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Orthopedic Joint Mobilization and Manipulation
An Evidence-Based Approach
by Robert C. Manske, B.J. Lehecka, Michael P. Reiman and Janice K. Loudon
272 Pages
Orthopedic Joint Mobilization and Manipulation: An Evidence-Based Approach With Web Study Guide is a guide to clinical applications that can provide relief for a wide range of musculoskeletal ailments related to pain, dysfunction, and limited joint mobility. Ideal for physical therapy and athletic training students and professionals, this comprehensive resource provides a clear understanding of how thrust and nonthrust techniques work to eliminate pain and re-establish normal joint motion and function.
The text presents a thorough overview of the literature supporting the use of joint mobilization, joint manipulation, and manual therapy, and it incorporates the concepts and theories with easy-to-apply clinical methods for treating common musculoskeletal conditions. To bridge the gap between research and practice, readers will find an array of exceptional learning aids:
• Videos demonstrating proper procedures for 60 techniques
• A web study guide featuring 11 interactive case studies with questions regarding the proper treatment protocols
• Anatomical artwork overlaid on technique photos to show underlying bones, and directional arrows on the photos to guide hand placement and indicate thrust direction
• Technique guidelines, organized by body region, that address client and clinician positioning, stabilization, mobilization, and objectives
• Tables for each body region that use research evidence to compare outcomes of various interventions
• Clinical Tips sidebars offering insight and understanding into the why and how of techniques
Orthopedic Joint Mobilization and Manipulation is organized in four parts. Part I introduces the science behind joint mobilization and manipulation, including general joint kinesiology, evidence for joint mobilization, and general application guidelines. Parts II through IV then present mobilization and manipulation techniques for specific body regions of the craniomandibular complex and spine, the upper extremity, and the lower extremity.
A treatment finder at the front of the text allows readers to easily find techniques by body region. Each technique is presented in a consistent approach that addresses client and clinician positioning, stabilization, mobilization, and objective. Extensive medical illustrations provide strong visual cues. Tables containing evidence for manual therapy as well as charts on joint arthrology are included. At the end of the text is an appendix housing 26 self-mobilization techniques, along with photos, that clients can do on their own.
In addition to the learning aids, instructors will find helpful tools for teaching a course. The instructor guide features a sample syllabus, suggested laboratory activities, and class projects. A set of chapter quizzes offers 10 questions per chapter that can be used to track student progress and comprehension.
Orthopedic Joint Mobilization and Manipulation is an indispensable resource offering a variety of thrust and nonthrust techniques to relieve pain and restore normal joint function. Supported with research, this versatile text is ideal for use in classrooms, labs, clinics, and professional settings.
Part I. Introduction
Chapter 1. Basic Science Behind Joint Mobilization and Manipulation
History and Legislation
Mobilization and Manipulation
Joint Congruency and Position
Joint Movements
Convex and Concave Rules
Effects of Mobilization and Manipulation
Evidence for Joint Mobilization
Summary
Chapter 2. General Application Guidelines
General Examination
End-Feels
Capsular Patterns
Clinical Application of Joint Thrusts and Nonthrusts
Safety and Risk of Injury
Contraindications and Precautions for Thrust and Nonthrust Techniques
Summary
Part II. Mobilization and Manipulation of the Craniomandibular Complex and Spine
Chapter 3. Temporomandibular Joint
Anatomy
Joint Kinematics
Treatment Techniques
Chapter 4. Cervical Spine
Anatomy
Joint Kinematics
Treatment Techniques
Chapter 5. Thoracic Spine
Anatomy
Joint Kinematics
Treatment Techniques
Chapter 6. Lumbar Spine and Pelvis
Anatomy
Joint Kinematics
Treatment Techniques
Part III. Mobilization and Manipulation of the Upper Extremity
Chapter 7. Shoulder Joint
Anatomy
Joint Kinematics
Treatment Techniques
Chapter 8. Elbow Joint
Anatomy
Joint Kinematics
Treatment Techniques
Chapter 9. Wrist and Hand
Anatomy
Joint Kinematics
Treatment Techniques
Part IV. Mobilization and Manipulation of the Lower Extremity
Chapter 10. Hip Joint
Anatomy
Joint Kinematics
Treatment Techniques
Chapter 11. Knee Joint
Anatomy
Joint Kinematics
Treatment Techniques
Chapter 12. Ankle Joint
Anatomy
Joint Kinematics
Treatment Techniques
Chapter 13. Foot
Anatomy
Joint Kinematics
Treatment Techniques
Robert C. Manske PT, DPT, MPT, MEd, SCS, ATC, CSCS, is a professor in the doctoral physical therapy program at Wichita State University (WSU) in Wichita, Kansas. He graduated from WSU with a bachelor of arts degree in physical education in 1991, received a master of physical therapy degree in 1994, and earned a master of education degree in physical education in 2000. He received his DPT from Massachusetts General Institute of Health Professions in 2006.
Manske has been an APTA Board Certified Sports Physical Therapist since 2002, is a Certified Strength and Conditioning Specialist (CSCS) through the National Strength and Conditioning Association, and is a certified athletic trainer (ATC) through the Board of Certification for the Athletic Trainer. He was a two-term vice president of the APTA Sports Physical Therapy Section. He has received numerous awards for excellence in teaching at the local, state, and national levels, including the APTA Sports Physical Therapy Section’s Excellence in Education Award in 2007 and the Ron Peyton Award in 2018.
Manske has published multiple books, chapters, articles, and home study courses related to orthopedic and sports rehabilitation, and he has been editor of nine books on various topics related to orthopedics and sports. He is an associate editor for International Journal of Sports Physical Therapy and is currently a manuscript reviewer for Journal of Orthopedic and Sports Physical Therapy, Sports Health, Athletic Training and Sports Health Care, Physical Therapy in Sports, and American Journal of Sports Medicine (AJSM). From 2005 through 2007 and 2011 through 2017, he was a principle reviewer for AJSM.
Manske has lectured at the state and national levels during meetings for APTA, NATA, and NSCA. In addition to his full-time faculty appointment, he is a physical therapist and athletic trainer at Via Christi Health and also serves as a teaching associate for the University of Kansas Medical Center Department of Rehabilitation Sciences and for the Via Christi Family Practice Sports Medicine Residency Program.
B.J. Lehecka, DPT, is an assistant professor in the department of physical therapy in the College of Health Professions at Wichita State University (WSU) in Wichita, Kansas. At WSU, Lehecka teaches course work concerning the hip and spine regions, posture, gait, proprioceptive neuromuscular facilitation, musculoskeletal evaluation, and the treatment of musculoskeletal pathology. In 2016, he was awarded WSU’s Rodenberg Award for Excellence in Teaching due to his outstanding work in the classroom.
Lehecka has published multiple peer-reviewed journal articles, authored and edited numerous book chapters, and presented at state, national, and international conferences. He earned his bachelor’s degree in kinesiology from Kansas State University in 2006 and a doctorate in physical therapy from Wichita State University in 2009. Lehecka serves his community as a physical therapist and is a PhD candidate at Rocky Mountain University of Health Professions.
Michael P. Reiman, PT, DPT, MEd, OCS, SCS, ATC, FAAOMPT, CSCS, is an associate professor in the department of community and family practice at Duke University Medical Center in Durham, North Carolina. He is also part of the clinical faculty in the Duke University Medical Center manual therapy fellowship program. Reiman has published more than 50 articles in peer-reviewed journals as well as 10 book chapters and three home study courses. He coauthored Functional Testing in Human Performance (Human Kinetics, 2009) with Robert C. Manske. He has given numerous presentations at national, regional, and local conferences.
Reiman is a member of the American Physical Therapy Association, American Academy of Orthopaedic Manual Physical Therapists, Kansas Physical Therapy Association, National Athletic Trainers’ Association, National Strength and Conditioning Association, and Alpha Eta Society. He serves as an associate editor for Journal of Physical Therapy and is a member of the editorial boards for International Journal of Sports Physical Therapy and Journal of Sport Rehabilitation. He is a reviewer for British Journal of Sports Medicine, Journal of Sports Science and Medicine, Physiotherapy Theory and Practice, Journal of Sport Rehabilitation, Journal of Manual and Manipulative Therapy, Journal of Orthopaedic and Sports Physical Therapy, Clinical Anatomy, and Journal of Athletic Training.
Reiman is a level 1 track and field coach and a level 1 Olympic weightlifting club coach. He also works as a strength and conditioning specialist for women’s volleyball at Friends University in Wichita, Kansas, and for the men’s and women’s volleyball teams at Newman University in Wichita.
Reiman resides in Hillsborough, North Carolina, where he enjoys spending time with his family, hiking in the surrounding hills, and wakeboarding with his children.
Janice K. Loudon, PT, PhD, SCS, ATC, CSCS, is a professor in the department of physical therapy education at Rockhurst University in Kansas City, Missouri. She has more than 30 years of experience in clinical sports medicine and has worked as a physical therapy instructor for over 20 years. Dr. Loudon was previously an associate professor at Duke University and at the University of Kansas Medical Center in Kansas City.
Dr. Loudon is a board-certified sport physical therapist, certified athletic trainer, and certified strength and conditioning specialist. She is also a member of the National Athletic Trainers' Association (NATA) and the American Physical Therapy Association (APTA). She serves as the associate editor of the home study courses for APTA’s Sports Physical Therapy Section.
Loudon has published multiple articles in peer-reviewed journals, written several book chapters, and coauthored Clinical Mechanics and Kinesiology (Human Kinetics, 2013) and two editions of The Clinical Orthopedic Assessment Guide (Human Kinetics, 1998, 2008). She is a frequent presenter at national, state, and local conferences.
Loudon resides in Overland Park, Kansas. In her spare time, she enjoys hiking, cycling, gardening, and rooting for the Kansas Jayhawks.
Effects of mobilization and manipulation
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Mechanical Effects
The mechanical effects of joint mobilization relate to the restoration of normal joint mobility or range of motion. This includes flexibility and mobility of capsular and other soft tissue structures such as ligaments and tendons. Following injury and immobilization, soft tissues can become shortened and limit overall joint mobility. Adequate force must be applied to the tissues to create mechanical effects. Higher grade mobilizations may increase the joint mobility back to normal by restoring relative amounts of play in the once-restricted joint motion. Another theory of mechanical effect is the releasing or freeing of the facet joint meniscoid entrapment. A meniscoid entrapment may include a locking caused by entrapment of a facet joint meniscoid in a groove formed in the articular cartilage or by a meniscus piece that has broken free and formed a loose body that is entrapped (Lewitt, 1985).These meniscoids can become extremely painful sources of dysfunction. Fortunately, either gapping or an isometric movement that pulls the facet laterally can theoretically dislodge the impingement; the result can be immediate pain relief and improvement of joint motion. Current evidence supports only transient biomechanical effects on studies quantifying motion (Colloca, Keller, Harrison, Moore, Gunzburg, and Harrison, 2006; Coppieters and Alshami, 2007; Coppieters and Butler, 2007; Gal, Herzog, Kawchuk, Conway, and Zhang, 1997)but not a lasting positional change (Hsieh, Vicenzino, Yang, Hu, and Yang, 2002; Tullberg, Blomberg, Branth, and Johnsson, 1998).Neurophysiological and psychological effects should therefore be strongly considered.
Neurophysiological Effects
Applications of joint mobilizations and manipulation have been reported to create both local and distal neurophysiological effects (Bialosky, Bishop, and Bialosky, 2009; Bishop, Beneciuk, and George, 2011; Coranoda, Gay, and Bialosky, 2012; George, Bishop, and Bialosky, 2006). These effects may be especially enhanced when using the spine as the region of mobilization or manipulation application. Spinal soft tissues are highly innervated and may provide a large degree of afferent input into the central nervous system (Groen, Baljet, and Drukker, 1990). This input can come from multiple sources such as type I and II mechanoreceptors and free nerve endings found in cervical spine facet joints and muscle spindles of the cervical spine. Similar mechanisms might be seen in the remainder of the spine, but the number of nerve endings may be lower and less consistent in lower levels of the spine (McLain and Pickar, 1998). Movement such as mobilization or manipulation will fire these receptors and provide input to the central nervous system. These nerve receptors terminate in the spinal cord synapsing in the ventral and dorsal horn to signal proprioceptive and nociceptive information (Bolton, 1998).
Animal and human models have shown that the periaqueductal gray area of the midbrain is key for control of mediation of endogenous analgesia (Cannon, Prieto, and Lee, 1982; Hosobuchi, Adams, and Linchitz 1977; Reynolds, 1969). The periaqueductal gray area is in coordination with a complex network of systems including the nociceptive system, the autonomic nervous system, and the motor system. It has also been shown that type I and II mechanoreceptors from joints, muscles, and tendons project to the periaqueductal gray area (Yezierski, 1991). Evidence via postmanipulation sympathetic response combined with analgesia in symptomatic and asymptomatic subjects suggests a neurophysiologic response to spinal manipulation via mechanoreceptors (Wright, 1995). These effects may lie in the stimulation of the descending pain-inhibitory system of the central nervous system from midbrain to spinal cord.
Controversy persists regarding whether analgesic effects from mobilization and manipulation occur following treatment. Some reports suggest that mobilization or manipulation may stimulate a release of endogenous opioid peptides that bind to nervous system receptor sites, producing analgesia. Vernon and colleagues found increased levels of plasma beta-endorphin following manipulation, but these levels diminished to normal levels after only 15 minutes (Vernon, Dhami, Howley, et al., 1986). Controversy continues, as others have not succeeded in documenting these increased levels of endorphin compared to control groups (Christian, Stanton, and Sissons, 1998; Sanders, Reinnert, and Tepe, 1990).
The neurophysiological effect may also include a change in muscle activation patterns in which the motor system may be inhibited. The ability of mobilization and manipulation to inhibit muscle may vary depending on technique, location and nature of pain, and even the given muscles targeted with the manipulation. If mobilization or manipulation affects muscles, the neurophysiologic effects most likely occur locally at the targeted joint or region and the corresponding innervation distally associated with the shared innervation. The effects desired from performing the mobilization or manipulation are to increase facilitation of the deeper, more local muscles that assist with neuromuscular control of the area and, ideally, to inhibit the more superficial, global muscles that may be causing pain due to increased guarding of the joint or segments involved.
Psychological Effects
At least in the spinal model, evidence of improvement of psychological outcomes following manipulation is limited. In a meta-analysis, Williams, Hendry, Lewis, and colleagues (2007) reviewed 129 randomized controlled trials of spinal manipulation and identified 12 studies reporting psychological outcomes. These studies suggest that spinal manipulation may improve psychological outcomes compared to verbal interventions. Further, other variables, such as clinician and client expectations, may also play a role in the degree to which symptoms improve (Cross, Leach, Fawkes, and Moore, 2015; Riley, Bialosky, Cote, Swanson, Tafuto, Sizer, and Brismée, 2015). The greatest effect seems to be in those with a positive attitude and an expectation that the intervention will be helpful.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Clinical application of joint thrusts and nonthrusts
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors.
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors. For example, select clients may tolerate only small forces and amplitudes of nonthrusts over a short duration. If significant pain is present, nonthrusts should be applied using relatively small amplitudes and small forces. Maitland described four grades of nonthrust techniques (figure 2.1) (Maitland, 2005). Grades I and II are small and large amplitude nonthrusts, respectively, that do not reach the end of a joint's available arthrokinematic motion. These grades are generally for painful joints or apprehensive clients. Grades III and IV are large and small amplitude nonthrusts, respectively, that reach the end of a joint's available motion. These grades are generally used to increase arthrokinematic motion.
Maitland grades of movement.
Recommendations for the force, frequency, and amplitude of nonthrust techniques also vary depending on the joint being treated. For example, in the lumbar spine, evidence shows the average force for grade IV nonthrusts ranges from 90 N to 240 N (Snodgrass, 2006). In the knee, grade IV nonthrusts appear to be between 30 N and 78 N (Pentelka, Hebron, Shapleski, and Goldshtein, 2012). In larger joints, such as the knee and hip, clinicians should be able to appreciate arthrokinematic motion visually in addition to feeling the joint translation with their hands. This observation is more challenging at smaller joints such as the cervical spine.
Concerning the frequency of nonthrusts, one estimate is that clinicians apply oscillations at a rate of 1 to 1.5 per second (Snodgrass, 2006). One recommendation has been made for at least 4 sets of 60 seconds of oscillations to induce the analgesia at the lumbar spine (Pentelka et al., 2012). However, clinicians should modify their frequency and duration of manual therapy techniques to fit client needs.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Effects of mobilization and manipulation
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Mechanical Effects
The mechanical effects of joint mobilization relate to the restoration of normal joint mobility or range of motion. This includes flexibility and mobility of capsular and other soft tissue structures such as ligaments and tendons. Following injury and immobilization, soft tissues can become shortened and limit overall joint mobility. Adequate force must be applied to the tissues to create mechanical effects. Higher grade mobilizations may increase the joint mobility back to normal by restoring relative amounts of play in the once-restricted joint motion. Another theory of mechanical effect is the releasing or freeing of the facet joint meniscoid entrapment. A meniscoid entrapment may include a locking caused by entrapment of a facet joint meniscoid in a groove formed in the articular cartilage or by a meniscus piece that has broken free and formed a loose body that is entrapped (Lewitt, 1985).These meniscoids can become extremely painful sources of dysfunction. Fortunately, either gapping or an isometric movement that pulls the facet laterally can theoretically dislodge the impingement; the result can be immediate pain relief and improvement of joint motion. Current evidence supports only transient biomechanical effects on studies quantifying motion (Colloca, Keller, Harrison, Moore, Gunzburg, and Harrison, 2006; Coppieters and Alshami, 2007; Coppieters and Butler, 2007; Gal, Herzog, Kawchuk, Conway, and Zhang, 1997)but not a lasting positional change (Hsieh, Vicenzino, Yang, Hu, and Yang, 2002; Tullberg, Blomberg, Branth, and Johnsson, 1998).Neurophysiological and psychological effects should therefore be strongly considered.
Neurophysiological Effects
Applications of joint mobilizations and manipulation have been reported to create both local and distal neurophysiological effects (Bialosky, Bishop, and Bialosky, 2009; Bishop, Beneciuk, and George, 2011; Coranoda, Gay, and Bialosky, 2012; George, Bishop, and Bialosky, 2006). These effects may be especially enhanced when using the spine as the region of mobilization or manipulation application. Spinal soft tissues are highly innervated and may provide a large degree of afferent input into the central nervous system (Groen, Baljet, and Drukker, 1990). This input can come from multiple sources such as type I and II mechanoreceptors and free nerve endings found in cervical spine facet joints and muscle spindles of the cervical spine. Similar mechanisms might be seen in the remainder of the spine, but the number of nerve endings may be lower and less consistent in lower levels of the spine (McLain and Pickar, 1998). Movement such as mobilization or manipulation will fire these receptors and provide input to the central nervous system. These nerve receptors terminate in the spinal cord synapsing in the ventral and dorsal horn to signal proprioceptive and nociceptive information (Bolton, 1998).
Animal and human models have shown that the periaqueductal gray area of the midbrain is key for control of mediation of endogenous analgesia (Cannon, Prieto, and Lee, 1982; Hosobuchi, Adams, and Linchitz 1977; Reynolds, 1969). The periaqueductal gray area is in coordination with a complex network of systems including the nociceptive system, the autonomic nervous system, and the motor system. It has also been shown that type I and II mechanoreceptors from joints, muscles, and tendons project to the periaqueductal gray area (Yezierski, 1991). Evidence via postmanipulation sympathetic response combined with analgesia in symptomatic and asymptomatic subjects suggests a neurophysiologic response to spinal manipulation via mechanoreceptors (Wright, 1995). These effects may lie in the stimulation of the descending pain-inhibitory system of the central nervous system from midbrain to spinal cord.
Controversy persists regarding whether analgesic effects from mobilization and manipulation occur following treatment. Some reports suggest that mobilization or manipulation may stimulate a release of endogenous opioid peptides that bind to nervous system receptor sites, producing analgesia. Vernon and colleagues found increased levels of plasma beta-endorphin following manipulation, but these levels diminished to normal levels after only 15 minutes (Vernon, Dhami, Howley, et al., 1986). Controversy continues, as others have not succeeded in documenting these increased levels of endorphin compared to control groups (Christian, Stanton, and Sissons, 1998; Sanders, Reinnert, and Tepe, 1990).
The neurophysiological effect may also include a change in muscle activation patterns in which the motor system may be inhibited. The ability of mobilization and manipulation to inhibit muscle may vary depending on technique, location and nature of pain, and even the given muscles targeted with the manipulation. If mobilization or manipulation affects muscles, the neurophysiologic effects most likely occur locally at the targeted joint or region and the corresponding innervation distally associated with the shared innervation. The effects desired from performing the mobilization or manipulation are to increase facilitation of the deeper, more local muscles that assist with neuromuscular control of the area and, ideally, to inhibit the more superficial, global muscles that may be causing pain due to increased guarding of the joint or segments involved.
Psychological Effects
At least in the spinal model, evidence of improvement of psychological outcomes following manipulation is limited. In a meta-analysis, Williams, Hendry, Lewis, and colleagues (2007) reviewed 129 randomized controlled trials of spinal manipulation and identified 12 studies reporting psychological outcomes. These studies suggest that spinal manipulation may improve psychological outcomes compared to verbal interventions. Further, other variables, such as clinician and client expectations, may also play a role in the degree to which symptoms improve (Cross, Leach, Fawkes, and Moore, 2015; Riley, Bialosky, Cote, Swanson, Tafuto, Sizer, and Brismée, 2015). The greatest effect seems to be in those with a positive attitude and an expectation that the intervention will be helpful.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Clinical application of joint thrusts and nonthrusts
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors.
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors. For example, select clients may tolerate only small forces and amplitudes of nonthrusts over a short duration. If significant pain is present, nonthrusts should be applied using relatively small amplitudes and small forces. Maitland described four grades of nonthrust techniques (figure 2.1) (Maitland, 2005). Grades I and II are small and large amplitude nonthrusts, respectively, that do not reach the end of a joint's available arthrokinematic motion. These grades are generally for painful joints or apprehensive clients. Grades III and IV are large and small amplitude nonthrusts, respectively, that reach the end of a joint's available motion. These grades are generally used to increase arthrokinematic motion.
Maitland grades of movement.
Recommendations for the force, frequency, and amplitude of nonthrust techniques also vary depending on the joint being treated. For example, in the lumbar spine, evidence shows the average force for grade IV nonthrusts ranges from 90 N to 240 N (Snodgrass, 2006). In the knee, grade IV nonthrusts appear to be between 30 N and 78 N (Pentelka, Hebron, Shapleski, and Goldshtein, 2012). In larger joints, such as the knee and hip, clinicians should be able to appreciate arthrokinematic motion visually in addition to feeling the joint translation with their hands. This observation is more challenging at smaller joints such as the cervical spine.
Concerning the frequency of nonthrusts, one estimate is that clinicians apply oscillations at a rate of 1 to 1.5 per second (Snodgrass, 2006). One recommendation has been made for at least 4 sets of 60 seconds of oscillations to induce the analgesia at the lumbar spine (Pentelka et al., 2012). However, clinicians should modify their frequency and duration of manual therapy techniques to fit client needs.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Effects of mobilization and manipulation
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Mechanical Effects
The mechanical effects of joint mobilization relate to the restoration of normal joint mobility or range of motion. This includes flexibility and mobility of capsular and other soft tissue structures such as ligaments and tendons. Following injury and immobilization, soft tissues can become shortened and limit overall joint mobility. Adequate force must be applied to the tissues to create mechanical effects. Higher grade mobilizations may increase the joint mobility back to normal by restoring relative amounts of play in the once-restricted joint motion. Another theory of mechanical effect is the releasing or freeing of the facet joint meniscoid entrapment. A meniscoid entrapment may include a locking caused by entrapment of a facet joint meniscoid in a groove formed in the articular cartilage or by a meniscus piece that has broken free and formed a loose body that is entrapped (Lewitt, 1985).These meniscoids can become extremely painful sources of dysfunction. Fortunately, either gapping or an isometric movement that pulls the facet laterally can theoretically dislodge the impingement; the result can be immediate pain relief and improvement of joint motion. Current evidence supports only transient biomechanical effects on studies quantifying motion (Colloca, Keller, Harrison, Moore, Gunzburg, and Harrison, 2006; Coppieters and Alshami, 2007; Coppieters and Butler, 2007; Gal, Herzog, Kawchuk, Conway, and Zhang, 1997)but not a lasting positional change (Hsieh, Vicenzino, Yang, Hu, and Yang, 2002; Tullberg, Blomberg, Branth, and Johnsson, 1998).Neurophysiological and psychological effects should therefore be strongly considered.
Neurophysiological Effects
Applications of joint mobilizations and manipulation have been reported to create both local and distal neurophysiological effects (Bialosky, Bishop, and Bialosky, 2009; Bishop, Beneciuk, and George, 2011; Coranoda, Gay, and Bialosky, 2012; George, Bishop, and Bialosky, 2006). These effects may be especially enhanced when using the spine as the region of mobilization or manipulation application. Spinal soft tissues are highly innervated and may provide a large degree of afferent input into the central nervous system (Groen, Baljet, and Drukker, 1990). This input can come from multiple sources such as type I and II mechanoreceptors and free nerve endings found in cervical spine facet joints and muscle spindles of the cervical spine. Similar mechanisms might be seen in the remainder of the spine, but the number of nerve endings may be lower and less consistent in lower levels of the spine (McLain and Pickar, 1998). Movement such as mobilization or manipulation will fire these receptors and provide input to the central nervous system. These nerve receptors terminate in the spinal cord synapsing in the ventral and dorsal horn to signal proprioceptive and nociceptive information (Bolton, 1998).
Animal and human models have shown that the periaqueductal gray area of the midbrain is key for control of mediation of endogenous analgesia (Cannon, Prieto, and Lee, 1982; Hosobuchi, Adams, and Linchitz 1977; Reynolds, 1969). The periaqueductal gray area is in coordination with a complex network of systems including the nociceptive system, the autonomic nervous system, and the motor system. It has also been shown that type I and II mechanoreceptors from joints, muscles, and tendons project to the periaqueductal gray area (Yezierski, 1991). Evidence via postmanipulation sympathetic response combined with analgesia in symptomatic and asymptomatic subjects suggests a neurophysiologic response to spinal manipulation via mechanoreceptors (Wright, 1995). These effects may lie in the stimulation of the descending pain-inhibitory system of the central nervous system from midbrain to spinal cord.
Controversy persists regarding whether analgesic effects from mobilization and manipulation occur following treatment. Some reports suggest that mobilization or manipulation may stimulate a release of endogenous opioid peptides that bind to nervous system receptor sites, producing analgesia. Vernon and colleagues found increased levels of plasma beta-endorphin following manipulation, but these levels diminished to normal levels after only 15 minutes (Vernon, Dhami, Howley, et al., 1986). Controversy continues, as others have not succeeded in documenting these increased levels of endorphin compared to control groups (Christian, Stanton, and Sissons, 1998; Sanders, Reinnert, and Tepe, 1990).
The neurophysiological effect may also include a change in muscle activation patterns in which the motor system may be inhibited. The ability of mobilization and manipulation to inhibit muscle may vary depending on technique, location and nature of pain, and even the given muscles targeted with the manipulation. If mobilization or manipulation affects muscles, the neurophysiologic effects most likely occur locally at the targeted joint or region and the corresponding innervation distally associated with the shared innervation. The effects desired from performing the mobilization or manipulation are to increase facilitation of the deeper, more local muscles that assist with neuromuscular control of the area and, ideally, to inhibit the more superficial, global muscles that may be causing pain due to increased guarding of the joint or segments involved.
Psychological Effects
At least in the spinal model, evidence of improvement of psychological outcomes following manipulation is limited. In a meta-analysis, Williams, Hendry, Lewis, and colleagues (2007) reviewed 129 randomized controlled trials of spinal manipulation and identified 12 studies reporting psychological outcomes. These studies suggest that spinal manipulation may improve psychological outcomes compared to verbal interventions. Further, other variables, such as clinician and client expectations, may also play a role in the degree to which symptoms improve (Cross, Leach, Fawkes, and Moore, 2015; Riley, Bialosky, Cote, Swanson, Tafuto, Sizer, and Brismée, 2015). The greatest effect seems to be in those with a positive attitude and an expectation that the intervention will be helpful.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Clinical application of joint thrusts and nonthrusts
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors.
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors. For example, select clients may tolerate only small forces and amplitudes of nonthrusts over a short duration. If significant pain is present, nonthrusts should be applied using relatively small amplitudes and small forces. Maitland described four grades of nonthrust techniques (figure 2.1) (Maitland, 2005). Grades I and II are small and large amplitude nonthrusts, respectively, that do not reach the end of a joint's available arthrokinematic motion. These grades are generally for painful joints or apprehensive clients. Grades III and IV are large and small amplitude nonthrusts, respectively, that reach the end of a joint's available motion. These grades are generally used to increase arthrokinematic motion.
Maitland grades of movement.
Recommendations for the force, frequency, and amplitude of nonthrust techniques also vary depending on the joint being treated. For example, in the lumbar spine, evidence shows the average force for grade IV nonthrusts ranges from 90 N to 240 N (Snodgrass, 2006). In the knee, grade IV nonthrusts appear to be between 30 N and 78 N (Pentelka, Hebron, Shapleski, and Goldshtein, 2012). In larger joints, such as the knee and hip, clinicians should be able to appreciate arthrokinematic motion visually in addition to feeling the joint translation with their hands. This observation is more challenging at smaller joints such as the cervical spine.
Concerning the frequency of nonthrusts, one estimate is that clinicians apply oscillations at a rate of 1 to 1.5 per second (Snodgrass, 2006). One recommendation has been made for at least 4 sets of 60 seconds of oscillations to induce the analgesia at the lumbar spine (Pentelka et al., 2012). However, clinicians should modify their frequency and duration of manual therapy techniques to fit client needs.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Effects of mobilization and manipulation
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Mechanical Effects
The mechanical effects of joint mobilization relate to the restoration of normal joint mobility or range of motion. This includes flexibility and mobility of capsular and other soft tissue structures such as ligaments and tendons. Following injury and immobilization, soft tissues can become shortened and limit overall joint mobility. Adequate force must be applied to the tissues to create mechanical effects. Higher grade mobilizations may increase the joint mobility back to normal by restoring relative amounts of play in the once-restricted joint motion. Another theory of mechanical effect is the releasing or freeing of the facet joint meniscoid entrapment. A meniscoid entrapment may include a locking caused by entrapment of a facet joint meniscoid in a groove formed in the articular cartilage or by a meniscus piece that has broken free and formed a loose body that is entrapped (Lewitt, 1985).These meniscoids can become extremely painful sources of dysfunction. Fortunately, either gapping or an isometric movement that pulls the facet laterally can theoretically dislodge the impingement; the result can be immediate pain relief and improvement of joint motion. Current evidence supports only transient biomechanical effects on studies quantifying motion (Colloca, Keller, Harrison, Moore, Gunzburg, and Harrison, 2006; Coppieters and Alshami, 2007; Coppieters and Butler, 2007; Gal, Herzog, Kawchuk, Conway, and Zhang, 1997)but not a lasting positional change (Hsieh, Vicenzino, Yang, Hu, and Yang, 2002; Tullberg, Blomberg, Branth, and Johnsson, 1998).Neurophysiological and psychological effects should therefore be strongly considered.
Neurophysiological Effects
Applications of joint mobilizations and manipulation have been reported to create both local and distal neurophysiological effects (Bialosky, Bishop, and Bialosky, 2009; Bishop, Beneciuk, and George, 2011; Coranoda, Gay, and Bialosky, 2012; George, Bishop, and Bialosky, 2006). These effects may be especially enhanced when using the spine as the region of mobilization or manipulation application. Spinal soft tissues are highly innervated and may provide a large degree of afferent input into the central nervous system (Groen, Baljet, and Drukker, 1990). This input can come from multiple sources such as type I and II mechanoreceptors and free nerve endings found in cervical spine facet joints and muscle spindles of the cervical spine. Similar mechanisms might be seen in the remainder of the spine, but the number of nerve endings may be lower and less consistent in lower levels of the spine (McLain and Pickar, 1998). Movement such as mobilization or manipulation will fire these receptors and provide input to the central nervous system. These nerve receptors terminate in the spinal cord synapsing in the ventral and dorsal horn to signal proprioceptive and nociceptive information (Bolton, 1998).
Animal and human models have shown that the periaqueductal gray area of the midbrain is key for control of mediation of endogenous analgesia (Cannon, Prieto, and Lee, 1982; Hosobuchi, Adams, and Linchitz 1977; Reynolds, 1969). The periaqueductal gray area is in coordination with a complex network of systems including the nociceptive system, the autonomic nervous system, and the motor system. It has also been shown that type I and II mechanoreceptors from joints, muscles, and tendons project to the periaqueductal gray area (Yezierski, 1991). Evidence via postmanipulation sympathetic response combined with analgesia in symptomatic and asymptomatic subjects suggests a neurophysiologic response to spinal manipulation via mechanoreceptors (Wright, 1995). These effects may lie in the stimulation of the descending pain-inhibitory system of the central nervous system from midbrain to spinal cord.
Controversy persists regarding whether analgesic effects from mobilization and manipulation occur following treatment. Some reports suggest that mobilization or manipulation may stimulate a release of endogenous opioid peptides that bind to nervous system receptor sites, producing analgesia. Vernon and colleagues found increased levels of plasma beta-endorphin following manipulation, but these levels diminished to normal levels after only 15 minutes (Vernon, Dhami, Howley, et al., 1986). Controversy continues, as others have not succeeded in documenting these increased levels of endorphin compared to control groups (Christian, Stanton, and Sissons, 1998; Sanders, Reinnert, and Tepe, 1990).
The neurophysiological effect may also include a change in muscle activation patterns in which the motor system may be inhibited. The ability of mobilization and manipulation to inhibit muscle may vary depending on technique, location and nature of pain, and even the given muscles targeted with the manipulation. If mobilization or manipulation affects muscles, the neurophysiologic effects most likely occur locally at the targeted joint or region and the corresponding innervation distally associated with the shared innervation. The effects desired from performing the mobilization or manipulation are to increase facilitation of the deeper, more local muscles that assist with neuromuscular control of the area and, ideally, to inhibit the more superficial, global muscles that may be causing pain due to increased guarding of the joint or segments involved.
Psychological Effects
At least in the spinal model, evidence of improvement of psychological outcomes following manipulation is limited. In a meta-analysis, Williams, Hendry, Lewis, and colleagues (2007) reviewed 129 randomized controlled trials of spinal manipulation and identified 12 studies reporting psychological outcomes. These studies suggest that spinal manipulation may improve psychological outcomes compared to verbal interventions. Further, other variables, such as clinician and client expectations, may also play a role in the degree to which symptoms improve (Cross, Leach, Fawkes, and Moore, 2015; Riley, Bialosky, Cote, Swanson, Tafuto, Sizer, and Brismée, 2015). The greatest effect seems to be in those with a positive attitude and an expectation that the intervention will be helpful.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Clinical application of joint thrusts and nonthrusts
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors.
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors. For example, select clients may tolerate only small forces and amplitudes of nonthrusts over a short duration. If significant pain is present, nonthrusts should be applied using relatively small amplitudes and small forces. Maitland described four grades of nonthrust techniques (figure 2.1) (Maitland, 2005). Grades I and II are small and large amplitude nonthrusts, respectively, that do not reach the end of a joint's available arthrokinematic motion. These grades are generally for painful joints or apprehensive clients. Grades III and IV are large and small amplitude nonthrusts, respectively, that reach the end of a joint's available motion. These grades are generally used to increase arthrokinematic motion.
Maitland grades of movement.
Recommendations for the force, frequency, and amplitude of nonthrust techniques also vary depending on the joint being treated. For example, in the lumbar spine, evidence shows the average force for grade IV nonthrusts ranges from 90 N to 240 N (Snodgrass, 2006). In the knee, grade IV nonthrusts appear to be between 30 N and 78 N (Pentelka, Hebron, Shapleski, and Goldshtein, 2012). In larger joints, such as the knee and hip, clinicians should be able to appreciate arthrokinematic motion visually in addition to feeling the joint translation with their hands. This observation is more challenging at smaller joints such as the cervical spine.
Concerning the frequency of nonthrusts, one estimate is that clinicians apply oscillations at a rate of 1 to 1.5 per second (Snodgrass, 2006). One recommendation has been made for at least 4 sets of 60 seconds of oscillations to induce the analgesia at the lumbar spine (Pentelka et al., 2012). However, clinicians should modify their frequency and duration of manual therapy techniques to fit client needs.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Effects of mobilization and manipulation
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Mechanical Effects
The mechanical effects of joint mobilization relate to the restoration of normal joint mobility or range of motion. This includes flexibility and mobility of capsular and other soft tissue structures such as ligaments and tendons. Following injury and immobilization, soft tissues can become shortened and limit overall joint mobility. Adequate force must be applied to the tissues to create mechanical effects. Higher grade mobilizations may increase the joint mobility back to normal by restoring relative amounts of play in the once-restricted joint motion. Another theory of mechanical effect is the releasing or freeing of the facet joint meniscoid entrapment. A meniscoid entrapment may include a locking caused by entrapment of a facet joint meniscoid in a groove formed in the articular cartilage or by a meniscus piece that has broken free and formed a loose body that is entrapped (Lewitt, 1985).These meniscoids can become extremely painful sources of dysfunction. Fortunately, either gapping or an isometric movement that pulls the facet laterally can theoretically dislodge the impingement; the result can be immediate pain relief and improvement of joint motion. Current evidence supports only transient biomechanical effects on studies quantifying motion (Colloca, Keller, Harrison, Moore, Gunzburg, and Harrison, 2006; Coppieters and Alshami, 2007; Coppieters and Butler, 2007; Gal, Herzog, Kawchuk, Conway, and Zhang, 1997)but not a lasting positional change (Hsieh, Vicenzino, Yang, Hu, and Yang, 2002; Tullberg, Blomberg, Branth, and Johnsson, 1998).Neurophysiological and psychological effects should therefore be strongly considered.
Neurophysiological Effects
Applications of joint mobilizations and manipulation have been reported to create both local and distal neurophysiological effects (Bialosky, Bishop, and Bialosky, 2009; Bishop, Beneciuk, and George, 2011; Coranoda, Gay, and Bialosky, 2012; George, Bishop, and Bialosky, 2006). These effects may be especially enhanced when using the spine as the region of mobilization or manipulation application. Spinal soft tissues are highly innervated and may provide a large degree of afferent input into the central nervous system (Groen, Baljet, and Drukker, 1990). This input can come from multiple sources such as type I and II mechanoreceptors and free nerve endings found in cervical spine facet joints and muscle spindles of the cervical spine. Similar mechanisms might be seen in the remainder of the spine, but the number of nerve endings may be lower and less consistent in lower levels of the spine (McLain and Pickar, 1998). Movement such as mobilization or manipulation will fire these receptors and provide input to the central nervous system. These nerve receptors terminate in the spinal cord synapsing in the ventral and dorsal horn to signal proprioceptive and nociceptive information (Bolton, 1998).
Animal and human models have shown that the periaqueductal gray area of the midbrain is key for control of mediation of endogenous analgesia (Cannon, Prieto, and Lee, 1982; Hosobuchi, Adams, and Linchitz 1977; Reynolds, 1969). The periaqueductal gray area is in coordination with a complex network of systems including the nociceptive system, the autonomic nervous system, and the motor system. It has also been shown that type I and II mechanoreceptors from joints, muscles, and tendons project to the periaqueductal gray area (Yezierski, 1991). Evidence via postmanipulation sympathetic response combined with analgesia in symptomatic and asymptomatic subjects suggests a neurophysiologic response to spinal manipulation via mechanoreceptors (Wright, 1995). These effects may lie in the stimulation of the descending pain-inhibitory system of the central nervous system from midbrain to spinal cord.
Controversy persists regarding whether analgesic effects from mobilization and manipulation occur following treatment. Some reports suggest that mobilization or manipulation may stimulate a release of endogenous opioid peptides that bind to nervous system receptor sites, producing analgesia. Vernon and colleagues found increased levels of plasma beta-endorphin following manipulation, but these levels diminished to normal levels after only 15 minutes (Vernon, Dhami, Howley, et al., 1986). Controversy continues, as others have not succeeded in documenting these increased levels of endorphin compared to control groups (Christian, Stanton, and Sissons, 1998; Sanders, Reinnert, and Tepe, 1990).
The neurophysiological effect may also include a change in muscle activation patterns in which the motor system may be inhibited. The ability of mobilization and manipulation to inhibit muscle may vary depending on technique, location and nature of pain, and even the given muscles targeted with the manipulation. If mobilization or manipulation affects muscles, the neurophysiologic effects most likely occur locally at the targeted joint or region and the corresponding innervation distally associated with the shared innervation. The effects desired from performing the mobilization or manipulation are to increase facilitation of the deeper, more local muscles that assist with neuromuscular control of the area and, ideally, to inhibit the more superficial, global muscles that may be causing pain due to increased guarding of the joint or segments involved.
Psychological Effects
At least in the spinal model, evidence of improvement of psychological outcomes following manipulation is limited. In a meta-analysis, Williams, Hendry, Lewis, and colleagues (2007) reviewed 129 randomized controlled trials of spinal manipulation and identified 12 studies reporting psychological outcomes. These studies suggest that spinal manipulation may improve psychological outcomes compared to verbal interventions. Further, other variables, such as clinician and client expectations, may also play a role in the degree to which symptoms improve (Cross, Leach, Fawkes, and Moore, 2015; Riley, Bialosky, Cote, Swanson, Tafuto, Sizer, and Brismée, 2015). The greatest effect seems to be in those with a positive attitude and an expectation that the intervention will be helpful.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Clinical application of joint thrusts and nonthrusts
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors.
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors. For example, select clients may tolerate only small forces and amplitudes of nonthrusts over a short duration. If significant pain is present, nonthrusts should be applied using relatively small amplitudes and small forces. Maitland described four grades of nonthrust techniques (figure 2.1) (Maitland, 2005). Grades I and II are small and large amplitude nonthrusts, respectively, that do not reach the end of a joint's available arthrokinematic motion. These grades are generally for painful joints or apprehensive clients. Grades III and IV are large and small amplitude nonthrusts, respectively, that reach the end of a joint's available motion. These grades are generally used to increase arthrokinematic motion.
Maitland grades of movement.
Recommendations for the force, frequency, and amplitude of nonthrust techniques also vary depending on the joint being treated. For example, in the lumbar spine, evidence shows the average force for grade IV nonthrusts ranges from 90 N to 240 N (Snodgrass, 2006). In the knee, grade IV nonthrusts appear to be between 30 N and 78 N (Pentelka, Hebron, Shapleski, and Goldshtein, 2012). In larger joints, such as the knee and hip, clinicians should be able to appreciate arthrokinematic motion visually in addition to feeling the joint translation with their hands. This observation is more challenging at smaller joints such as the cervical spine.
Concerning the frequency of nonthrusts, one estimate is that clinicians apply oscillations at a rate of 1 to 1.5 per second (Snodgrass, 2006). One recommendation has been made for at least 4 sets of 60 seconds of oscillations to induce the analgesia at the lumbar spine (Pentelka et al., 2012). However, clinicians should modify their frequency and duration of manual therapy techniques to fit client needs.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Effects of mobilization and manipulation
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Mechanical Effects
The mechanical effects of joint mobilization relate to the restoration of normal joint mobility or range of motion. This includes flexibility and mobility of capsular and other soft tissue structures such as ligaments and tendons. Following injury and immobilization, soft tissues can become shortened and limit overall joint mobility. Adequate force must be applied to the tissues to create mechanical effects. Higher grade mobilizations may increase the joint mobility back to normal by restoring relative amounts of play in the once-restricted joint motion. Another theory of mechanical effect is the releasing or freeing of the facet joint meniscoid entrapment. A meniscoid entrapment may include a locking caused by entrapment of a facet joint meniscoid in a groove formed in the articular cartilage or by a meniscus piece that has broken free and formed a loose body that is entrapped (Lewitt, 1985).These meniscoids can become extremely painful sources of dysfunction. Fortunately, either gapping or an isometric movement that pulls the facet laterally can theoretically dislodge the impingement; the result can be immediate pain relief and improvement of joint motion. Current evidence supports only transient biomechanical effects on studies quantifying motion (Colloca, Keller, Harrison, Moore, Gunzburg, and Harrison, 2006; Coppieters and Alshami, 2007; Coppieters and Butler, 2007; Gal, Herzog, Kawchuk, Conway, and Zhang, 1997)but not a lasting positional change (Hsieh, Vicenzino, Yang, Hu, and Yang, 2002; Tullberg, Blomberg, Branth, and Johnsson, 1998).Neurophysiological and psychological effects should therefore be strongly considered.
Neurophysiological Effects
Applications of joint mobilizations and manipulation have been reported to create both local and distal neurophysiological effects (Bialosky, Bishop, and Bialosky, 2009; Bishop, Beneciuk, and George, 2011; Coranoda, Gay, and Bialosky, 2012; George, Bishop, and Bialosky, 2006). These effects may be especially enhanced when using the spine as the region of mobilization or manipulation application. Spinal soft tissues are highly innervated and may provide a large degree of afferent input into the central nervous system (Groen, Baljet, and Drukker, 1990). This input can come from multiple sources such as type I and II mechanoreceptors and free nerve endings found in cervical spine facet joints and muscle spindles of the cervical spine. Similar mechanisms might be seen in the remainder of the spine, but the number of nerve endings may be lower and less consistent in lower levels of the spine (McLain and Pickar, 1998). Movement such as mobilization or manipulation will fire these receptors and provide input to the central nervous system. These nerve receptors terminate in the spinal cord synapsing in the ventral and dorsal horn to signal proprioceptive and nociceptive information (Bolton, 1998).
Animal and human models have shown that the periaqueductal gray area of the midbrain is key for control of mediation of endogenous analgesia (Cannon, Prieto, and Lee, 1982; Hosobuchi, Adams, and Linchitz 1977; Reynolds, 1969). The periaqueductal gray area is in coordination with a complex network of systems including the nociceptive system, the autonomic nervous system, and the motor system. It has also been shown that type I and II mechanoreceptors from joints, muscles, and tendons project to the periaqueductal gray area (Yezierski, 1991). Evidence via postmanipulation sympathetic response combined with analgesia in symptomatic and asymptomatic subjects suggests a neurophysiologic response to spinal manipulation via mechanoreceptors (Wright, 1995). These effects may lie in the stimulation of the descending pain-inhibitory system of the central nervous system from midbrain to spinal cord.
Controversy persists regarding whether analgesic effects from mobilization and manipulation occur following treatment. Some reports suggest that mobilization or manipulation may stimulate a release of endogenous opioid peptides that bind to nervous system receptor sites, producing analgesia. Vernon and colleagues found increased levels of plasma beta-endorphin following manipulation, but these levels diminished to normal levels after only 15 minutes (Vernon, Dhami, Howley, et al., 1986). Controversy continues, as others have not succeeded in documenting these increased levels of endorphin compared to control groups (Christian, Stanton, and Sissons, 1998; Sanders, Reinnert, and Tepe, 1990).
The neurophysiological effect may also include a change in muscle activation patterns in which the motor system may be inhibited. The ability of mobilization and manipulation to inhibit muscle may vary depending on technique, location and nature of pain, and even the given muscles targeted with the manipulation. If mobilization or manipulation affects muscles, the neurophysiologic effects most likely occur locally at the targeted joint or region and the corresponding innervation distally associated with the shared innervation. The effects desired from performing the mobilization or manipulation are to increase facilitation of the deeper, more local muscles that assist with neuromuscular control of the area and, ideally, to inhibit the more superficial, global muscles that may be causing pain due to increased guarding of the joint or segments involved.
Psychological Effects
At least in the spinal model, evidence of improvement of psychological outcomes following manipulation is limited. In a meta-analysis, Williams, Hendry, Lewis, and colleagues (2007) reviewed 129 randomized controlled trials of spinal manipulation and identified 12 studies reporting psychological outcomes. These studies suggest that spinal manipulation may improve psychological outcomes compared to verbal interventions. Further, other variables, such as clinician and client expectations, may also play a role in the degree to which symptoms improve (Cross, Leach, Fawkes, and Moore, 2015; Riley, Bialosky, Cote, Swanson, Tafuto, Sizer, and Brismée, 2015). The greatest effect seems to be in those with a positive attitude and an expectation that the intervention will be helpful.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Clinical application of joint thrusts and nonthrusts
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors.
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors. For example, select clients may tolerate only small forces and amplitudes of nonthrusts over a short duration. If significant pain is present, nonthrusts should be applied using relatively small amplitudes and small forces. Maitland described four grades of nonthrust techniques (figure 2.1) (Maitland, 2005). Grades I and II are small and large amplitude nonthrusts, respectively, that do not reach the end of a joint's available arthrokinematic motion. These grades are generally for painful joints or apprehensive clients. Grades III and IV are large and small amplitude nonthrusts, respectively, that reach the end of a joint's available motion. These grades are generally used to increase arthrokinematic motion.
Maitland grades of movement.
Recommendations for the force, frequency, and amplitude of nonthrust techniques also vary depending on the joint being treated. For example, in the lumbar spine, evidence shows the average force for grade IV nonthrusts ranges from 90 N to 240 N (Snodgrass, 2006). In the knee, grade IV nonthrusts appear to be between 30 N and 78 N (Pentelka, Hebron, Shapleski, and Goldshtein, 2012). In larger joints, such as the knee and hip, clinicians should be able to appreciate arthrokinematic motion visually in addition to feeling the joint translation with their hands. This observation is more challenging at smaller joints such as the cervical spine.
Concerning the frequency of nonthrusts, one estimate is that clinicians apply oscillations at a rate of 1 to 1.5 per second (Snodgrass, 2006). One recommendation has been made for at least 4 sets of 60 seconds of oscillations to induce the analgesia at the lumbar spine (Pentelka et al., 2012). However, clinicians should modify their frequency and duration of manual therapy techniques to fit client needs.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Effects of mobilization and manipulation
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Mechanical Effects
The mechanical effects of joint mobilization relate to the restoration of normal joint mobility or range of motion. This includes flexibility and mobility of capsular and other soft tissue structures such as ligaments and tendons. Following injury and immobilization, soft tissues can become shortened and limit overall joint mobility. Adequate force must be applied to the tissues to create mechanical effects. Higher grade mobilizations may increase the joint mobility back to normal by restoring relative amounts of play in the once-restricted joint motion. Another theory of mechanical effect is the releasing or freeing of the facet joint meniscoid entrapment. A meniscoid entrapment may include a locking caused by entrapment of a facet joint meniscoid in a groove formed in the articular cartilage or by a meniscus piece that has broken free and formed a loose body that is entrapped (Lewitt, 1985).These meniscoids can become extremely painful sources of dysfunction. Fortunately, either gapping or an isometric movement that pulls the facet laterally can theoretically dislodge the impingement; the result can be immediate pain relief and improvement of joint motion. Current evidence supports only transient biomechanical effects on studies quantifying motion (Colloca, Keller, Harrison, Moore, Gunzburg, and Harrison, 2006; Coppieters and Alshami, 2007; Coppieters and Butler, 2007; Gal, Herzog, Kawchuk, Conway, and Zhang, 1997)but not a lasting positional change (Hsieh, Vicenzino, Yang, Hu, and Yang, 2002; Tullberg, Blomberg, Branth, and Johnsson, 1998).Neurophysiological and psychological effects should therefore be strongly considered.
Neurophysiological Effects
Applications of joint mobilizations and manipulation have been reported to create both local and distal neurophysiological effects (Bialosky, Bishop, and Bialosky, 2009; Bishop, Beneciuk, and George, 2011; Coranoda, Gay, and Bialosky, 2012; George, Bishop, and Bialosky, 2006). These effects may be especially enhanced when using the spine as the region of mobilization or manipulation application. Spinal soft tissues are highly innervated and may provide a large degree of afferent input into the central nervous system (Groen, Baljet, and Drukker, 1990). This input can come from multiple sources such as type I and II mechanoreceptors and free nerve endings found in cervical spine facet joints and muscle spindles of the cervical spine. Similar mechanisms might be seen in the remainder of the spine, but the number of nerve endings may be lower and less consistent in lower levels of the spine (McLain and Pickar, 1998). Movement such as mobilization or manipulation will fire these receptors and provide input to the central nervous system. These nerve receptors terminate in the spinal cord synapsing in the ventral and dorsal horn to signal proprioceptive and nociceptive information (Bolton, 1998).
Animal and human models have shown that the periaqueductal gray area of the midbrain is key for control of mediation of endogenous analgesia (Cannon, Prieto, and Lee, 1982; Hosobuchi, Adams, and Linchitz 1977; Reynolds, 1969). The periaqueductal gray area is in coordination with a complex network of systems including the nociceptive system, the autonomic nervous system, and the motor system. It has also been shown that type I and II mechanoreceptors from joints, muscles, and tendons project to the periaqueductal gray area (Yezierski, 1991). Evidence via postmanipulation sympathetic response combined with analgesia in symptomatic and asymptomatic subjects suggests a neurophysiologic response to spinal manipulation via mechanoreceptors (Wright, 1995). These effects may lie in the stimulation of the descending pain-inhibitory system of the central nervous system from midbrain to spinal cord.
Controversy persists regarding whether analgesic effects from mobilization and manipulation occur following treatment. Some reports suggest that mobilization or manipulation may stimulate a release of endogenous opioid peptides that bind to nervous system receptor sites, producing analgesia. Vernon and colleagues found increased levels of plasma beta-endorphin following manipulation, but these levels diminished to normal levels after only 15 minutes (Vernon, Dhami, Howley, et al., 1986). Controversy continues, as others have not succeeded in documenting these increased levels of endorphin compared to control groups (Christian, Stanton, and Sissons, 1998; Sanders, Reinnert, and Tepe, 1990).
The neurophysiological effect may also include a change in muscle activation patterns in which the motor system may be inhibited. The ability of mobilization and manipulation to inhibit muscle may vary depending on technique, location and nature of pain, and even the given muscles targeted with the manipulation. If mobilization or manipulation affects muscles, the neurophysiologic effects most likely occur locally at the targeted joint or region and the corresponding innervation distally associated with the shared innervation. The effects desired from performing the mobilization or manipulation are to increase facilitation of the deeper, more local muscles that assist with neuromuscular control of the area and, ideally, to inhibit the more superficial, global muscles that may be causing pain due to increased guarding of the joint or segments involved.
Psychological Effects
At least in the spinal model, evidence of improvement of psychological outcomes following manipulation is limited. In a meta-analysis, Williams, Hendry, Lewis, and colleagues (2007) reviewed 129 randomized controlled trials of spinal manipulation and identified 12 studies reporting psychological outcomes. These studies suggest that spinal manipulation may improve psychological outcomes compared to verbal interventions. Further, other variables, such as clinician and client expectations, may also play a role in the degree to which symptoms improve (Cross, Leach, Fawkes, and Moore, 2015; Riley, Bialosky, Cote, Swanson, Tafuto, Sizer, and Brismée, 2015). The greatest effect seems to be in those with a positive attitude and an expectation that the intervention will be helpful.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Clinical application of joint thrusts and nonthrusts
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors.
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors. For example, select clients may tolerate only small forces and amplitudes of nonthrusts over a short duration. If significant pain is present, nonthrusts should be applied using relatively small amplitudes and small forces. Maitland described four grades of nonthrust techniques (figure 2.1) (Maitland, 2005). Grades I and II are small and large amplitude nonthrusts, respectively, that do not reach the end of a joint's available arthrokinematic motion. These grades are generally for painful joints or apprehensive clients. Grades III and IV are large and small amplitude nonthrusts, respectively, that reach the end of a joint's available motion. These grades are generally used to increase arthrokinematic motion.
Maitland grades of movement.
Recommendations for the force, frequency, and amplitude of nonthrust techniques also vary depending on the joint being treated. For example, in the lumbar spine, evidence shows the average force for grade IV nonthrusts ranges from 90 N to 240 N (Snodgrass, 2006). In the knee, grade IV nonthrusts appear to be between 30 N and 78 N (Pentelka, Hebron, Shapleski, and Goldshtein, 2012). In larger joints, such as the knee and hip, clinicians should be able to appreciate arthrokinematic motion visually in addition to feeling the joint translation with their hands. This observation is more challenging at smaller joints such as the cervical spine.
Concerning the frequency of nonthrusts, one estimate is that clinicians apply oscillations at a rate of 1 to 1.5 per second (Snodgrass, 2006). One recommendation has been made for at least 4 sets of 60 seconds of oscillations to induce the analgesia at the lumbar spine (Pentelka et al., 2012). However, clinicians should modify their frequency and duration of manual therapy techniques to fit client needs.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Effects of mobilization and manipulation
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Mechanical Effects
The mechanical effects of joint mobilization relate to the restoration of normal joint mobility or range of motion. This includes flexibility and mobility of capsular and other soft tissue structures such as ligaments and tendons. Following injury and immobilization, soft tissues can become shortened and limit overall joint mobility. Adequate force must be applied to the tissues to create mechanical effects. Higher grade mobilizations may increase the joint mobility back to normal by restoring relative amounts of play in the once-restricted joint motion. Another theory of mechanical effect is the releasing or freeing of the facet joint meniscoid entrapment. A meniscoid entrapment may include a locking caused by entrapment of a facet joint meniscoid in a groove formed in the articular cartilage or by a meniscus piece that has broken free and formed a loose body that is entrapped (Lewitt, 1985).These meniscoids can become extremely painful sources of dysfunction. Fortunately, either gapping or an isometric movement that pulls the facet laterally can theoretically dislodge the impingement; the result can be immediate pain relief and improvement of joint motion. Current evidence supports only transient biomechanical effects on studies quantifying motion (Colloca, Keller, Harrison, Moore, Gunzburg, and Harrison, 2006; Coppieters and Alshami, 2007; Coppieters and Butler, 2007; Gal, Herzog, Kawchuk, Conway, and Zhang, 1997)but not a lasting positional change (Hsieh, Vicenzino, Yang, Hu, and Yang, 2002; Tullberg, Blomberg, Branth, and Johnsson, 1998).Neurophysiological and psychological effects should therefore be strongly considered.
Neurophysiological Effects
Applications of joint mobilizations and manipulation have been reported to create both local and distal neurophysiological effects (Bialosky, Bishop, and Bialosky, 2009; Bishop, Beneciuk, and George, 2011; Coranoda, Gay, and Bialosky, 2012; George, Bishop, and Bialosky, 2006). These effects may be especially enhanced when using the spine as the region of mobilization or manipulation application. Spinal soft tissues are highly innervated and may provide a large degree of afferent input into the central nervous system (Groen, Baljet, and Drukker, 1990). This input can come from multiple sources such as type I and II mechanoreceptors and free nerve endings found in cervical spine facet joints and muscle spindles of the cervical spine. Similar mechanisms might be seen in the remainder of the spine, but the number of nerve endings may be lower and less consistent in lower levels of the spine (McLain and Pickar, 1998). Movement such as mobilization or manipulation will fire these receptors and provide input to the central nervous system. These nerve receptors terminate in the spinal cord synapsing in the ventral and dorsal horn to signal proprioceptive and nociceptive information (Bolton, 1998).
Animal and human models have shown that the periaqueductal gray area of the midbrain is key for control of mediation of endogenous analgesia (Cannon, Prieto, and Lee, 1982; Hosobuchi, Adams, and Linchitz 1977; Reynolds, 1969). The periaqueductal gray area is in coordination with a complex network of systems including the nociceptive system, the autonomic nervous system, and the motor system. It has also been shown that type I and II mechanoreceptors from joints, muscles, and tendons project to the periaqueductal gray area (Yezierski, 1991). Evidence via postmanipulation sympathetic response combined with analgesia in symptomatic and asymptomatic subjects suggests a neurophysiologic response to spinal manipulation via mechanoreceptors (Wright, 1995). These effects may lie in the stimulation of the descending pain-inhibitory system of the central nervous system from midbrain to spinal cord.
Controversy persists regarding whether analgesic effects from mobilization and manipulation occur following treatment. Some reports suggest that mobilization or manipulation may stimulate a release of endogenous opioid peptides that bind to nervous system receptor sites, producing analgesia. Vernon and colleagues found increased levels of plasma beta-endorphin following manipulation, but these levels diminished to normal levels after only 15 minutes (Vernon, Dhami, Howley, et al., 1986). Controversy continues, as others have not succeeded in documenting these increased levels of endorphin compared to control groups (Christian, Stanton, and Sissons, 1998; Sanders, Reinnert, and Tepe, 1990).
The neurophysiological effect may also include a change in muscle activation patterns in which the motor system may be inhibited. The ability of mobilization and manipulation to inhibit muscle may vary depending on technique, location and nature of pain, and even the given muscles targeted with the manipulation. If mobilization or manipulation affects muscles, the neurophysiologic effects most likely occur locally at the targeted joint or region and the corresponding innervation distally associated with the shared innervation. The effects desired from performing the mobilization or manipulation are to increase facilitation of the deeper, more local muscles that assist with neuromuscular control of the area and, ideally, to inhibit the more superficial, global muscles that may be causing pain due to increased guarding of the joint or segments involved.
Psychological Effects
At least in the spinal model, evidence of improvement of psychological outcomes following manipulation is limited. In a meta-analysis, Williams, Hendry, Lewis, and colleagues (2007) reviewed 129 randomized controlled trials of spinal manipulation and identified 12 studies reporting psychological outcomes. These studies suggest that spinal manipulation may improve psychological outcomes compared to verbal interventions. Further, other variables, such as clinician and client expectations, may also play a role in the degree to which symptoms improve (Cross, Leach, Fawkes, and Moore, 2015; Riley, Bialosky, Cote, Swanson, Tafuto, Sizer, and Brismée, 2015). The greatest effect seems to be in those with a positive attitude and an expectation that the intervention will be helpful.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Clinical application of joint thrusts and nonthrusts
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors.
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors. For example, select clients may tolerate only small forces and amplitudes of nonthrusts over a short duration. If significant pain is present, nonthrusts should be applied using relatively small amplitudes and small forces. Maitland described four grades of nonthrust techniques (figure 2.1) (Maitland, 2005). Grades I and II are small and large amplitude nonthrusts, respectively, that do not reach the end of a joint's available arthrokinematic motion. These grades are generally for painful joints or apprehensive clients. Grades III and IV are large and small amplitude nonthrusts, respectively, that reach the end of a joint's available motion. These grades are generally used to increase arthrokinematic motion.
Maitland grades of movement.
Recommendations for the force, frequency, and amplitude of nonthrust techniques also vary depending on the joint being treated. For example, in the lumbar spine, evidence shows the average force for grade IV nonthrusts ranges from 90 N to 240 N (Snodgrass, 2006). In the knee, grade IV nonthrusts appear to be between 30 N and 78 N (Pentelka, Hebron, Shapleski, and Goldshtein, 2012). In larger joints, such as the knee and hip, clinicians should be able to appreciate arthrokinematic motion visually in addition to feeling the joint translation with their hands. This observation is more challenging at smaller joints such as the cervical spine.
Concerning the frequency of nonthrusts, one estimate is that clinicians apply oscillations at a rate of 1 to 1.5 per second (Snodgrass, 2006). One recommendation has been made for at least 4 sets of 60 seconds of oscillations to induce the analgesia at the lumbar spine (Pentelka et al., 2012). However, clinicians should modify their frequency and duration of manual therapy techniques to fit client needs.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Effects of mobilization and manipulation
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Clinicians use joint mobilization and manipulation for 2 main indications: joint pain and joint hypomobility. Three main categories of effects of mobilization or manipulation are described here: mechanical, neurophysiological, and psychological.
Mechanical Effects
The mechanical effects of joint mobilization relate to the restoration of normal joint mobility or range of motion. This includes flexibility and mobility of capsular and other soft tissue structures such as ligaments and tendons. Following injury and immobilization, soft tissues can become shortened and limit overall joint mobility. Adequate force must be applied to the tissues to create mechanical effects. Higher grade mobilizations may increase the joint mobility back to normal by restoring relative amounts of play in the once-restricted joint motion. Another theory of mechanical effect is the releasing or freeing of the facet joint meniscoid entrapment. A meniscoid entrapment may include a locking caused by entrapment of a facet joint meniscoid in a groove formed in the articular cartilage or by a meniscus piece that has broken free and formed a loose body that is entrapped (Lewitt, 1985).These meniscoids can become extremely painful sources of dysfunction. Fortunately, either gapping or an isometric movement that pulls the facet laterally can theoretically dislodge the impingement; the result can be immediate pain relief and improvement of joint motion. Current evidence supports only transient biomechanical effects on studies quantifying motion (Colloca, Keller, Harrison, Moore, Gunzburg, and Harrison, 2006; Coppieters and Alshami, 2007; Coppieters and Butler, 2007; Gal, Herzog, Kawchuk, Conway, and Zhang, 1997)but not a lasting positional change (Hsieh, Vicenzino, Yang, Hu, and Yang, 2002; Tullberg, Blomberg, Branth, and Johnsson, 1998).Neurophysiological and psychological effects should therefore be strongly considered.
Neurophysiological Effects
Applications of joint mobilizations and manipulation have been reported to create both local and distal neurophysiological effects (Bialosky, Bishop, and Bialosky, 2009; Bishop, Beneciuk, and George, 2011; Coranoda, Gay, and Bialosky, 2012; George, Bishop, and Bialosky, 2006). These effects may be especially enhanced when using the spine as the region of mobilization or manipulation application. Spinal soft tissues are highly innervated and may provide a large degree of afferent input into the central nervous system (Groen, Baljet, and Drukker, 1990). This input can come from multiple sources such as type I and II mechanoreceptors and free nerve endings found in cervical spine facet joints and muscle spindles of the cervical spine. Similar mechanisms might be seen in the remainder of the spine, but the number of nerve endings may be lower and less consistent in lower levels of the spine (McLain and Pickar, 1998). Movement such as mobilization or manipulation will fire these receptors and provide input to the central nervous system. These nerve receptors terminate in the spinal cord synapsing in the ventral and dorsal horn to signal proprioceptive and nociceptive information (Bolton, 1998).
Animal and human models have shown that the periaqueductal gray area of the midbrain is key for control of mediation of endogenous analgesia (Cannon, Prieto, and Lee, 1982; Hosobuchi, Adams, and Linchitz 1977; Reynolds, 1969). The periaqueductal gray area is in coordination with a complex network of systems including the nociceptive system, the autonomic nervous system, and the motor system. It has also been shown that type I and II mechanoreceptors from joints, muscles, and tendons project to the periaqueductal gray area (Yezierski, 1991). Evidence via postmanipulation sympathetic response combined with analgesia in symptomatic and asymptomatic subjects suggests a neurophysiologic response to spinal manipulation via mechanoreceptors (Wright, 1995). These effects may lie in the stimulation of the descending pain-inhibitory system of the central nervous system from midbrain to spinal cord.
Controversy persists regarding whether analgesic effects from mobilization and manipulation occur following treatment. Some reports suggest that mobilization or manipulation may stimulate a release of endogenous opioid peptides that bind to nervous system receptor sites, producing analgesia. Vernon and colleagues found increased levels of plasma beta-endorphin following manipulation, but these levels diminished to normal levels after only 15 minutes (Vernon, Dhami, Howley, et al., 1986). Controversy continues, as others have not succeeded in documenting these increased levels of endorphin compared to control groups (Christian, Stanton, and Sissons, 1998; Sanders, Reinnert, and Tepe, 1990).
The neurophysiological effect may also include a change in muscle activation patterns in which the motor system may be inhibited. The ability of mobilization and manipulation to inhibit muscle may vary depending on technique, location and nature of pain, and even the given muscles targeted with the manipulation. If mobilization or manipulation affects muscles, the neurophysiologic effects most likely occur locally at the targeted joint or region and the corresponding innervation distally associated with the shared innervation. The effects desired from performing the mobilization or manipulation are to increase facilitation of the deeper, more local muscles that assist with neuromuscular control of the area and, ideally, to inhibit the more superficial, global muscles that may be causing pain due to increased guarding of the joint or segments involved.
Psychological Effects
At least in the spinal model, evidence of improvement of psychological outcomes following manipulation is limited. In a meta-analysis, Williams, Hendry, Lewis, and colleagues (2007) reviewed 129 randomized controlled trials of spinal manipulation and identified 12 studies reporting psychological outcomes. These studies suggest that spinal manipulation may improve psychological outcomes compared to verbal interventions. Further, other variables, such as clinician and client expectations, may also play a role in the degree to which symptoms improve (Cross, Leach, Fawkes, and Moore, 2015; Riley, Bialosky, Cote, Swanson, Tafuto, Sizer, and Brismée, 2015). The greatest effect seems to be in those with a positive attitude and an expectation that the intervention will be helpful.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
Clinical application of joint thrusts and nonthrusts
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors.
Parameters applied to joint thrusts and nonthrusts vary widely. The force, frequency, and amplitude of techniques vary depending on client, clinician, and joint factors. For example, select clients may tolerate only small forces and amplitudes of nonthrusts over a short duration. If significant pain is present, nonthrusts should be applied using relatively small amplitudes and small forces. Maitland described four grades of nonthrust techniques (figure 2.1) (Maitland, 2005). Grades I and II are small and large amplitude nonthrusts, respectively, that do not reach the end of a joint's available arthrokinematic motion. These grades are generally for painful joints or apprehensive clients. Grades III and IV are large and small amplitude nonthrusts, respectively, that reach the end of a joint's available motion. These grades are generally used to increase arthrokinematic motion.
Maitland grades of movement.
Recommendations for the force, frequency, and amplitude of nonthrust techniques also vary depending on the joint being treated. For example, in the lumbar spine, evidence shows the average force for grade IV nonthrusts ranges from 90 N to 240 N (Snodgrass, 2006). In the knee, grade IV nonthrusts appear to be between 30 N and 78 N (Pentelka, Hebron, Shapleski, and Goldshtein, 2012). In larger joints, such as the knee and hip, clinicians should be able to appreciate arthrokinematic motion visually in addition to feeling the joint translation with their hands. This observation is more challenging at smaller joints such as the cervical spine.
Concerning the frequency of nonthrusts, one estimate is that clinicians apply oscillations at a rate of 1 to 1.5 per second (Snodgrass, 2006). One recommendation has been made for at least 4 sets of 60 seconds of oscillations to induce the analgesia at the lumbar spine (Pentelka et al., 2012). However, clinicians should modify their frequency and duration of manual therapy techniques to fit client needs.
Learn more about Orthopedic Joint Mobilization and Manipulation With Web Study Guide.
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