Mobilization

 Maitland mobilization
• Maitland concept uses passive and accessory mobilization to treat
mechanical pain and stiffness, and can be applied on peripheral or
spinal joints

• Maitland concept can be uses in assessment and treatment

Key Terms:
Accessory Movement - Accessory or joint play movements are joint movements
which cannot be performed by the individual. These movements include roll, spin and
slide which accompany physiological movements of a joint. The accessory movements
are examined passively to assess range and symptom response in the open pack
position of a joint. Understanding this idea of accessory movements and their
dysfunction is essential to applying the Maitland concept clinically[4].

Physiological Movement - The movements which can be achieved and performed

actively by a person and can be analyzed for quality and symptom response [4].

Injuring Movement - Making the pain/symptoms 'come on' by moving the joint in a
particular direction during the clinical assessment[4].

Overpressure - Each joint has a passive range of movement which exceeds its
available active range. To achieve this range a stretch is applied to the end of normal
passive movement. This range nearly always has a degree of discomfort and
assessment of dislocation or subluxation should be acquired during the subjective
assessment[4].
Principles of
Techniques
Decisions Which Need to be
Made[4]
1. The Direction - of the mobilization needs to be clinically reasoned by the
therapist and needs to be appropriate for the diagnosis made. Not all directions
will be effective for any dysfunction.

2. The Desired Effect - what effect of the mobilization is the therapist wanting?
Relieve pain or stretch stiffness?

3. The Starting Position - of the patient and the therapist to make the treatment
effective and comfortable. This also involves thinking about how the forces from
the therapists hands will be placed to have a localized effect.

4. The Method of Application - The position, range, amplitude, rhythm and

duration of the technique.

5. The Expected Response - Should the patient be pain-free, have an increased

range or have reduced soreness?

6. How Might the Technique be Progressed - Duration, frequency or rhythm?

How to Choose the Direction

To make sure you settle on appropriate mobilizations it is important to get the type of glide, the
direction and speed correct.

Different Types of Mobilization: How Many Glides?

Each joint has a different movement arc in a different direction to other joints and therefore
care needs to be taken when choosing which direction to manipulate; Although it is not part of
the conceptualization used by Maitland, this is where the Concave Convex Rule could come
into use, but for now consider the number of possible glides a clinician may use:

1.A-P (Anteroposterior) [Link] Distraction

[Link] Glide
2.P-A (Posteroanterior) [Link] Glide

[Link] Caudad

[Link] Cephalad

Due to anatomical position and other physical limitations not all peripheral or spinal joints can
be subjected to all of the types of glide. Here are examples of mobilizations of joints of the
body
 Concave Convex Rule: Up, down, Left or
Right?
Choosing the direction of the mobilization is integral to ensuring you are having the desired clinical outcome.
This is where a knowledge of Arthrokinematics is important. In summary:

There are two important things to remember:

•When a convex surface (i.e., Humeral Head) moves on a stable concave surface (i.e., Glenoid Fossa) the
sliding of the convex articulating surface occurs in the opposite direction to the motion of the bony lever (i.e.,
the Humerus)[7].

The opposite can be said for

•When a concave surface (i.e., Tibia; talocrural joint) is moving on a stable convex surface (i.e., Talus) sliding
occurs in the same direction of the bony level[7].

Examples:

To improve shoulder flexion, you would perform an A-P mobilization due to the way the convex humerus
articulates with the concave glenoid fossa.

An easier way to visualize this is to try and show this rule with your hands. (Picture from[8])
How to Choose the Grade: How Far into Range and
Quickly or Slowly?
Grades of Mobilizations
Grade I – small amplitude movement at the beginning of the available range of
movement
Grade II – large amplitude movement at within the available range of
movement
Grade III – large amplitude movement that moves into stiffness or muscle
spasm
Grade IV – small amplitude movement stretching into stiffness or muscle
spasm
**A 5th grade is possible but further training will be required to perform
safely**
In many places, you are obliged to obtain a written consent from your patient
before applying grade 5 manipulation .
The grading scale has been separated into two due to their clinical indications:[4]
•Lower grades (I + II) are used to reduce pain and irritability (use VAS + SIN
scores).
•Higher grades(III + IV) are used to stretch the joint capsule and passive tissues
Speaking impact
Therapeutic Effect: How and Why Does
This Work; Mechanisms of Action
There are a number of complex systems which interact to
produce the pain-relieving effects of mobilizations,
subsequently there is not a single theory into its
mechanism. Therefore, this article will outline the basics and
evidence for the claims and further links will be added for
additional more in-depth information.
Pain Gate Theory
The pain gate theory (PGT) was first proposed in 1965 by Melzack and Wall[13] and is a commonly
used explanation of pain transmission. Thinking of pain theory in this way is very simplified and may
not be suitable in some contexts, however when discussing pain with patients this description can be
very useful.

In order to understand the PGT, the sensory nerves need to be explained. At its most simple
explanation there are 3 types of sensory nerves involved of transmission of stimuli[14][15]:

1.α-Beta fibers - Large diameter and myelinated - touch and pressure - Fast (50m/s)

2.α-Delta fibers - Small diameter and myelinated - temperature and pain (well localized,
sharp/prickly) - Medium (15m/s)

3.C fibers - Small diameter and un-myelinated - pain (dull, poorly localized, persistent) - Slow (1m/s)

The size of the fibers is an important consideration as the bigger a nerve is the quicker the
conduction, additionally conduction speed is also increased by the presence of a myelin sheath,
subsequently large myelinated nerves are very efficient at conduction. This means that α-
Beta fibers are the quickest of the 3 types followed by α-Delta fibers and finally C fibers[16].
he interplay between these nerves is significant, but it does not encompass the entire story. It is
important to note that only a subset of these nerves act as pain receptors. α-Delta fibers, which are
often associated with transmitting sharp, quick pain sensations, play a distinct role in the sensory
system. All of these nerves synapse onto projection cells, which travel up the spinothalamic tract to the
brain. Here, they pass through the thalamus to various regions, including the somatosensory cortex and
the limbic system. Within the spinal cord, inhibitory interneurons act as 'gatekeepers'. When there is
no sensation from the nerves the inhibitory interneurons stop signals travelling up the spinal cord as
there is no important information needing to reach the brain, so the gate is 'closed'[13]. When the
smaller fibers are stimulated the inhibitory interneurons do not act, so the gate is 'open', and pain is
sensed. When the larger α-Beta fibers are stimulated they reach the inhibitory interneurons faster and,
as larger fibers inhibit the interneuron from working, 'close' the gate. This explains why, after stubbing
your toe or bumping your head, rubbing the area helps; it stimulates the α-Beta fibers, which in turn
close the gate to pain perception[13]

Descending Inhibition

The sensation of pain is subject not only to modulation during its ascending transmission from the
periphery to the cortex but also to segmental modulation and descending control from higher centers[17].

It needs to be thought of as not just a linear process, instead a complex interaction of a multitude of
different biochemical and physical factors which must be thoroughly understood to understand the
process.
Should Manual Therapists Take
Blood Pressure?
A controversial and often neglected
consideration when performing manual therapy,
particularly on the neck, is the impact therapy
has on blood pressure and a 2012 article by
[18]

Taylor and Kerry highlighted this as

a professional issue which should be a major
concern to physiotherapists everywhere.. The Thank you
influence manual therapy has on blood pressure
can be caused by the central effect on the CNS
or local effects caused by the close proximity of
the cervical arteries. this can be a serious risk to
patients, explain here:
"Because of the proximity of the vertebral artery
to the lateral cervical articulations, caution must
be used during manipulation of the cervical spine
(MCS). It is thought that stroke can be induced as
a result of MCS by mechanical compression or
excessive stretching of arterial walls, but the
 Maitland techniques
:
PPIVM (passive physiological intervertebral
movement)

PAIVM (passive accessory intervertebral

movement) :
• PA central vertebral pressure at
SP
• PA unilateral vertebral pressure
at TP
• Transverse at SP
 Mulligan Concept

• Straight forward technique from weigh

bearing position to correct positional fault,
decrease pain, decreases stiffness and
increase ROM with pain free
Principles of Treatment
1.A passive accessory joint mobilization is applied following the principles of Kaltenborn. This
accessory glide must itself be pain free.

[Link] assessment, the therapist will identify one or more comparable signs as described by
Maitland. These signs may be; a loss of joint movement, pain associated with movement, or pain
associated with specific functional activities

[Link] therapist must continuously monitor the patient's reaction to ensure no pain is recreated. The
therapist investigates various combinations of parallel or perpendicular glides to find the correct
treatment plane and grade of accessory movement.

[Link] sustaining the accessory glide, the patient is requested to perform the comparable sign.
The comparable sign should now be significantly improved

[Link] to improve the comparable sign would indicate that the therapist has not found the correct
treatment plane, grade of mobilization, spinal segment or that the technique is not indicated.

[Link] previously restricted and/or painful motion or activity is repeated by the patient while the
therapist continues to maintain the appropriate accessory glide.
Techniques
NAGS- Natural Apophyseal Glides.
SNAGS - Sustained Natural Apophyseal
Glides.
Reverse NAGS
MWMS- Mobilization with Movements.
SMWLM- Spinal mobilization with limb
movement
Traction
Facet joints angle
SNAGs
• SNAGs stand for Sustained Natural Apophyseal Glides.

• SNAGs can be applied to all the spinal joints, the rib cage and the
sacroiliac joint.

• The therapist applies the appropriate accessory zygapophyseal glide

while the patient performs the symptomatic movement.

• This must result in full range pain free movement.

• SNAGs are most successful when symptoms are provoked by a

movement and are not multilevel.

• They are not the choice in conditions that are highly irritable.(Patient has
unidirectional symptoms )

• Although SNAGs are usually performed in weight bearing positions they

can be adapted for use in non weight bearing positions.
NAGs
• NAGs stand for 'Natural Apophyseal Glides”.

• NAGs are used for the cervical and upper thoracic spine.

• They consist of oscillatory mobilizations instead of sustained glide like SNAGs, and it
can be applied to the facet joints between 2nd cervical and 3rd thoracic vertebrae.

• NAGs are mid-range to end range facet joint mobilizations applied antero-superiorly
along the treatment planes of the joint selected.

• Useful for grossly restricted spinal movement. (Multidirectional symptoms=

capsular pattern)

• NAGs for the treatment of choice in highly irritable conditions

Reversed NAGs
• They consist of oscillatory mobilizations instead of sustained glide like
SNAGs, and it can be applied to the facet joints between 5th cervical
and 4th thoracic vertebrae.

• Useful for grossly restricted spinal movement. (Multidirectional

symptoms= capsular pattern)

• Used for kyphotic or cervico-thoracic hump patient

NOTE: In NAGs & SNAGs we move the affected level on the non one, but
in reversed NAGs vice versa