Mulligan Bent Leg Raise Technique

Original Editor - Gayatri Jadav Upadhyay

Top Contributors - Gayatri Jadav Upadhyay, Sheik Abdul Khadir and Ajay Upadhyay  


Description

The Mulligan bent leg raise (BLR) technique is used for improving range of straight leg raise (SLR) in subjects with LBP and/or referred thigh pain (Mulligan, 1999) [1]and also in order to improve flexibility of hamstring in clients with tight hamstrings. The intention of this technique is to restore normal mobility and reduce LBP and physical impairment. It stretches the lower extremity muscles in combination of hamstring, adductors and rotators.

Indication

  • Low Back Pain with limited SLR or Painful SLR
  • Hamstring tightness & to stretch Thoraco lumbar fascia.

Clinical Application

It has been suggested that improving SLR mobility reduces the degree of impairment in LBP (Blunt et al.[2], 1997; Hall et al.,[3] 2001; Hanten and Chandler, [4]1994).

The SLR test has biomechanical effects on pelvis movement, on lumbosacral neural structures (Breig and Troup,[5] 1979; Butler, [6]1991) and hamstring muscles (Burns and Mierau, [7]1997). Hence, it is important when investigating SLR to evaluate the component movements that include hip flexion and posterior pelvic rotation (Hall et al., 2001).[8]

The BLR technique (Mulligan, 1999) [9]consists of three repetitions of pain-free, 5 s, isometric contraction of the hamstrings, performed in five progressively greater positions of hip flexion.

Dixon and Keating (2000) [10] suggest that improvement in range of SLR must be greater than 6 degree to state that a real change in SLR range has occurred. Consequently, the change in range produced by the BLR is of clinical relevance only 24 h after the intervention.


Technique [11]

Patient Position 

  • Supine lying at edge of the plinth
  • Hip and Knee in 90O Flexion and heel off the plinth

Therapist Position

  • Walk Stance on the affected side 

Hand Placement

  • Shoulder of the inner hand is placed under the popliteal fossa.
  • Therapist grasps the lower end of thigh with both the hands.

Mobilization

  • Longitudinal traction is applied along the long axis of the femur.
  • Therapist takes the hip in to flexion until first resistance is felt.
  • If patient complains of stretch pain or if therapist feels resistance due to muscle tightness, contract-relax is applied by asking the patient to push the therapist's shoulder gently (hold for five seconds). Now, the therapist can take the patient's hip into further flexion, if pain free.
  • If patients complains of 'THE' pain during this maneuver, then hip can be moved into abduction or external rotation / more traction before further hip flexion is added. 
  • Hold the end position for about 20 seconds.
  • Repeat the process three times and reassess the changes brought about by this mobilization.

Reasoning [11]

  • Sciatic nerve passes through gluteus maximus and adductor magnus at hip level and this technique might release the adhesion between them. Stretching of the gluteus maximus and adductor magnus part of hamstrings (as knee is kept in flexed position) helps in breaking the adhesions between these muscles and sciatic nerve. Hence, mobilization of the sciatic nerve will occur in relation to these muscles without the nerve getting stretched.
  • Helps in opening of the facet joints and the intervertebral foramen of the lumbar spine ()as during end range pelvis goes into posterior tilt.
  • This might also help in stretching and releasing thoracolumbar fascia. 

Key Evidence

A number of studies have investigated techniques to improve range of SLR in asymptomatic samples(Clark et al.,[12] 1999; Hall et al.,[13] 2001; Sullivan et al.,[14]1992; Worrell et al.,[15] 1994). The improvement in range determined in these studies ranged from 81 to 131. Only two other studies, known to us, have investigated the effect of treatment interventions on SLR range in subjects with LBP (Beyerlein et al.,[16] 2002; Meszaros et al., [17]2000). Improvement in SLR range was 111 (Beyerlein et al., 2002) and 81 (Meszaros et al., 2000). However, these studies did not incorporate a placebo or control group. That was Toby Hall who underwent a preliminary randomized trial of immediate effects after a single intervention of Mulligan bent leg raise technique.

Improvement of SLR range because of the BLR technique might be due to mobilization of the painful, sensitized nerve tissues, similar to the ‘‘slider’’ effects described by Butler [18](1991) and Elvey and Hall [19](1997). Another beneficial effect of the BLR technique might be a change in stretch tolerance of the hamstrings. Goeken and Hof (1994) demonstrated that the increased range of SLR, following stretching, is mediated via an increase in hip flexion & pelvic rotation as well as hamstring length, and not related to increased hamstring viscoelastic properties.

An assumption can be made that the BLR technique triggers neurophysiological responses influencing the muscle stretch tolerance. In the study by Toby Hall there was increased posterior pelvic rotation. An increase in hamstring extensibility might reduce stress on painful lumbar tissues and hence allow an increase in posterior pelvic rotation resulting in greater lumbar flexion.

Resources

Beyerlein C, Hall TM, Hansson U, Odemark M, Sainsbury D, Lim HT. Effektivita¨ t der Mulligan-straight-leg-raise-Traktionstechnik auf die Beweglichkeit bei Patienten mit Ru¨ ckenschmerzen. Manuelle Therapie 2002;6:61–8.

Breig A, Troup JDG. Biomechanical considerations in the straight-legraising test. Cadaveric and clinical studies of the effects of medial hip rotation. Spine 1979;4(3):242–50.

Butler DS. Clinical neurobiomechanics. In: Mobilisation of the nervous system. Melbourne: Churchill Livingstone; 1991. p. 35–54.

Dixon JK, Keating JL. Variability in straight leg raise measurements: review. Physiotherapy 2000;86(7):361–70.

Elvey RL, Hall TM. Neural tissue evaluation and treatment.In: Donatelli R, editor. Physical therapy of the shoulder 3rd. New York; PA: Churchill Livingstone; 1997. p. 131–52.

Hanten WP, Chandler S. Effects of myofascial release leg pull and sagittall plane isometric contract-relax technique on passive straight leg-raise angle. Journal of Orthopaedic and Sports Physical Therapy 1994;20:138–44.

Hall TM, Cacho A, McNee C, Riches J, Walsh J. Effects of Mulligan traction straight leg raise on range of movement. The Journal of Manual and Manipulative Therapy 2001;9:128–33.

Mulligan BR. Other spinal therapies. In: Manual therapy: ‘‘nags’’,‘‘snags’’, ‘‘mwms’’ etc. 4th. Wellington: Plane View Services; 1999. p. 68–86.

Hall T, Hardt S, Schäfer A, Wallin L. Mulligan bent leg raise technique--a preliminary randomized trial of immediate effects after a single intervention. Man Ther. 2006 May;11(2):130-5.

Recent Related Research (from Pubmed)

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References

  1. Mulligan BR. Other spinal therapies. In: Manual therapy: ‘‘nags’’,‘‘snags’’, ‘‘mwms’’ etc. 4th. Wellington: Plane View Services; 1999. p. 68–86.
  2. Blunt KL, Rajwani MH, Guerriero RC. The effectiveness offckLRchiropractic management of fibromyalgia patients: a pilot study. Journal of Manipulative and Physiological Therapeutics 1997;20(6):389–98.
  3. Hall TM, Cacho A, McNee C, Riches J, Walsh J. Effects of Mulligan traction straight leg raise on range of movement. The Journal of Manual and Manipulative Therapy 2001;9:128–33.
  4. Hanten WP, Chandler S. Effects of myofascial release leg pull and sagittall plane isometric contract-relax technique on passive straight leg-raise angle. Journal of Orthopaedic and Sports Physical Therapy 1994;20:138–44.
  5. Breig A, Troup JDG. Biomechanical considerations in the straight-legraising test. Cadaveric and clinical studies of the effects of medial hip rotation. Spine 1979;4(3):242–50.
  6. Butler DS. Clinical neurobiomechanics. In: Mobilisation of the nervous system. Melbourne: Churchill Livingstone; 1991. p. 35–54.
  7. Burns SH, Mierau DR. Chiropractic management of low back pain. Singer KP, editor. Clinical anatomy and management of low back pain. Oxford: Butterworth-Heinemann; 1997. p. 344–57.
  8. Hall TM, Cacho A, McNee C, Riches J, Walsh J. Effects of Mulligan traction straight leg raise on range of movement. The Journal of Manual and Manipulative Therapy 2001;9:128–33.
  9. Mulligan BR. Other spinal therapies. In: Manual therapy: ‘‘nags’’,‘‘snags’’, ‘‘mwms’’ etc. 4th. Wellington: Plane View Services; 1999. p. 68–86.
  10. Dixon JK, Keating JL. Variability in straight leg raise measurements: review. Physiotherapy 2000;86(7):361–70.
  11. 11.0 11.1 Dr. Deepak Kumar, Brian R. Mulligan ; Manual of Mulligan Concept ;Capri Institute of Manual Therapy; first edition; 2014; Pg- 60-61
  12. Clark S, Christiansen A, Hellman DF, Hugunin JW, Hurst KM. Effects of ipsilateral anterior thigh soft tissue stretching on passive unilateral straight-leg raise. Journal of Orthopaedic and Sports Physical Therapy 1999;29(1):4–9.
  13. Hall TM, Cacho A, McNee C, Riches J, Walsh J. Effects of Mulligan traction straight leg raise on range of movement. The Journal of Manual and Manipulative Therapy 2001;9:128–33.
  14. Sullivan MK, Dejulia JJ, Worrell TW. Effect of pelvic position and stretching method on hamstring muscle flexibility. Medical Science and Sports Exercise 1992;24(12):1383–9.
  15. Worrell TW, Smith TL, Winegardner J. Effect of hamstring stretching on hamstring muscle performance. Journal of Orthopaedic and Sports Physical Therapy 1994;20(3):154–9.
  16. Beyerlein C, Hall TM, Hansson U, Odemark M, Sainsbury D, Lim HT. Effektivita¨ t der Mulligan-straight-leg-raise-Traktionstechnik auf die Beweglichkeit bei Patienten mit Ru¨ ckenschmerzen. Manuelle Therapie 2002;6:61–8.
  17. Meszaros TF, Olson R, Kulig C, Creighton D, Czarnecki E. Effect of 10%, 30% and 60% body weight traction on the straight leg raise test of symptomatic patients with low back pain. Journal of Orthopadic and Sports Physical Therapy 2000;30(10):595–601.
  18. Butler DS. Clinical neurobiomechanics. In: Mobilisation of the nervous system. Melbourne: Churchill Livingstone; 1991. p. 35–54.
  19. Elvey RL, Hall TM. Neural tissue evaluation and treatment. Donatelli R, editor. Physical therapy of the shoulder 3rd.New York; PA: Churchill Livingstone; 1997. p. 131–52.