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James May, Ryan Krzyzanowicz, Alan Nasypany, Russell Baker and Jeffrey Seegmiller


Although randomized controlled trials indicate that the Mulligan Concept (MC) of mobilization with movement can improve pain-free grip strength and pressure pain threshold in patients with lateral epicondylalgia of the elbow, improve ankle dorsiflexion in patients with subacute ankle sprains, and decrease the signs and symptoms of patients with cervicogenic headache, little is known about the clinical application, use, and profile of certified Mulligan practitioners (CMPs) in America.


To better understand the use and value of applying the MC philosophy in clinical-care environments from the perspective of American CMPs while establishing a clinical profile of a CMP.


Quantitative descriptive design. Setting: Online survey instrument.


American CMPs.

Data Collection and Analysis:

Online survey instrument.


CMPs use the MC to treat a broad spectrum of spinal and peripheral clinical pathologies in primarily outpatient clinics with an active and athletic population. American CMPs also find value in the MC.


American CMPs continue to use and find value in the MC intervention strategy to treat a broad spectrum of spinal and peripheral conditions in their clinical practices.

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Christanie Monreal, Lindsay Luinstra, Lindsay Larkins and James May

Context: Technological advances have given smartphones the capabilities of sensitive clinical measurement equipment at lesser cost and higher availability. The Clinometer is a smartphone application that can be used to measure the joint range of motion in a clinical setting, but psychometric properties of the tool’s use measuring cervical range of motion (CROM) are not established. Objectives: The purpose of this study was to examine the validity and intrarater reliability of the Clinometer application for the measurement of CROM (ie, flexion, extension, rotation, lateral flexion) and to determine the minimal detectable change and SEM. Design: A blinded, repeated-measures correlational design was employed. Setting: The study was conducted collaboratively between 2 athletic training clinics. Participants: A convenience sample of healthy adults ages 18–30 years were recruited. Participants with any history in the last 3 months of cervical or thoracic pathology, pain, or any musculoskeletal injury were excluded. Main Outcome Measures: Three repetitions of each motion were measured by a primary researcher with a goniometer. The same researcher then conducted 3 blinded measurements with the Clinometer application following the same procedure. A second researcher, blinded to the goniometer measurements, recorded the results. Thirty minutes later, testing was repeated with the application. The Pearson correlation was calculated to determine validity of the application compared with goniometry. Results: The measurements between devices had moderate to excellent concurrent validity, with the coefficients ranging between 0.544 and 0.888, P < .01. Test–retest reliability of the CROM measurement using the application was moderate to excellent, with intraclass correlation coefficients ranging between .774 and .928. Across all movements, the SEM ranged from 1.17° to 2.01°, and the minimal detectable change ranged from 1.18° to 2.02°. Conclusion: The Clinometer application is a valid and reliable instrument for measuring active CROM. Level of evidence: clinical measurement, level 1b.

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John M. Mayer, James E. Graves, Todd M. Manini, James L. Nuzzo and Lori L. Ploutz-Snyder

The purpose of this preliminary study was to assess lumbar multifidus, erector spinae, and quadratus lum-borum muscle activity during lifts as measured by changes in transverse relaxation time (T2) from magnetic resonance imaging (MRI). Thirteen healthy adults performed dynamic squat, stoop, and asymmetric stoop lifts at a standard load, with each lift followed by MRI. Increase in T2 for the multifidus and erector spinae was greater for the stoop than squat. No difference in T2 increase was noted between the multifidus and erector spinae for the squat or stoop. Increase in T2 for the contralateral multifidus was less for the asymmetric stoop than stoop. Future research using MRI and other biomechanical techniques is needed to fully characterize lumbar muscle activity during lifts for various populations, settings, postures, and loads.

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Garry T. Allison, Renee Weston, Rachael Shaw, Jocelyn Longhurst, Linda James, Kathleen Kyle, Katrina Nehyba, Suy May Low and Michelle May

The purpose of this study was to assess the reliability of quadriceps muscle stiffness assessments in individuals with Osgood–Schlatter disease (OSD). Ten subjects were tested for four trials on two occasions within a 2-week period on a Kin-Com dynamometer. A regression coefficient was derived from force-angle data to determine stiffness. Intertriai and interday Intraclass correlations (ICC) and standard error of measurement (SEM) were derived from a repeated-measures ANOVA. Between-trial assessments were more reliable for the outer range 65 to 100° knee flexion (ICC = .95 & .81) than the inner range 35 to 65° knee flexion (ICC = .72 & .57) for both sessions. The average SEMs for outer and inner ranges (over 35°) were 1.1 and 1.3 N, respectively. Assessments between days were less reliable, which may reflect the weekly variation in the presentation of athletes' with- OSD. It remains unclear if the SEM lies within the limits of clinical significance.

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Barbara N. Campaigne, Kyle W. Landt, Frederick W. James, Joan Reimar, Wayne Mays and Mark A. Sperling

Systolic time intervals (STI) were measured before and after exercise in 18 diabetic adolescents (D) and 18 age- and sex-matched nondiabetic controls (C). At similar heart rates, pre-exercise pre-ejection period (PEP) and left ventricular ejection time (LVET) were significantly shorter in D compared to C (p<0.05). There was no difference between the two groups in the PEP/LVET ratio. Following exercise there were no differences in STIs between groups. However, the change in PEP and LVET from pre- to postexercise was significantly less in D compared to C (delta PEP 38 vs. 53±3 msec, p<0.01; delta LVET 120 vs. 134±4 msec, p<0.05). These data suggest a hypercontractile state at rest in D and a blunted response to exercise when compared to C. This study provides data that may be relevant to the early identification of individuals at risk for premature diabetic cardiomyopathy.

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James M. May, Alan Nasypany, Julie Paolino, Russell Baker and Jeffrey Seegmiller


While the incidence and reinjury rates of lateral ankle sprain (LAS) continue to persist at high rates across many sporting activities, further exploration of assessment and treatment beyond the traditional ligamentous and strength/proprioceptive model is warranted. Further, assessing and treating both arthrokinematic and osteokinematic changes associated with LAS can provide insight into a more diverse approach to treating ankle pathology.


To examine the clinical use of the Mulligan Concept mobilization with movement (MWM) while treating patients diagnosed with an acute grade I or II LAS through authentic patient care.


An a priori case series.


Intercollegiate athletic training clinic.


Intercollegiate patients diagnosed with an acute grade I or II LAS.


The Mulligan Concept distal fibular anterior to posterior MWM.

Main Outcome Measures:

Pain-Intensity Numeric Rating Scale (NRS) with Non-Weight Bearing (NRS-NWB) and Weight Bearing (NRS-WB), Disablement of the Physically Active Scale (DPAscale), Foot and Ankle Ability Measure (FAAM) with Activity of Daily living (FAMM-ADL) and Sport (FAAM-Sport), Client Specific Impairment Measure (CSIM), Y-Balance Composite (YBC), and Weight Bearing Measure for Dorsiflexion (WBDF).


Patients who are diagnosed with an acute grade I or II LAS and are treated with the Mulligan Concept report immediate and long-lasting minimal clinically important differences in patient outcome measures.


Clinicians who examine and use the Mulligan Concept MWM to treat acute LAS can expect immediate positive results that are progressively retained over time specific to patient-centered outcome measures as well as functional clinicianbased measures. Based on the immediate and positive results, clinicians should examine associated osteokinematic and arthrokinematic changes beyond that of the traditional ligamentous model.

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Erica S. Albertin, Emilie N. Miley, James May, Russell T. Baker and Don Reordan

Clinical Scenario: Hip osteoarthritis currently affects up to 28% of the population, and the number of affected Americans is expected to rise as the American population increases and ages. Limited hip range of motion (ROM) has been identified as a predisposing factor to hip osteoarthritis and limited patient function. Clinicians often apply therapy techniques, such as stretching and strengthening exercises, to improve hip ROM. Although traditional therapy has been recommended to improve hip ROM, the efficiency of the treatments within the literature is questionable due to lack of high-quality studies. More recently, clinicians have begun to utilize joint mobilization and the Mulligan Concept mobilization with movement techniques to increase ROM at the hip; however, there is a paucity of research on the lasting effects of mobilizations. Given the difficulties in improving ROM immediately (within a single treatment) and with long-lasting results (over the course of months), it is imperative to examine the evidence for the effectiveness of traditional therapy techniques and more novel manual therapy techniques. Focused Clinical Question: Is there evidence to suggest manual mobilizations techniques at the hip are effective at treating hip ROM limitations? Summary of Clinical Findings: 5 Randomized Controlled Studies, improved patient function and ROM with the Mulligan concept, high velocity low amplitude improved. Clinical Bottom Line: We found moderate evidence to suggest favorable outcomes following the use of hip mobilizations aimed at improving hip ROM and patient function. Strength of Recommendation: Strength of the studies identified are 1B.

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Alex J. Rhinehart, Kevin M. Schroeder, James May, Russell Baker and Alan Nasypany

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Robert J. Bonser, Christy L. Hancock, Bethany L. Hansberger, Rick A. Loutsch, Eric K. Stanford, Alli K. Zeigel, Russell T. Baker, James May, Alan Nasypany and Scott Cheatham

Clinical Scenario:

Hamstring tightness is a common condition leading to dysfunctional or restricted movement that is often treated with stretching. Neurodynamics has been proposed as an alternative to stretching by targeting the neural system rather than muscle tissue.

Focused Clinical Question:

In an active population, what is the effect of using neurodynamic sliders compared with stretching on traditional measures of range of motion (ROM)?

Summary of Key Findings:

The authors of a well-designed study found that neurodynamic sliders were more effective than static stretching, while the authors of 2 less-well-designed studies reported no difference with static stretching or that proprioceptive neuromuscular facilitation stretching was more effective than neurodynamic sliders.

Clinical Bottom Line:

Evidence exists to support the use of neurodynamic sliders to increase measures of hamstring ROM in patients who present with limited hamstring flexibility; however, the effectiveness of neurodynamic sliders compared with traditional stretching is inconclusive.

Strength of Recommendation:

Grade B evidence exists that neurodynamic sliders perform as well as traditional stretching techniques at increasing measures of hamstring ROM in patients with limited hamstring flexibility.

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Christina M. Patch, Caterina G. Roman, Terry L. Conway, Ralph B. Taylor, Kavita A. Gavand, Brian E. Saelens, Marc A. Adams, Kelli L. Cain, Jessa K. Engelberg, Lauren Mayes, Scott C. Roesch and James F. Sallis

Background: A common hypothesis is that crime is a major barrier to physical activity, but research does not consistently support this assumption. This article advances research on crime-related safety and physical activity by developing a multilevel conceptual framework and reliable measures applicable across age groups. Methods: Criminologists and physical activity researchers collaborated to develop a conceptual framework. Survey development involved qualitative data collection and resulted in 155 items and 26 scales. Intraclass correlation coefficients (ICCs) were computed to assess test–retest reliability in a subsample of participants (N = 176). Analyses were conducted separately by age groups. Results: Test–retest reliability for most scales (63 of 104 ICCs across 4 age groups) was “excellent” or “good” (ICC ≥ .60) and only 18 ICCs were “poor” (ICC < .40). Reliability varied by age group. Adolescents (aged 12–17 y) had ICCs above the .40 threshold for 21 of 26 scales (81%). Young adults (aged 18–39 y) and middle-aged adults (aged 40–65 y) had ICCs above .40 for 24 (92%) and 23 (88%) scales, respectively. Older adults (aged 66 y and older) had ICCs above .40 for 18 of 26 scales (69%). Conclusions: The conceptual framework and reliable measures can be used to clarify the inconclusive relationships between crime-related safety and physical activity.