
The averting of evils is a species of prayer; but such prayer is
never to be used for the injury of men, except that the Gnostic, in
devoting attention to righteousness, may make use of this petition in
the case of those who are past feeling.
Prayer is, then, to speak more boldly, converse with God. Though
whispering, consequently, and not opening the lips we speak in
silence, yet we cry inwardly. For God hears continually all the inward
converse. So also we raise the head and lift the hands to heaven,
and set the feet in motion at the closing utterance of the prayer,
following the eagerness of the spirit directed towards the intellectual
essence; and endeavouring to abstract the body from the earth,
along with the discourse, raising the soul aloft, winged with longing
for better things, we compel it to advance to the region of holiness,
magnanimously despising the chain of the flesh. For we know right
well, that the Gnostic willingly passes over the whole world, as the
Jews certainly did over Egypt, showing clearly, above all, that he will
be as near as possible to God.
Now, if some assign definite hours for prayer—as, for example,
the third, and sixth, and ninth—yet the Gnostic prays throughout his
whole life, endeavouring by prayer to have fellowship with God. And,
briefly, having reached to this, he leaves behind him all that is of no
service, as having now received the perfection of the man that acts
by love. But the distribution of the hours into a threefold division,
honoured with as many prayers, those are acquainted with, who
know the blessed triad of the holy abodes.
Having got to this point, I recollect the doctrines about there
being no necessity to pray, introduced by certain of the heterodox,
that is, the followers of the heresy of Prodicus. That they may not
then be inflated with conceit about this godless wisdom of theirs, as
if it were strange, let them learn that it was embraced before by the
philosophers called Cyrenaics. Nevertheless, the unholy knowledge
(gnosis) of those falsely called [Gnostics] shall meet with confutation
at a fitting time; so that the assault on them, by no means brief,
may not, by being introduced into the commentary, break the
discourse in hand, in which we are showing that the only really holy
and pious man is he who is truly a Gnostic according to the rule of
the church, to whom alone the petition made in accordance with the
will of God is granted,[1240] on asking and on thinking. For as God
can do all that He wishes, so the Gnostic receives all that he asks.
For, universally, God knows those who are and those who are not
worthy of good things; whence He gives to each what is suitable.
Wherefore to those that are unworthy, though they ask often, He
will not give; but He will give to those who are worthy.
Nor is petition superfluous, though good things are given without
claim.
Now thanksgiving and request for the conversion of our
neighbours is the function of the Gnostic; as also the Lord prayed,
giving thanks for the accomplishment of His ministry, praying that as
many as possible might attain to knowledge; that in the saved, by
salvation, through knowledge, God might be glorified, and He who is
alone good and alone Saviour might be acknowledged through the
Son from age to age. But also faith, that one will receive, is a
species of prayer gnostically laid up in store.
But if any occasion of converse with God becomes prayer, no
opportunity of access to God ought to be omitted. Without doubt,
the holiness of the Gnostic, in union with [God’s] blessed Providence,
exhibits in voluntary confession the perfect beneficence of God. For
the holiness of the Gnostic, and the reciprocal benevolence of the
friend of God, are a kind of corresponding movement of providence.
For neither is God involuntarily good, as the fire is warming; but in
Him the imparting of good things is voluntary, even if He receive the
request previously. Nor shall he who is saved be saved against his
will, for he is not inanimate; but he will above all voluntarily and of
free choice speed to salvation. Wherefore also man received the
commandments in order that he might be self-impelled, to whatever
he wished of things to be chosen and to be avoided. Wherefore God
does not do good by necessity, but from His free choice benefits
those who spontaneously turn. For the Providence which extends to
us from God is not ministerial, as that service which proceeds from
inferiors to superiors. But in pity for our weakness, the continual
dispensations of Providence work, as the care of shepherds towards
the sheep, and of a king towards his subjects; we ourselves also
conducting ourselves obediently towards our superiors, who take the
management of us, as appointed, in accordance with the
commission from God with which they are invested.
Consequently those who render the most free and kingly service,
which is the result of a pious mind and of knowledge, are servants
and attendants of the Divinity. Each place, then, and time, in which
we entertain the idea of God, is in reality sacred.
When, then, the man who chooses what is right, and is at the
same time of thankful heart, makes his request in prayer, he
contributes to the obtaining of it, gladly taking hold in prayer of the
thing desired. For when the Giver of good things perceives the
susceptibility on our part, all good things follow at once the
conception of them. Certainly in prayer the character is sifted, how it
stands with respect to duty.
But if voice and expression are given us, for the sake of
understanding, how can God not hear the soul itself, and the mind,
since assuredly soul hears soul, and mind, mind? Whence God does
not wait for loquacious tongues, as interpreters among men, but
knows absolutely the thoughts of all; and what the voice intimates to
us, that our thought, which even before the creation He knew would
come into our mind, speaks to God. Prayer, then, may be uttered
without the voice, by concentrating the whole spiritual nature within
on expression by the mind, in undistracted turning towards God.
And since the dawn is an image of the day of birth, and from that
point the light which has shone forth at first from the darkness
increases, there has also dawned on those involved in darkness a
day of the knowledge of truth. In correspondence with the manner
of the sun’s rising, prayers are made looking towards the sunrise in
the east. Whence also the most ancient temples looked towards the
west, that people might be taught to turn to the east when facing
the images. “Let my prayer be directed before Thee as incense, the
uplifting of my hands as the evening sacrifice,”[1241] say the Psalms.
In the case of wicked men, therefore, prayer is most injurious, not
to others alone, but to themselves also. If, then, they should ask and
receive what they call pieces of good fortune, these injure them
after they receive them, being ignorant how to use them. For they
pray to possess what they have not, and they ask things which
seem, but are not, good things. But the Gnostic will ask the
permanence of the things he possesses, adaptation for what is to
take place, and the eternity of those things which he shall receive.
And the things which are really good, the things which concern the
soul, he prays that they may belong to him, and remain with him.
And so he desires not anything that is absent, being content with
what is present. For he is not deficient in the good things which are
proper to him; being already sufficient for himself, through divine
grace and knowledge. But having become sufficient in himself, he
stands in no want of other things. But knowing the sovereign will,
and possessing as soon as he prays, being brought into close
contact with the almighty power, and earnestly desiring to be
spiritual, through boundless love, he is united to the Spirit.
Thus he, being magnanimous, possessing, through knowledge,
what is the most precious of all, the best of all, being quick in
applying himself to contemplation, retains in his soul the permanent
energy of the objects of his contemplation, that is the perspicacious
keenness of knowledge. And this power he strives to his utmost to
acquire, by obtaining command of all the influences which war
against the mind; and by applying himself without intermission to
speculation, by exercising himself in the training of abstinence from
pleasures, and of right conduct in what he does; and besides,
furnished with great experience both in study and in life, he has
freedom of speech, not the power of a babbling tongue, but a power
which employs plain language, and which neither for favour nor fear
conceals aught of the things which may be worthily said at the
fitting time, in which it is highly necessary to say them. He, then,
having received the things respecting God from the mystic choir of
the truth itself, employs language which urges the magnitude of
virtue in accordance with its worth; and shows its results with an
inspired elevation of prayer, being associated gnostically, as far as
possible, with intellectual and spiritual objects.
Whence he is always mild and meek, accessible, affable, long-
suffering, grateful, endued with a good conscience. Such a man is
rigid, not alone so as not to be corrupted, but so as not to be
tempted. For he never exposes his soul to submission, or capture at
the hands of Pleasure and Pain. If the Word, who is Judge, call; he,
having grown inflexible, and not indulging a whit the passions, walks
unswervingly where justice advises him to go; being very well
persuaded that all things are managed consummately well, and that
progress to what is better goes on in the case of souls that have
chosen virtue, till they come to the Good itself, to the Father’s
vestibule, so to speak, close to the great High Priest. Such is our
Gnostic, faithful, persuaded that the affairs of the universe are
managed in the best way. Particularly, he is well pleased with all that
happens. In accordance with reason, then, he asks for none of those
things in life required for necessary use; being persuaded that God,
who knows all things, supplies the good with whatever is for their
benefit, even though they do not ask.
For my view is, that as all things are supplied to the man of art
according to the rules of art, and to the Gentile in a Gentile way, so
also to the Gnostic all things are supplied gnostically. And the man
who turns from among the Gentiles will ask for faith, while he that
ascends to knowledge will ask for the perfection of love. And the
Gnostic, who has reached the summit, will pray that contemplation
may grow and abide, as the common man will for continual good
health.
Nay, he will pray that he may never fall from virtue; giving his
most strenuous co-operation in order that he may become infallible.
For he knows that some of the angels, through carelessness, were
hurled to the earth, not having yet quite reached that state of
oneness, by extricating themselves from the propensity to that of
duality.
But him, who from this has trained himself to the summit of
knowledge and the elevated height of the perfect man, all things
relating to time and place help on, now that he has made it his
choice to live infallibly, and subjects himself to training in order to
the attainment of the stability of knowledge on each side. But in the
case of those in whom there is still a heavy corner, leaning
downwards, even that part which has been elevated by faith is
dragged down. In him, then, who by gnostic training has acquired
virtue which cannot be lost, habit becomes nature. And just as
weight in a stone, so the knowledge of such an one is incapable of
being lost. Not without, but through the exercise of will, and by the
force of reason, and knowledge, and Providence, is it brought to
become incapable of being lost. Through care it becomes incapable
of being lost. He will employ caution so as to avoid sinning, and
consideration to prevent the loss of virtue.
Now knowledge appears to produce consideration, by teaching to
perceive the things that are capable of contributing to the
permanence of virtue. The highest thing is, then, the knowledge of
God; wherefore also by it virtue is so preserved as to be incapable of
being lost. And he who knows God is holy and pious. The Gnostic
has consequently been demonstrated by us to be the only pious
man.
He rejoices in good things present, and is glad on account of
those promised, as if they were already present. For they do not
elude his notice, as if they were still absent, because he knows by
anticipation what sort they are. Being then persuaded by knowledge
how each future thing shall be, he possesses it. For want and defect
are measured with reference to what appertains to one. If, then, he
possesses wisdom, and wisdom is a divine thing, he who partakes of
what has no want will himself have no want. For the imparting of
wisdom does not take place by activity and receptivity moving and
stopping each other, or by aught being abstracted or becoming
defective. Activity is therefore shown to be undiminished in the act
of communication. So, then, our Gnostic possesses all good things,
as far as possible; but not likewise in number; since otherwise he
would be incapable of changing his place through the due inspired
stages of advancement and acts of administration.
Him God helps, by honouring him with closer oversight. For were
not all things made for the sake of good men, for their possession
and advantage, or rather salvation? He will not then deprive, of the
things which exist for the sake of virtue, those for whose sake they
were created. For, evidently in honour of their excellent nature and
their holy choice, he inspires those who have made choice of a good
life with strength for the rest of their salvation; exhorting some, and
helping others, who of themselves have become worthy. For all good
is capable of being produced in the Gnostic; if indeed it is his aim to
know and do everything intelligently. And as the physician ministers
health to those who co-operate with him in order to health, so also
God ministers eternal salvation to those who co-operate for the
attainment of knowledge and good conduct; and since what the
commandments enjoin are in our own power, along with the
performance of them, the promise is accomplished.
And what follows seems to me to be excellently said by the
Greeks. An athlete of no mean reputation among those of old,
having for a long time subjected his body to thorough training in
order to the attainment of manly strength, on going up to the
Olympic games, cast his eye on the statue of the Pisæan Zeus, and
said: “O Zeus, if all the requisite preparations for the contest have
been made by me, come, give me the victory, as is right.” For so, in
the case of the Gnostic, who has unblameably and with a good
conscience fulfilled all that depends on him, in the direction of
learning, and training, and well-doing, and pleasing God, the whole
contributes to carry salvation on to perfection. From us, then, are
demanded the things which are in our own power, and of the things
which pertain to us, both present and absent, the choice, and desire,
and possession, and use, and permanence.
Wherefore also he who holds converse with God must have his
soul immaculate and stainlessly pure, it being essential to have
made himself perfectly good.
But also it becomes him to make all his prayers gently along with
the good. For it is a dangerous thing to take part in others’ sins.
Accordingly the Gnostic will pray along with those who have more
recently believed, for those things in respect of which it is their duty
to act together. And his whole life is a holy festival. His sacrifices are
prayers, and praises, and readings in the Scriptures before meals,
and psalms and hymns during meals and before bed, and prayers
also again during night. By these he unites himself to the divine
choir, from continual recollection, engaged in contemplation which
has everlasting remembrance.
And what? Does he not also know the other kind of sacrifice,
which consists in the giving both of doctrines and of money to those
who need? Assuredly. But he does not use wordy prayer by his
mouth; having learned to ask of the Lord what is requisite. In every
place, therefore, but not ostensibly and visibly to the multitude, he
will pray. But while engaged in walking, in conversation, while in
silence, while engaged in reading and in works according to reason,
he in every mood prays. If he but form the thought in the secret
chamber of his soul, and call on the Father “with unspoken
groanings,”[1242] He is near, and is at his side, while yet speaking.
Inasmuch as there are but three ends of all action, he does
everything for its excellence and utility; but doing aught for the sake
of pleasure,[1243] he leaves to those who pursue the common life.
CHAPTER VIII.
THE GNOSTIC SO ADDICTED TO TRUTH AS NOT TO NEED TO USE AN OATH.
The man of proved character in such piety is far from being apt to
lie and to swear. For an oath is a decisive affirmation, with the taking
of the divine name. For how can he, that is once faithful, show
himself unfaithful, so as to require an oath; and so that his life may
not be a sure and decisive oath? He lives, and walks, and shows the
trustworthiness of his affirmation in an unwavering and sure life and
speech. And if the wrong lies in the judgment of one who does and
says [something], and not in the suffering of one who has been
wronged,[1244] he will neither lie nor commit perjury so as to wrong
the Deity, knowing that it by nature is incapable of being harmed.
Nor yet will he lie or commit any transgression, for the sake of the
neighbour whom he has learned to love, though he be not on terms
of intimacy. Much more, consequently, will he not lie or perjure
himself on his own account, since he never with his will can be
found doing wrong to himself.
But he does not even swear, preferring to make averment, in
affirmation by “yea,” and in denial by “nay.” For it is an oath to
swear, or to produce[1245] anything from the mind in the way of
confirmation in the shape of an oath. It suffices then, with him, to
add to an affirmation or denial the expression “I say truly,” for
confirmation to those who do not perceive the certainty of his
answer. For he ought, I think, to maintain a life calculated to inspire
confidence towards those without, so that an oath may not even be
asked; and towards himself and those with whom he associates,
[1246] good feeling, which is voluntary righteousness.
The Gnostic swears truly, but is not apt to swear, having rarely
recourse to an oath, just as we have said. And his speaking truth on
oath arises from his accord with the truth. This speaking truth on
oath, then, is found to be the result of correctness in duties. Where,
then, is the necessity for an oath to him who lives in accordance
with the extreme of truth? He, then, that does not even swear will
be far from perjuring himself. And he who does not transgress in
what is ratified by compacts, will never swear; since the ratification
of the violation and of the fulfilment is by actions; as certainly lying
and perjury in affirming and swearing are contrary to duty. But he
who lives justly, transgressing in none of his duties, when the
judgment of truth is scrutinized, swears truth by his acts.
Accordingly, testimony by the tongue is in his case superfluous.
Therefore, persuaded always that God is everywhere, and fearing
not to speak the truth, and knowing that it is unworthy of him to lie,
he is satisfied with the divine consciousness and his own alone. And
so he lies not, nor does ought contrary to his compacts. And so he
swears not even when asked for his oath; nor does he ever deny, so
as to speak falsehood, though he should die by tortures.
CHAPTER IX.
THOSE WHO TEACH OTHERS, OUGHT TO EXCEL IN VIRTUES.
The gnostic dignity is augmented and increased by him who has

undertaken the first place in the teaching of others, and received the
dispensation by word and deed of the greatest good on earth, by
which he mediates contact and fellowship with the Divinity. And as
those who worship terrestrial things pray to them as if they heard,
confirming compacts before them; so, in men who are living images,
the true majesty of the Word is received by the trustworthy teacher;
and the beneficence exerted towards them is carried up to the Lord,
after whose image he who is a true man by instruction creates and
harmonizes, renewing to salvation the man who receives instruction.
For as the Greeks called steel Ares, and wine Dionysus, on account
of a certain relation; so the Gnostic, considering the benefit of his
neighbours as his own salvation, may be called a living image of the
Lord, not as respects the peculiarity of form, but the symbol of
power and similarity of preaching.
Whatever, therefore, he has in his mind, he bears on his tongue,
to those who are worthy to hear, speaking as well as living from
assent and inclination. For he both thinks and speaks the truth;
unless at any time, medicinally, as a physician for the safety of the
sick, he may lie or tell an untruth, according to the Sophists.
For instance, the noble apostle circumcised Timothy, though
loudly declaring and writing that circumcision made with hands
profits nothing.[1247] But that he might not, by dragging all at once
away from the law to the circumcision of the heart through faith
those of the Hebrews who were reluctant listeners, compel them to
break away from the synagogue, he, “accommodating himself to the
Jews, became a Jew that he might gain all.”[1248] He, then, who
submits to accommodate himself merely for the benefit of his
neighbours, for the salvation of those for whose sake he
accommodates himself, not partaking in any dissimulation through
the peril impending over the just from those who envy them, such
an one by no means acts with compulsion.[1249] But for the benefit
of his neighbours alone, he will do things which would not have
been done by him primarily, if he did not do them on their account.
Such an one gives himself for the Church, for the disciples whom he
has begotten in faith; for an example to those who are capable of
receiving the supreme economy of the philanthropic and God-loving
Instructor, for confirmation of the truth of his words, for the exercise
of love to the Lord. Such an one is unenslaved by fear, true in word,
enduring in labour, never willing to lie by uttered word, and in it
always securing sinlessness; since falsehood, being spoken with a
certain deceit, is not an inert word, but operates to mischief.
On every hand, then, the Gnostic alone testifies to the truth in
deed and word. For he always does rightly in all things, both in word
and action, and in thought itself.
Such, then, to speak cursorily, is the piety of the Christian. If,
then, he does these things according to duty and right reason, he
does them piously and justly. And if such be the case, the Gnostic
alone is really both pious, and just, and God-fearing.
The Christian is not impious. For this was the point incumbent on
us to demonstrate to the philosophers; so that he will never in any
way do aught bad or base (which is unjust). Consequently,
therefore, he is not impious; but he alone fears God, holily and
dutifully worshipping the true God, the universal Ruler, and King, and
Sovereign, with the true piety.
CHAPTER X.
STEPS TO PERFECTION.
For knowledge (gnosis), to speak generally, a perfecting of man

as man, is consummated by acquaintance with divine things, in
character, life, and word, accordant and conformable to itself and to
the divine Word. For by it faith is perfected, inasmuch as it is solely
by it that the believer becomes perfect. Faith is an internal good,
and without searching for God, confesses His existence, and glorifies
Him as existent. Whence by starting from this faith, and being
developed by it, through the grace of God, the knowledge respecting
Him is to be acquired as far as possible.
Now we assert that knowledge (gnosis) differs from the wisdom
(σοφία), which is the result of teaching. For as far as anything is
knowledge, so far is it certainly wisdom; but in as far as aught is
wisdom, it is not certainly knowledge. For the term wisdom appears
only in the knowledge of the uttered word.
But it is not doubting in reference to God, but believing, that is
the foundation of knowledge. But Christ is both the foundation and
the superstructure, by whom are both the beginning and the ends.
And the extreme points, the beginning and the end—I mean faith
and love—are not taught. But knowledge, conveyed from
communication through the grace of God as a deposit, is entrusted
to those who show themselves worthy of it; and from it the worth of
love beams forth from light to light. For it is said, “To him that hath
shall be given:”[1250] to faith, knowledge; and to knowledge, love;
and to love, the inheritance.
And this takes place, whenever one hangs on the Lord by faith, by
knowledge, by love, and ascends along with Him to where the God
and guard of our faith and love is. Whence at last (on account of the
necessity for very great preparation and previous training in order
both to hear what is said, and for the composure of life, and for
advancing intelligently to a point beyond the righteousness of the
law) it is that knowledge is committed to those fit and selected for it.
It leads us to the endless and perfect end, teaching us beforehand
the future life that we shall lead, according to God, and with gods;
after we are freed from all punishment and penalty which we
undergo, in consequence of our sins, for salutary discipline. After
which redemption the reward and the honours are assigned to those
who have become perfect; when they have got done with
purification, and ceased from all service, though it be holy service,
and among saints. Then become pure in heart, and near to the Lord,
there awaits them restoration to everlasting contemplation; and they
are called by the appellation of gods, being destined to sit on
thrones with the other gods that have been first put in their places
by the Saviour.
Knowledge is therefore quick in purifying, and fit for that
acceptable transformation to the better. Whence also with ease it
removes [the soul] to what is akin to the soul, divine and holy, and
by its own light conveys man through the mystic stages of
advancement; till it restores the pure in heart to the crowning place
of rest; teaching to gaze on God, face to face, with knowledge and
comprehension. For in this consists the perfection of the gnostic
soul, in its being with the Lord, where it is in immediate subjection
to Him, after rising above all purification and service.
Faith is then, so to speak, a comprehensive knowledge of the
essentials; and knowledge is the strong and sure demonstration of
what is received by faith, built upon faith by the Lord’s teaching,
conveying [the soul] on to infallibility, science, and comprehension.
And, in my view, the first saving change is that from heathenism to
faith, as I said before; and the second, that from faith to knowledge.
And the latter terminating in love, thereafter gives the loving to the
loved, that which knows to that which is known. And, perchance,
such an one has already attained the condition of “being equal to
the angels.”[1251] Accordingly, after the highest excellence in the
flesh, changing always duly to the better, he urges his flight to the
ancestral hall, through the holy septenniad [of heavenly abodes] to
the Lord’s own mansion; to be a light, steady, and continuing
eternally, entirely and in every part immutable.
The first mode of the Lord’s operation mentioned by us is an
exhibition of the recompense resulting from piety. Of the very great
number of testimonies that there are, I shall adduce one, thus
summarily expressed by the prophet David: “Who shall ascend to
the hill of the Lord, or who shall stand in His holy place? He who is
guiltless in his hands, and pure in his heart; who hath not lifted up
his soul to vanity, or sworn deceitfully to his neighbour. He shall
receive blessing from the Lord, and mercy from God his Saviour. This
is the generation of them that seek the Lord, that seek the face of
the God of Jacob.”[1252] The prophet has, in my opinion, concisely
indicated the Gnostic. David, as appears, has cursorily demonstrated
the Saviour to be God, by calling Him “the face of the God of Jacob,”
who preached and taught concerning the Spirit. Wherefore also the
apostle designates as “the express image (χαρακτῆρα) of the glory
of the Father”[1253] the Son, who taught the truth respecting God,
and expressed the fact that the Almighty is the one and only God
and Father, “whom no man knoweth but the Son, and he to whom
the Son shall reveal Him.”[1254] That God is one is intimated by
those “who seek the face of the God of Jacob;” whom being the only
God, our Saviour and God characterizes as the Good Father. And “the
generation of those that seek Him” is the elect race, devoted to
inquiry after knowledge. Wherefore also the apostle says, “I shall
profit you nothing, unless I speak to you, either by revelation, or by
knowledge, or by prophecy, or by doctrine.”[1255]
Although even by those who are not Gnostics some things are
done rightly, yet not according to reason; as in the case of fortitude.
For some who are naturally high-spirited, and have afterwards
without reason fostered this disposition, rush to many things, and
act like brave men, so as sometimes to succeed in achieving the
same things; just as endurance is easy for mechanics. But it is not
from the same cause, or with the same object; not were they to give
their whole body. “For they have not love,” according to the apostle.
[1256]
All the action, then, of a man possessed of knowledge is right

action; and that done by a man not possessed of knowledge is
wrong action, though he observe a plan; since it is not from
reflection that he acts bravely, nor does he direct his action in those
things which proceed from virtue to virtue, to any useful purpose.
The same holds also with the other virtues. So too the analogy is
preserved in religion. Our Gnostic, then, not only is such in reference
to holiness; but corresponding to the piety of knowledge are the
commands respecting the rest of the conduct of life. For it is our
purpose at present to describe the life of the Gnostic, not to present
the system of dogmas, which we shall afterwards explain at the
fitting time, preserving the order of topics.
CHAPTER XI.
DESCRIPTION OF THE GNOSTIC’S LIFE.
Respecting the universe, he conceives truly and grandly in virtue

of his reception of divine teaching. Beginning, then, with admiration
of the Creation, and affording of himself a proof of his capability for
receiving knowledge, he becomes a ready pupil of the Lord. Directly
on hearing of God and Providence, he believed in consequence of
the admiration he entertained. Through the power of impulse thence
derived he devotes his energies in every way to learning, doing all
those things by means of which he shall be able to acquire the
knowledge of what he desires. And desire blended with inquiry
arises as faith advances. And this is to become worthy of
speculation, of such a character, and such importance. So shall the
Gnostic taste of the will of God. For it is not his ears, but his soul,
that he yields up to the things signified by what is spoken.
Accordingly, apprehending essences and things through the words,
he brings his soul, as is fit, to what is essential; apprehending [e.g.]
in the peculiar way in which they are spoken to the Gnostic, the
commands, “Do not commit adultery,” “Do not kill;” and not as they
are understood by other people. Training himself, then, in scientific
speculation, he proceeds to exercise himself in larger generalizations
and grander propositions; knowing right well that “He that teacheth
man knowledge,” according to the prophet, is the Lord, the Lord
acting by man’s mouth. So also He assumed flesh.
As is right, then, he never prefers the pleasant to the useful; not
even if a beautiful woman were to entice him, when overtaken by
circumstances, by wantonly urging him: since Joseph’s master’s wife
was not able to seduce him from his stedfastness; but as she
violently held his coat, divested himself of it,—becoming bare of sin,
but clothed with seemliness of character. For if the eyes of the
master—the Egyptian, I mean—saw not Joseph, yet those of the
Almighty looked on. For we hear the voice, and see the bodily forms;
but God scrutinizes the thing itself, from which the speaking and the
looking proceed.
Consequently, therefore, though disease, and accident, and what
is most terrible of all, death, come upon the Gnostic, he remains
inflexible in soul,—knowing that all such things are a necessity of
creation, and that, also by the power of God, they become the
medicine of salvation, benefiting by discipline those who are difficult
to reform; allotted according to desert, by Providence, which is truly
good.
Using the creatures, then, when the Word prescribes, and to the
extent it prescribes, in the exercise of thankfulness to the Creator, he
becomes master of the enjoyment of them.
He never cherishes resentment or harbours a grudge against any
one, though deserving of hatred for his conduct. For he worships the
Maker, and loves him, who shares life, pitying and praying for him on
account of his ignorance. He indeed partakes of the affections of the
body, to which, susceptible as it is of suffering by nature, he is
bound. But in sensation he is not the primary subject of it.
Accordingly, then, in involuntary circumstances, by withdrawing
himself from troubles to the things which really belong to him, he is
not carried away with what is foreign to him. And it is only to things
that are necessary for him that he accommodates himself, in so far
as the soul is preserved unharmed. For it is not in supposition or
seeming that he wishes to be faithful; but in knowledge and truth,
that is, in sure deed and effectual word. Wherefore he not only
praises what is noble, but endeavours himself to be noble; changing
by love from a good and faithful servant into a friend, through the
perfection of habit, which he has acquired in purity from true
instruction and great discipline.
Striving, then, to attain to the summit of knowledge (gnosis);
decorous in character; composed in mien; possessing all those
advantages which belong to the true Gnostic; fixing his eye on fair
models, on the many patriarchs who have lived rightly, and on very
many prophets and angels reckoned without number, and above all,
on the Lord, who taught and showed it to be possible for him to
attain that highest life of all,—he therefore loves not all the good
things of the world, which are within his grasp, that he may not
remain on the ground, but the things hoped for, or rather already
known, being hoped for so as to be apprehended.
So then he undergoes toils, and trials, and afflictions, not as those
among the philosophers who are endowed with manliness, in the
hope of present troubles ceasing, and of sharing again in what is
pleasant; but knowledge has inspired him with the firmest
persuasion of receiving the hopes of the future. Wherefore he
contemns not alone the pains of this world, but all its pleasures.
They say, accordingly, that the blessed Peter, on seeing his wife
led to death, rejoiced on account of her call and conveyance home,
and called very encouragingly and comfortingly, addressing her by
name, “Remember thou the Lord.” Such was the marriage of the
blessed, and their perfect disposition towards those dearest to them.
Thus also the apostle says, “that he who marries should be as
though he married not,” and deem his marriage free of inordinate
affection, and inseparable from love to the Lord; to which the true
husband exhorted his wife to cling on her departure out of this life to
the Lord.
Was not then faith in the hope after death conspicuous in the
case of those who gave thanks to God even in the very extremities
of their punishments? For firm, in my opinion, was the faith they
possessed, which was followed by works of faith.
In all circumstances, then, is the soul of the Gnostic strong, in a
condition of extreme health and strength, like the body of an
athlete.
For he is prudent in human affairs, in judging what ought to be
done by the just man; having obtained the principles from God from
above, and having acquired, in order to the divine resemblance,
moderation in bodily pains and pleasures. And he struggles against
fears boldly, trusting in God. Certainly, then, the gnostic soul,
adorned with perfect virtue, is the earthly image of the divine
powers: its development being the joint result of nature, of training,
of reason, all together. This beauty of the soul becomes a temple of
the Holy Spirit, when it acquires a disposition in the whole of life
corresponding to the gospel. Such an one consequently withstands
all fear of everything terrible, not only of death, but also poverty and
disease, and ignominy, and things akin to these; being unconquered
by pleasure, and lord over irrational desires. For he well knows what
is and what is not to be done; being perfectly aware what things are
really to be dreaded, and what not. Whence he bears intelligently
what the Word intimates to him to be requisite and necessary;
intelligently discriminating what is really safe (that is, good), from
what appears so; and things to be dreaded from what seem so, such
as death, disease, and poverty; which are rather so in opinion than
in truth.
This is the really good man, who is without passions; having,
through the habit or disposition of a soul endued with virtue,
transcended the whole life of passion. He has everything dependent
on himself for the attainment of the end. For those accidents which
are called terrible are not formidable to the good man, because they
are not evil. And those which are really to be dreaded are foreign to
the gnostic Christian, being diametrically opposed to what is good,
because evil; and it is impossible for contraries to meet in the same
person at the same time. He, then, who faultlessly acts the drama of
life which God has given him to play, knows both what is to be done
and what is to be endured.
Is it not then from ignorance of what is and what is not to be
dreaded that cowardice arises? Consequently the only man of
courage is the Gnostic, who knows both present and future good
things; along with these, knowing, as I have said, also the things
which are in reality not to be dreaded. Because, knowing vice alone
to be hateful, and destructive of what contributes to knowledge,
protected by the armour of the Lord, he makes war against it.
For if anything is caused through folly, and the operation or rather
co-operation of the devil, this thing is not straightway the devil or
folly. For no action is wisdom. For wisdom is a habit. And no action is
a habit. The action, then, that arises from ignorance, is not already
ignorance, but an evil through ignorance, but not ignorance. For
neither perturbations of mind nor sins are vices, though proceeding
from vice.
No one, then, who is irrationally brave is a Gnostic; since one
might call children brave, who, through ignorance of what is to be
dreaded, undergo things that are frightful. So they touch fire even.
And the wild beasts that rush close on the points of spears, having a
brute courage, might be called valiant. And such people might
perhaps call jugglers valiant, who tumble on swords with a certain
dexterity, practising a mischievous art for sorry gain. But he who is
truly brave, with the peril arising from the bad feeling of the
multitude before his eyes, courageously awaits whatever comes. In
this way he is distinguished from others that are called martyrs,
inasmuch as some furnish occasions for themselves, and rush into
the heart of dangers, I know not how (for it is right to use mild
language); while they, in accordance with right reason, protect
themselves; then, on God really calling them, promptly surrender
themselves, and confirm the call, from being conscious of no
precipitancy, and present the man to be tested in the exercise of
true rational fortitude. Neither, then, enduring lesser dangers from
fear of greater, like other people, nor dreading censure at the hands
of their equals, and those of like sentiments, do they continue in the
confession of their calling; but from love to God they willingly obey
the call, with no other aim in view than pleasing God, and not for
the sake of the reward of their toils.
For some suffer from love of glory, and others from fear of some
other sharper punishment, and others for the sake of pleasures and
delights after death, being children in faith; blessed indeed, but not
yet become men in love to God, as the Gnostic is. For there are, as
in the gymnastic contests, so also in the Church, crowns for men
and for children. But love is to be chosen for itself, and for nothing
else. Therefore in the Gnostic, along with knowledge, the perfection
of fortitude is developed from the discipline of life, he having always
studied to acquire mastery over the passions.
Accordingly, love makes its own athlete fearless and dauntless,
and confident in the Lord, anointing and training him; as
righteousness secures for him truthfulness in his whole life. For it
was a compendium of righteousness to say, “Let your yea be yea;
and your nay, nay.”
And the same holds with self-control. For it is neither for love of
honour, as the athletes for the sake of crowns and fame; nor, on the
other hand, for love of money, as some pretend to exercise self-
control, pursuing what is good with terrible suffering. Nor is it from
love of the body for the sake of health. Nor any more is any man
who is temperate from rusticity, who has not tasted pleasures, truly
a man of self-control. Certainly those who have led a laborious life,
on tasting pleasures, forthwith break down the inflexibility of
temperance into pleasures. Such are they who are restrained by law
and fear. For on finding a favourable opportunity they defraud the
law, by giving what is good the slip. But self-control, desirable for its
own sake, perfected through knowledge, abiding ever, makes the
man lord and master of himself; so that the Gnostic is temperate
and passionless, incapable of being dissolved by pleasures and
pains, as they say adamant is by fire.
The cause of these, then, is love, of all science the most sacred
and most sovereign.
For by the service of what is best and most exalted, which is
characterized by unity, it renders the Gnostic at once friend and son,
having in truth grown “a perfect man, up to the measure of full
stature.”[1257]
Further, agreement in the same thing is consent. But what is the
same is one. And friendship is consummated in likeness; the
community lying in oneness. The Gnostic, consequently, in virtue of
being a lover of the one true God, is the really perfect man and
friend of God, and is placed in the rank of son. For these are names
of nobility and knowledge, and perfection in the contemplation of
God; which crowning step of advancement the gnostic soul receives,
when it has become quite pure, reckoned worthy to behold
everlastingly God Almighty, “face,” it is said, “to face.” For having
become wholly spiritual, and having in the spiritual Church gone to
what is of kindred nature, it abides in the rest of God.
CHAPTER XII.
THE TRUE GNOSTIC IS BENEFICENT, CONTINENT, AND DESPISES WORLDLY
THINGS.
Let these things, then, be so.

And such being the attitude of the Gnostic towards the body and
the soul—towards his neighbours, whether it be a domestic, or a
lawful enemy, or whosoever—he is found equal and like. For he does
not “despise his brother,” who, according to the divine law, is of the
same father and mother. Certainly he relieves the afflicted, helping
him with consolations, encouragements, and the necessaries of life;
giving to all that need, though not similarly, but justly, according to
desert; furthermore, to him who persecutes and hates, even if he
need it; caring little for those who say to him that he has given out
of fear, if it is not out of fear that he does so, but to give help. For
how much more are those, who towards their enemies are devoid of
love of money, and are haters of evil, animated with love to those
who belong to them?
Such an one from this proceeds to the accurate knowledge of
whom he ought chiefly to give to, and how much, and when, and
how.
And who could with any reason become the enemy of a man who
gives no cause for enmity in any way? And is it not just as in the
case of God? We say that God is the adversary of no one, and the
enemy of no one (for He is the Creator of all, and nothing that exists
is what He wills it not to be; but we assert that the disobedient, and
those who walk not according to His commandments, are enemies to
Him, as being those who are hostile to His covenant). We shall find
the very same to be the case with the Gnostic, for he can never in
any way become an enemy to any one; but those may be regarded
enemies to him who turn to the contrary path.
In particular, the habit of liberality which prevails among us is
called “righteousness;” but the power of discriminating according to
desert, as to greater and less, with reference to those who are
proper subjects of it, is a form of the very highest righteousness.
There are things practised in a vulgar style by some people, such
as control over pleasures. For as, among the heathen, there are
those who, from the impossibility of obtaining what one sees,[1258]
and from fear of men, and also for the sake of greater pleasures,
abstain from the delights that are before them; so also, in the case
of faith, some practise self-restraint, either out of regard to the
promise or from fear of God. Well, such self-restraint is the basis of
knowledge, and an approach to something better, and an effort after
perfection. For “the fear of the Lord,” it is said, “is the beginning of
wisdom.”[1259] But the perfect man, out of love, “beareth all things,
endureth all things,”[1260] “as not pleasing man, but God.”[1261]
Although praise follows him as a consequence, it is not for his own
advantage, but for the imitation and benefit of those who praise
him.
According to another view, it is not he who merely controls his
passions that is called a continent man, but he who has also
achieved the mastery over good things, and has acquired surely the
great accomplishments of science, from which he produces as fruits
the activities of virtue. Thus the Gnostic is never, on the occurrence
of an emergency, dislodged from the habit peculiar to him. For the
scientific possession of what is good is firm and unchangeable, being
the knowledge of things divine and human. Knowledge, then, never
becomes ignorance; nor does good change into evil. Wherefore also
he eats, and drinks, and marries, not as principal ends of existence,
but as necessary. I name marriage even, if the Word prescribe, and
as is suitable. For having become perfect, he has the apostles for
examples; and one is not really shown to be a man in the choice of
single life; but he surpasses men, who, disciplined by marriage,
procreation of children, and care for the house, without pleasure or
pain, in his solicitude for the house has been inseparable from God’s
love, and withstood all temptation arising through children, and wife,
and domestics, and possessions. But he that has no family is in a
great degree free of temptation. Caring, then, for himself alone, he
is surpassed by him who is inferior, as far as his own personal
salvation is concerned, but who is superior in the conduct of life,
preserving certainly, in his care for the truth, a minute image.
But we must as much as possible subject the soul to varied
preparatory exercise, that it may become susceptible to the
reception of knowledge. Do you not see how wax is softened and
copper purified, in order to receive the stamp applied to it? Just as
death is the separation of the soul from the body, so is knowledge as
it were the rational death urging the spirit away, and separating it
from the passions, and leading it on to the life of well-doing, that it
may then say with confidence to God, “I live as Thou wishest.” For
he who makes it his purpose to please men cannot please God, since
the multitude choose not what is profitable, but what is pleasant.
But in pleasing God, one as a consequence gets the favour of the
good among men. How, then, can what relates to meat, and drink,
and amorous pleasure, be agreeable to such an one? since he views
with suspicion even a word that produces pleasure, and a pleasant
movement and act of the mind. “For no one can serve two masters,
God and Mammon,”[1262] it is said; meaning not simply money, but
the resources arising from money bestowed on various pleasures. In
reality, it is not possible for him who magnanimously and truly knows
God, to serve antagonistic pleasures.
There is one alone, then, who from the beginning was free of
concupiscence—the philanthropic Lord, who for us became man. And
whosoever endeavour to be assimilated to the impress given by Him,
strive, from exercise, to become free of concupiscence. For he who
has exercised concupiscence and then restrained himself, is like a
widow who becomes again a virgin by continence. Such is the
reward of knowledge, rendered to the Saviour and Teacher, which
He Himself asked for,—abstinence from what is evil, activity in doing
good, by which salvation is acquired.
As, then, those who have learned the arts procure their living by
what they have been taught, so also is the Gnostic saved, procuring
life by what he knows. For he who has not formed the wish to
extirpate the passion of the soul, kills himself. But, as seems,
ignorance is the starvation of the soul, and knowledge its
sustenance.
Such are the gnostic souls, which the Gospel likened to the
consecrated virgins who wait for the Lord. For they are virgins, in
respect of their abstaining from what is evil. And in respect of their
waiting out of love for the Lord, and kindling their light for the
contemplation of things, they are wise souls, saying, “Lord, for long
we have desired to receive Thee; we have lived according to what
Thou hast enjoined, transgressing none of Thy commandments.
Wherefore also we claim the promises. And we pray for what is
beneficial, since it is not requisite to ask of Thee what is most
excellent. And we shall take everything for good; even though the
exercises that meet us, which Thine arrangement brings to us for
the discipline of our stedfastness, appear to be evil.”
The Gnostic, then, from his exceeding holiness, is better prepared
to fail when he asks, than to get when he does not ask.
His whole life is prayer and converse with God. And if he be pure
from sins, he will by all means obtain what he wishes. For God says
to the righteous man, “Ask, and I will give thee; think, and I will do.”
If beneficial, he will receive it at once; and if injurious, he will never
ask it, and therefore he will not receive it. So it shall be as he
wishes.
But if one say to us, that some sinners even obtain according to
their requests, [we should say] that this rarely takes place, by
reason of the righteous goodness of God. And it is granted to those
who are capable of doing others good. Whence the gift is not made
for the sake of him that asked it; but the divine dispensation,
foreseeing that one would be saved by his means, renders the boon
again righteous. And to those who are worthy, things which are
really good are given, even without their asking.
Whenever, then, one is righteous, not from necessity or out of
fear or hope, but from free choice, this is called the royal road,
which the royal race travel. But the byways are slippery and
precipitous. If, then, one take away fear and honour, I do not know
if the illustrious among the philosophers, who use such freedom of
speech, will any longer endure afflictions.
Now lusts and other sins are called “briars and thorns.”
Accordingly the Gnostic labours in the Lord’s vineyard, planting,
pruning, watering; being the divine husbandman of what is planted
in faith. Those, then, who have not done evil, think it right to receive
the wages of ease. But he who has done good out of free choice,
demands the recompense as a good workman. He certainly shall
receive double wages—both for what he has not done, and for what
good he has done.
Such a Gnostic is tempted by no one except with God’s
permission, and that for the benefit of those who are with him; and
he strengthens them for faith, encouraging them by manly
endurance. And assuredly it was for this end, for the establishment
and confirmation of the churches, that the blessed apostles were
brought into trial and to martyrdom.
The Gnostic, then, hearing a voice ringing in his ear, which says,
“Whom I shall strike, do thou pity,” beseeches that those who hate
him may repent. For the punishment of malefactors, to be
consummated in the highways, is for children to witness;[1263] for
there is no possibility of the Gnostic, who has from choice trained
himself to be excellent and good, ever being instructed or delighted
with such spectacles.[1264] And so, having become incapable of
being softened by pleasures, and never falling into sins, he is not
corrected by the examples of other men’s sufferings. And far from
being pleased with earthly pleasures and spectacles is he who has
shown a noble contempt for the prospects held out in this world,
although they are divine.
“Not every one,” therefore, “that says Lord, Lord, shall enter into
the kingdom of God; but he that doeth the will of God.”[1265] Such is
the gnostic labourer, who has the mastery of worldly desires even
while still in the flesh; and who, in regard to things future and still
invisible, which he knows, has a sure persuasion, so that he regards
them as more present than the things within reach. This able
workman rejoices in what he knows, but is cramped on account of
his being involved in the necessities of life; not yet deemed worthy
of the active participation in what he knows. So he uses this life as if
it belonged to another,—so far, that is, as is necessary.
He knows also the enigmas of the fasting of those days—I mean
the Fourth and the Preparation. For the one has its name from
Hermes, and the other from Aphrodite. He fasts in his life, in respect
of covetousness and voluptuousness, from which all the vices grow.
For we have already often above shown the three varieties of
fornication, according to the apostle—love of pleasure, love of
money, idolatry. He fasts, then, according to the Law, abstaining
from bad deeds, and, according to the perfection of the Gospel, from
evil thoughts. Temptations are applied to him, not for his
purification, but, as we have said, for the good of his neighbours, if,
making trial of toils and pains, he has despised and passed them by.
The same holds of pleasure. For it is the highest achievement for
one who has had trial of it, afterwards to abstain. For what great
thing is it, if a man restrains himself in what he knows not? He, in
fulfilment of the precept, according to the Gospel, keeps the Lord’s
day, when he abandons an evil disposition, and assumes that of the
Gnostic, glorifying the Lord’s resurrection in himself. Further also,
when he has received the comprehension of scientific speculation,
he deems that he sees the Lord, directing his eyes towards things
invisible, although he seems to look on what he does not wish to
look on; chastising the faculty of vision, when he perceives himself
pleasurably affected by the application of his eyes; since he wishes
to see and hear that alone which concerns him.
In the act of contemplating the souls of the brethren, he beholds
the beauty of the flesh also, with the soul itself, which has become
habituated to look solely upon that which is good, without carnal
pleasure. And they are really brethren; inasmuch as, by reason of
their elect creation, and their oneness of character, and the nature of
their deeds, they do, and think, and speak the same holy and good
works, in accordance with the sentiments with which the Lord
wished them as elect to be inspired.
For faith shows itself in their making choice of the same things;
and knowledge, in learning and thinking the same things; and hope,
in desiring[1266] the same things.
And if, through the necessity of life, he spend a small portion of
time about his sustenance, he thinks himself defrauded, being
diverted by business. Thus not even in dreams does he look on
aught that is unsuitable to an elect man. For thoroughly[1267] a
stranger and sojourner in the whole of life is every such one, who,
inhabiting the city, despises the things in the city which are admired
by others, and lives in the city as in a desert, so that the place may
not compel him, but his mode of life show him to be just.
This Gnostic, to speak compendiously, makes up for the absence
of the apostles, by the rectitude of his life, the accuracy of his
knowledge, by benefiting his relations, by “removing the mountains”
of his neighbours, and putting away the irregularities of their soul.
Although each of us is his[1268] own vineyard and labourer.
He, too, while doing the most excellent things, wishes to elude
the notice of men, persuading the Lord along with himself that he is
living in accordance with the commandments, preferring these
things from believing them to exist. “For where any one’s mind is,
there also is his treasure.”[1269]
He impoverishes himself, in order that he may never overlook a
brother[1270] who has been brought into affliction, through the
perfection that is in love, especially if he know that he will bear want
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Edinburgh London New York Philadelphia St Louis Toronto

Elsevier Australia. ACN 001 002 357

© 2011 Elsevier Australia

National Library of Australia Cataloguing-in-Publication Data

ISBN: 9780729538954 (pbk.)

Subjects: Physical therapy--Australia.

Physical therapy--Handbooks, manuals, etc

Movement therapy--Handbooks, manuals, etc

Other Authors/Contributors: Vicenzino, Bill.

Dewey Number: 615.82

Publisher: Melinda McEvoy

SECTION FOUR CASE STUDIES 101

Pam Teys MPhty (Sports Phty), BPhty, Grad Cert CH Yang

Darren Rivett, Bill Vicenzino, Wayne Hing and Toby Hall

similarly developing their interests in manual therapy.

Bill Vicenzino, Wayne Hing, Toby Hall and Darren Rivett

(i) (ii) (iii)

Mobilisation with Movement Pain threshold

• Level (amount of force)

CSIM SUBSTANTIALLY IMPROVED: NO YES YES3 NO

MOBILISATION PARAMETERS TO VARY: 4

IF NO CHANGE AFTER 4 WHEN 100% IMPROVED OR NO

in 24 patients with pain-limited shoulder elevation Amount of force application

Centre of tibial plateau

5 when the force is applied at the most appropriate loca-

liminary as they may be, there is no study yet of the 50

Leanne Bisset, Wayne Hing and Bill Vicenzino

INTRODUCTION The aim of this chapter is to synthesise the evidence

Table 3.1 Levels of evidence, adapted[12] Quality assessment

The gnostic dignity is augmented and increased by him who has

For knowledge (gnosis), to speak generally, a perfecting of man

All the action, then, of a man possessed of knowledge is right

Respecting the universe, he conceives truly and grandly in virtue

Let these things, then, be so.

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