Technique principles
Ch 8
Learning manual techniques
• Years of study and practice
• Novice practitioners…Dangerously heavy-
handed.
• Grade III can cause injury
• First master test techniques…. Grade I and II
movements, before attempting Grade III stretch
mobilization techniques.
• Practice on asymptomatic subjects… within-the-
slack Grade II mobilization
Learning specific manual mobility testing in
the spine
• Segmental movement tests…monitoring
change in a patient's physical status and for
assessing response to treatment.
• Requires skill
• Start with soft tissue treatments
Applying manual techniques
• Variations in functional joint anatomy
• Normal joint play end-feel= normal joint
• Considerable normal anatomical variation
from individual to individual
• Considerable asymmetry from one side of the
body to the other within an individual.
• Abnormal quality of movement
• Repetitive asymmetrical activities
Objective
• Joint play testing techniques can also be
applied in the resting position as gentle Grade
I and II traction mobilizations for pain relief or
relaxation.
• Grade III stretch-mobilization techniques can
sometimes also be used for symptom
localization and end-feel testing.
• Changes in grip, fixation, and positioning…..
Test / treatment / more specific.
• "Test“= usually used for testing only
• Objective of the test
• Linear, translatoric tests
• Rotatoric tests
"Test and mobilization"
• Testing joint play (grade II),
• For traction pain relief mobilization in the
resting position (grade I and IISZ),
• For relaxation (grade I through IITZ
• Stretch-traction mobilizations (grade III)
• Same grip.
"Test and stretch mobilization"
• Testing joint play (grade II)
• Stretch-mobilizations (grade III)
• Same grip
Stretch mobilization"
• Grade III stretch mobilizations
• Alternate grips, locking techniques, or stronger
fixation
• Joint pre-positioned outside the resting
position
Starting position
• Patient's position
• Minimum patient repositioning.
• Position patient in a comfortable position,
then position specific joint(s) to be mobilized.
• Involved joints must be in resting position or
in the actual resting position
• Standing position…feet somewhat separated and parallel for
stability.
• Sitting position….. Feet supported on the floor proper
positioning of the spine during evaluation and treatment.
• Prone position … pillow under stomach to position the
lumbar spine in the resting position.
• Under thorax to maintain a resting position there.
• Sometimes lower the head piece of the treatment table in
order to achieve a resting position and adequate muscle
relaxation in the spine.
• Opening for the patient's nose and mouth
• Sidelying position…hip and knee joints flexed.
• Normal spinal curvatures
• Broad pelvis…pillow or a roll under the patient's
waist ???????
• Supine position…. Head supported
• Legs should be slightly abducted and relaxed.
• Pillow under the patient's knees/ under the
lumbar area.
• Occasional modifications
Therapist's position
• Ergonomically and biomechanically sound
posture
• Maximally close to the patient
• Wide base of support,
• Flexed hips and knees,
• Natural lumbar lordosis.
• Adjust height of the treatment table
Hand placement and fixation/stabilization
• Move one hand with the patient's body
• keep the other hand stable for palpation,
stabilization or fixation
• Both hands monitor the quality and quantity
of movement
• Pics show technique in the terminal position.
Grip
• For testing and gentle mid-range mobilizations =
smaller contact surface
• Longer duration stretch-mobilizations = broader
contact ,stronger fixation, body weight usage
• Excessive pressure…distort the movement and
palpation
• Well-placed grip close to the joint space… grade I
traction
• Occasional adjustments
Therapist's stable hand
• Positioned just proximal to the joint space.
• Fingers …palpate the joint space
• Palpating finger …..Positioned at the targeted
joint space with contact to both joint partners.
commonly used
contacts for movement palpation
• Occiput ……mastoid process
• Atlas …..posterior vertebral arch & transverse
process
• Cervical Spine (C2 - C7)….. facet joints and
spinous processes
• Thoracic Spine …..spinous processes
• Lumbar Spine …..spinous processes
• Sacroiliac Joint …..sacral sulcus
• Spinal flexion and extension….. Palpating finger
between the spinous processes from the posterior
side.
• Spinous process separation with flexion and
approximation with extension.
• Combined movement testing ….Palpating finger is
placed on the lateral side of the spinous processes.
• Side to which the spinous processes are moving
during that particular movement;
• End-feel….slightly increase the contact
pressure in your stable hand / forearm of your
stable hand, to fixate one joint partner.
• With adequate fixation, an end-range test
technique can be used as a specific grade Ill
mobilization.
• Fixation is an important component of specific
Grade III stretch mobilization techniques,
• Performed slowly and sustained for longer
periods of time.
• The fixating action of your hand can be
enhanced with the use of locking techniques
• Fixation ….. wedges, belts, and other external
fixating devices.
Therapist's moving hand
• Smaller joints…mobilizing hand grips the joint
partner to be moved as close to the joint
space as possible.
• With larger joints….both hands and body may
move together to apply the movement while
fixation is provided by a strap or wedge.
• Placed as specifically as possible ….movement
occurs as specifically as possible at the
targeted segment or tissue .
Procedure
Joint pre-positioning
• Uniaxial joint… one plane of movement;
• Biaxial joint… two planes;
• Triaxial joint… three planes.
• Pre-positioning with a rotatoric movement.
• Mobilization…linear movement.
• Pain relief or relaxation…begin in the actual
resting position.
• Progressively reach resting position.
• Stretching, three-dimensional positioning
anywhere within the available range-of-
motion.
• Resting position restriction outside the
resting position.
• Pre-positioning vary
• Adjust according to situation
Mobilization technique
• performed slowly,
• For joint play testing including end-feel
(Grade I, II or III) ,
• move slowly and ease into the Grade Ill range.
• For pain relief (Grade I - IISZ),
• use oscillations or slow, repetitive,
intermittent traction movements, not reaching
Transition Zone.
• For relaxation (grade I - IITZ),
• Apply slow intermittent traction mobilizations,
• Not reaching first stop.
• For stretching (grade iii),
• Apply linear traction or glide movements
• Even more slowly
• Sustain each stretch for at least 30 - 40 seconds, ideally a
minute or more.
• Repeat in a cyclic manner for a 10 - 15 minute session or to
patient tolerance.
• Home exercise to maintain the mobility gains.
• stretch-glide mobilizations with Grade I
traction/ sustain decompression
• Use of gravity and your body weight
specific spinal manual therapy procedure
• Movement in the targeted segment or tissue
avoiding unnecessary movement in neighboring
structures.
• Spinal segmental tests….start with the targeted
segment in resting position.
• After testing, return to the initial position
• Next segment testing
• Accurate palpation of movement quantity and
quality needs sensitivity and specificity.
• Therapist safety and treatment effectiveness
are further enhanced by:
• Proper use of body mechanics
• Adjustable treatment tables, fixation belts,
sand bags, wedges, and other ergonomic and
patient positioning aids.
• Patient assistance…no muscular tension
Symbols
X = Fixation or stabilization
= Direction of linear movement (testing and treatment)
Direction of rotatoric movement (testing and
pre-positioning prior to linear treatment
Recording
• Documentation need special symbols,
shorthand, or abbreviations.
• Identifying an intervertebral segment
• Name only the cranial vertebra
• C2 identifies the c2-c3 mobile segment,
• C2 movement is movement between c2 and
c3
• direction of segmental movement, …..cranial
vertebra in relation to its adjacent caudal
vertebra.
• If cranial vertebra is fixated and the caudal
vertebra is moved, the movement is still
described as a "relative movement of the
cranial vertebra”.
The Star Diagram
• shorthand for recording certain specific evaluation findings and
treatment directions in the spine.
• Made by a combination of longer lines which form the star (star
lines), shorter lines crossing the star lines (cross lines), and arrows.
- - -+ = No movement (Class 0, Ankylosis)
- - I- + = Significant restriction (Class 1 Hypomobility)
- I- - + = Slight restriction (Class 2 Hypomobility)
---+ = Hypermobility
