Tuesday, September 29, 2009

Cadaver study of axial distraction mobilization of the glenohumeral joint support end range mobilization

The axial distraction mobilization techniques are frequently employed for treating patients with joint hypomobility. To know the biomechanical effects 3 different positions of glenohumeral abduction on a fresh cadaveric specimen ware chosen. They are

1. resting position
2. neutral position
3. end-range position

Result indicated that displacement of the humeral head ware as follows:

1. largest in the resting position (27.38 mm)
2. followed by the neutral (22.01 mm)
3. and the end range position (9.34 mm).

Greater gain in mobility was obtained in distraction at the end range position.

During distraction mobilization, the force applied by the therapist and displacement of the humeral head depends on the joint position tested. These results also provide rationales for choosing end range distraction mobilization for improving joint mobility.


Authors: Ar-Tyan Hsuab, Jing-Fang Chiuc, Jia Hao Changd

Wednesday, September 23, 2009

Mulligan’s positional fault corrections cause pain relief & mecanical corrections for long lasting effect!!!

According to Vicenzino et al (2007) there are an increasing number of reports espousing the clinically beneficial effects of Mulligan's mobilization-with-movement (MWM) treatment techniques. The most frequent reported effect is that of an immediate and substantial pain reduction accompanied by improved function.

Manual therapy effects on pain have been explained by many authors. The mechanism involved is thought to be an effect of mechanoreceptor response that affects the pain gait. Few others claim pain relief may be due to supra-spinal mechanisms based on opiate-like substance releases. However recent findings refer the supra-spinal mechanisms may not be involved especially spinal manual therapy-induced hypoalgesia.

Naloxone antagonism and tolerance studies employ widely accepted tests for the identification of endogenous opioid-mediated pain control mechanisms. Paungmali et al (2004) reported that rapid initial hypoalgesia caused by Mulligan MWM was not antagonized by naloxone, suggesting a nonopioid mechanism of action in tennis elbow i.e. existence of similar non-opiate pain control mechanism seen after spinal manual therapy. Vicenzino et al described this effect as unique & characteristic hypoalgesia of Mulligan’s techniques. The selective and specific effect of this treatment technique warrants further investigations in physical modulation of musculoskeletal pain.

Ankle positional fault corrections!!!

Study that indicates Mulligan’s ankle technique first corrects mechanical errors:

Talocrural dorsiflexion is a major impairment following ankle sprain. Lack of posterior talar glide and weight-bearing ankle dorsiflexion are common physical impairments in individuals with recurrent ankle sprains. MWM of the ankle joint involves the application of a combined posterior talar glide mobilization and active dorsiflexion movement. Collins et al reported this MWM treatment for ankle dorsiflexion has a mechanical rather than hypoalgesic effect in subacute ankle sprains. Vicenzino et al reported both the weight-bearing and non-weight-bearing Mulligan’s MWM treatment techniques improve posterior talar glide by 55% and 50% in recurrent ankle sprain cases. Treatment of existing positional faults leads to increased chances of not getting back the ankle sprain may the plausible mechanism. However these authors indicated future research to explore the mechanism by which this occurs to better understand the role of manipulative therapy.


1. J Manipulative Physiol Ther. 2004 Mar-Apr;27(3):180-5.
2. Vicenzino B et al; Man Ther. 2001 Nov;6(4):205-12.
3. Man Ther. 2007 May;12(2):98-108. Epub 2006 Sep 7.
4. Collins N et al; Man Ther. 2004 May;9(2):77-82.
5. Vicenzino B et al; J Orthop Sports Phys Ther. 2006 Jul;36(7):464-71.

Manual therapy class (theory) : Mulligan's technique-MWM effects on peripheral joints

Viewing end plate from injury prospective

* This following information must be seen in the light of my previous 2 posts especially the last post. This class ends the series.

1. The vertebral body & the end plate:

According to Prakash et al, many factors decide the integrity of the body of the vertebra. Gross design of the vertebral body is one of the most important adaptations for axial loading. The body of the vertebra is inter-segmental in origin, which results in dual vascular and nerve supply, both from superior and inferior aspects of the body. The vertebral body ossifies from 3 primary centers, one for centrum, which will form the major portion of body, and the other two for neural arches. The cartilaginous growth plate is mainly responsible for the longitudinal vertebral growth.

2. Intra-structural strength variation of end plates with specific reference to lumbar & sacral regions:

Many studies indicate that some regions of the vertebral body may be stronger than others. Hence the failure strengths are different in different part of the end plate. Working in end plate strength of lumbar & sacral region Grant et al (2001) & Hou et al (2009) found that:

1. Posterolateral regions being stronger (parts closest to the pedicles are the strongest) and stiffer than the anterior and central regions. The central regions were porous, as the fused trabeculae and peripheral regions had fewer and smaller pore structures.

2. Sacral and inferior lumbar endplates were both found to be stronger than the superior lumbar endplates.

Grant et al’s study (2001) reveals interesting aspects of end plate strength i.e. significant regional strength and stiffness variations in the lumbar and sacral endplates & the center of the bone is the weakest part of the lumbar endplates and it is also not the strongest region of the sacral endplate.

Similarly Hou et al’s study reveals further that failure load distribution did not change with the BMD (bone mineral density) decrease. There is inter-segmental variation in failure strength noted in a same region for example failure loads of the lumbar endplates showed an increasing tendency from L1-L5 segments. They concluded the differences in the anatomic structures of different regions are the histologic foundation of biomechanical properties of lumbar endplates.

Relationship of disc generation & end plate strength:

In another study Grant et al (2002) reveal that increased disc degeneration is associated with an overall failure load decrease in the inferior lumbar endplates. The strength in the central regions of the superior endplates was reduced with increasing degeneration, but this was not observed peripherally. Further locations of the strongest regions of the endplate did not change with either bone density or disc degeneration i.e. postero-lateral regions remain the strongest part of end plate under these condition.

Effect of endplate removal on the structural properties:

Recent reports indicate that there is a significant effect of end plate removal on the local structural characteristics of the vertebral end plate. Oxland et al reported with end plate removal, the mean failure load decrease to about 33% of the intact failure load & there is a trend toward greater decreases posteriorly. Further with end plate removal, the mean stiffness also decreases substantially with the greater decrease laterally.


1. Prakash; Osteoporos Int. 2007 Jul;18(7):891-903. Epub 2007 Apr 3.
2. Grant et al; Spine (Phila Pa 1976). 2001 Apr 15;26(8):889-96.
3. Hou et al; Spine (Phila Pa 1976). 2009 May 20;34(12):E427-33.
4. Grant et al; J Orthop Res. 2002 Sep;20(5):1115-20.
5. Oxland TR et al; Spine (Phila Pa 1976). 2003 Apr 15;28(8):771-7.
6. Lowe TG et al; Spine (Phila Pa 1976). 2004 Nov 1;29(21):2389-94.

Class in disc pain-3 (end plate- an anatomic region often unexplored)

Tuesday, September 22, 2009

Schmorl's nodes


Schmorl’s nodes are nothing but protrusions of disc material into the surface of the vertebral body i.e. intraosseous disk herniation. It is named after German pathologist Christian Georg Schmorl (1861-1932). Schmorl's node can be detected radiographically but it is imaged better by CT or MRI. MRI is not only useful in detecting the recently developed Schmorl's nodes but also in differentiating between symptomatic and asymptomatic Schmorl's nodes (4). With reference to Schmorl’s nodes discs in MRI are generally noted for size, location, margins, internal and surrounding T1/T2 signal, adjacent disc herniation or bulge, concentric ring, underlying fracture including malignancy, infection, or prior disc surgery.

The migrating disc material of a Schmorl’s node when comes in contact with the marrow of vertebra it leads to inflammation. Many times protrusions are also associated with necrosis of the vertebral bone. Whether these protrusions and inflammation cause the necrosis, or the cartilage that migrates into vertebra become necrotic due to other conditions, is under investigation.

Few researchers claim that Schmorl’s node may be present by birth. However, the common belief is that it develops following back trauma (especially axial compressive force for example via a direct fall on buttocks), although this is incompletely understood. Clinically they may or may not be symptomatic. However, their etiological significance for back pain is controversial. Let us review it in a greater depth.
How Schmorl’s node manifests?

Clinical pain syndromes associated with acute, traumatic Schmorl's nodes (SNs) is limited. Wagner et al (2000) reported most of the Schmorl’s nodes could be traced to episodes of significant, sudden-onset, localized, nonradiating back pain and tenderness.

When the Schmorl's nodes produce pain? An explanation:

Under MRI, Schmorl's nodes reveal vascularization of the nodes and associated bone marrow edema (3). Takahashi et al (1995) postulated that after fracture healing and subsidence of inflammation, the Schmorl's nodes become asymptomatic, in analogy with old vertebral compression fractures. However many cases complain of persistence lower back pain.

Stäbler et al (3) reviewed MRI of 372 patients for Schmorl's nodes, vascularization of Schmorl's nodes, and associated bone marrow edema of lumbar and thoracic spine location. They tried to correlate the size of the node to clinical complaints. Diameter wise sizes of the Schmorl’s node vary. Two distinctly different varieties are marked on Gado-MRI investigations.

Type 1: Vascularized Schmorl's nodes without bone marrow edema

Type 2: Vascularized Schmorl's nodes surrounded by bone marrow edema

The diameter of the Schmorl’s node increases from type 1 through to type 2. The mean diameter of type 1 Schmorl’s node is found to be around 6.4mm where type 2 Schmorl’s node is around 8.2mm. However this study also revealed that subjects having Schmorl’s node size yet asymptomatic have a diameter of the node around 5.2mm. Once Schmorl’s node is associated with bone marrow edema there is a tendency of back pain. Such people have a Schmorl’s node diameter of around 7.9mm.

Similarly, Takahashi et al (4) reported, in all symptomatic cases, the vertebral body marrow surrounding the Schmorl's node was seen as low signal intensity on T1-weighted images and as high signal intensity on T2-weighted images. It was confirmed by histological examination that the MRI findings indicated the presence of inflammation and oedema in the vertebral bone marrow. These MRI findings were not seen in asymptomatic individuals. Inflammatory changes in the vertebral body marrow induced by intraosseous fracture and biological reactions to intraspongious disc materials might cause pain.

Characteristics of Schmorl's nodes:

Wu HT et al reported lumbar Schmorl’s nodes are generally located at the central or outer third of the endplate. They also reported majority of Schmorl's nodes are associated with disc bulging. However, a small proportion of Schmorl's nodes are also associated with disc herniation. fracture, tumor, or infection (2).

1. More than 80 percent Schmorl's nodes have well-defined margins.

2. Another common finding is concentric rings in the marrow surrounding the node. As reported by Wu et al (2006) this feature has 72% negative predictive value for absence of infection, tumor and fracture.

Time-course changes in edematous Schmorl's nodes:
Wagner et al reported many Schmorl’s nodes not immediately apparent as Schmorl’s nodes manifested only as vertebral body edema representing endplate fracture evolve into classical chronic Schmorl’s nodes at follow-up in MR imaging studies. These authors also reported enhancement of the invaginated disk material and enhancement of the surrounding vertebral body.

According to Wu et al although most remain unchanged, a relatively large minority of edematous Schmorl's nodes evolve in size and signal over a relatively short time. The statistics is as follows: In almost half cases node size of Schmorl's nodes does not change in time course. In almost quarter of the cases increased size occurs. Some evolve to form well-defined concentric rings in the surrounding marrow that appear to be analogous to degenerative changes of endplates. Concentric ring formation has a high negative predictive value for "idiopathic" Schmorl's nodes without underlying fracture, infection, or malignancy (2).

1. Wagner AL et al; AJNR Am J Neuroradiol. 2000 Feb;21(2):276-81.
2. Wu HT et al; Skeletal Radiol. 2006 Apr;35(4):212-9. Epub 2006 Feb 10.

3. Stäbler A et al; AJR Am J Roentgenol. 1997 Apr;168(4):933-8.

4. Takahashi K et al; Eur Spine J. 1995;4(1):56-9.

My Class on disc pain-2 (Schmorl’s node- a unusual disc pain source!)

Sunday, September 20, 2009

Understanding Inter-vertebral disc & generation of pain from it

* The interveretbral disc is referred as disc in this following text

The intervertebral discs lie between the vertebral bodies, linking them together. The components of the disc are nucleus pulposus, annulus fibrosus and cartilagenous end-plates. The blood supply to the disc is only to the cartilagenous end-plates. The nerve supply is basically through the sinovertebral nerve. Biochemically, the important constituents of the disc are collagen fibers, elastin fibers and aggrecan. (3)

The role that abnormalities play in the etiopathogenesis of different disorders is not always clear. Disorders may be caused by a genetic predisposition or a tissue response to an insult or altered mechanical environment. According to Roberts et al (2006), whatever the initial cause, a change in the morphology of the tissue is likely to alter the physiologic and mechanical functioning of the tissue (2) which is very important from all varieties (medicinal, physical therapy or surgical) of treatment prospective.

Upcoming new therapies are focusing on to substitute the biochemical constituents, or augment nucleus pulposus or regenerate cartilaginous end-plate or finally artificial disc implantation (3). Let us discuss IV disc & it’s pathologies.

The disc

1. Disc the facilitator of spine movement & flexibility: The intervertebral disc is a highly organized matrix laid down by relatively few cells in a specific manner. The central gelatinous nucleus pulposus is contained within the more collagenous anulus fibrosus laterally and the cartilage end plates inferiorly and superiorly. The anulus consists of concentric rings or lamellae, with fibers in the outer lamellae continuing into the longitudinal ligaments and vertebral bodies. This arrangement allows the discs to facilitate movement and flexibility within what would be an otherwise rigid spine (2).

2. Ageing related developmental considerations of the disc:

a. At birth, the human disc has some vascular supply within both the cartilage end plates and the anulus fibrosus, but these vessels soon recede, leaving the disc with little direct blood supply in the healthy adult (2).

b. With increasing age, water is lost from the matrix, and the proteoglycan content also changes and diminishes. The disc-particularly the nucleus-becomes less gelatinous and more fibrous, and cracks and fissures eventually form. More blood vessels begin to grow into the disc from the outer areas of the anulus. There is an increase in cell proliferation and formation of cell clusters as well as an increase in cell death. The cartilage end plate undergoes thinning, altered cell density, formation of fissures, and sclerosis of the subchondral bone (2).

3. Aging and degeneration are separate processes or the same? In point number 2 mentioned above aeging related developmental changes are considered. The changes described above are similar to those seen in degenerative disc disease. Hence question arises that as to whether aging and degeneration are separate processes or the same process occurring over a different timescale.

4. Separate pathological processes manifests separately: Disorders involving the disc manifests different changes in morphology. They are as follows:

a. Discs in patients with spinal deformities such as scoliosis: These discs have ectopic calcification in the cartilage end plate and sometimes in the disc itself. Additionally discs cells from patients with spondylolisthesis have been found to have very long cell processes.

b. Discs in patients with spondylolisthesis: cells from patients with spondylolisthesis also have been found to have very long cell processes.

c. Cells in herniated discs: Cells in herniated discs appear to have a higher degree of cellular senescence than cells in nonherniated discs and produce a greater abundance of matrix metalloproteinases.

5. Insight into vertebral disc nutrition & basis of disc disintegration- The disc is avascular, and the disc cells depend on diffusion from blood vessels at the disc's margins to supply the nutrients essential for cellular activity and viability and to remove metabolic wastes such as lactic acid. The nutrient supply can fail due to changes in blood supply, sclerosis of the subchondral bone or endplate calcification, all of which can block transport from blood supply to the disc or due to changes in cellular demand (1).

Urban et al (1); reviewed studies on disc blood supply, solute transport, studies of solute transport in animal and human disc in vitro, and of theoretical modeling studies that have examined factors affecting disc nutrition. The results emerged as follows:

a. Role of Diffusive transport & Convective transport: Small nutrients such as oxygen and glucose are supplied to the disc's cells virtually entirely by diffusion; convective transport, arising from load-induced fluid movement in and out of the disc, has virtually no direct influence on transport of these nutrients.

b. Disparity of Diffusive transport & Convective transport leads to: Steep concentration gradients of oxygen, glucose, and lactic acid across the disc; oxygen and glucose concentrations are lowest in the center of the nucleus where lactic acid concentrations are greatest.

The actual levels of concentration depend on the balance between diffusive transport and cellular demand and can fall to critical levels if the endplate calcifies or nutritional demand increases.

c. The result of disparity of Diffusive transport & Convective transport is disc degeneration: Loss of nutrient supply can lead to cell death, loss of matrix production, and increase in matrix degradation and hence to disc degeneration.

6. Disc neurobiology & pain generation:

The sinu-vertebral nerve: In the healthy cases only the outer third of the annulus fibrosus of the intervertebral disc is innervated (6). The main innervation of the intervertebral disc is formed by the sinuvertebral nerves. The sinuvertebral nerves are recurrent branches of the ventral rami that re-enter the intervertebral foramina to be distributed within the vertebral canal (4).

Sinuvertebral nerves are mixed polysegmental nerves and nerve plexuses, each being formed by a somatic root from a ventral ramus and an autonomic root from a grey ramus communicans (4).

Neuronal markers for pain-leading fibres were found in the dorsal region of the annulus, and especially in the posterior longitudinal ligament. The expression of neuronal markers in the sarcolemma of the paravertebral muscles is reduced after discotomy (4).

Routes of sympathetically mediated pain in spine: The discs are innervated via sinu-vertebral nerves. However, research in the 1980s suggested that pain sensation is conducted in part via the sympathetic system. This sympathetically mediated entry of pain sensation is by 2 different routes. One route enters the adjacent dorsal root segmentally, whereas the other supply is non-segmental ascending through the paravertebral sympathetic chain with re-entry for example in lumbar spine through the thoracolumbar white rami communicantes (5). The number of nerve bundles gets reduced by resection of sympathetic trunks (4).

Peculiarity of discogenic pain generation in an injured disc: Nerve ingrowths into the diseased intervertebral disc are found in chronic back pain. Freemont et al reported isolated nerve fibres that express substance P deep within diseased intervertebral discs and their association with pain suggests an important role for nerve growth into the intervertebral disc in the pathogenesis of chronic low back pain (6).

Sensory nerve endings in the degenerative lumbar disc penetrate deep into the disrupted nucleus pulposus, insensitive in the normal lumbar spine. Complex as well as free nerve endings would appear to contribute to pain transmission. The nature and mechanism of discogenic pain is still speculative but there is growing evidence to support a 'visceral pain' hypothesis, unique in the muscloskeletal system (5).

Faustmann (4) has summarised the neuroanatomical basis of discogenic pain as follows:

a. The intervertebral disc receives an extensive innervation, especially the annulus fibrosus.

b. Nerve extension into the nucleus pulposus of the degenerated disc.

c. The sinuvertebral nerve plexuses facilitate a polysegmental signal and pain spreading.

d. The innervation of the intervertebral disc is very high connected with the paravertebral muscles.

e. A local denervation of the paravertebral muscles is associated with post-discotomy syndrome.


1. Urban JP et al; Spine (Phila Pa 1976). 2004 Dec 1;29(23):2700-9.
2. Roberts S et al; J Bone Joint Surg Am. 2006 Apr;88 Suppl 2:10-4.
3. Raj PP; Pain Pract. 2008 Mar;8(1):18-44.
4. Faustmann PM; Z Orthop Ihre Grenzgeb. 2004 Nov-Dec;142(6):706-8.
5. Edgar MA; J Bone Joint Surg Br. 2007 Sep;89(9):1135-9.
6. Freemont AJ; Lancet. 1997 Jul 19;350(9072):178-81.

Class on disc pain mechanism-1

Saturday, September 19, 2009

Kaltenborn: Foundation of treatment technique

The treatment goal: To restore joint play & normalize roll-gliding that occurs in normal active physiological movements

1. Resting & actual resting positions: resting positions is otherwise called maximum loose pack position. In this position the capsule is lax maximally hence can accommodate maximum most fluid.

a. The term actual resting position is used for special circumstances where it is impossible, impractical or difficult to use maximum loose pack position.
b. Positional fault: Traction to decrease pain is usually performed form resting position. If it is difficult to perform traction from the resting position then the actual resting position is chosen. If traction to reduce pain performed from actual resting position produces pain then a positional fault is said to exist.
c. Once this is found first aim is to perform glide-mobilizations to correct the positional fault & it is obvious that one must find the direction of glide that is restricted & responsible for positional fault.
d. Once the positional fault is corrected traction & other mobilization techniques may then be performed.

2. Every hypo-mobile joint is initially treated with traction-mobilization for pain possibly with other electro-therapeutic adjunct. After there is improvement of pain glide-mobilization in the restricted direction can be carried out.

3. Traction-mobilization & Glide-mobilization should occur without pain.

4. In severely restricted joints usually the Glide-mobilization is painful in the restricted direction. In this case traction-mobilization &/or glide-mobilization in pain-free directions is performed until the joint is more mobile or gliding in the restricted direction is no longer painful.

Excerpts from my manual therapy class

Wednesday, September 16, 2009

Learing the basic skills of manual therapy: Fundamentals of Maitland’s Mobilization

Quotes from the legend:

1. The aim of examining movements is to find one or more comparable “signs” in an appropriate joint or joints.

2. Joint movements can never be classed as normal unless firm overpressure can be applied painlessly.

3. During examination and assessment pain should never be considered without relation to the range or vice versa.

Performing the act:

Different grades of movement are administered as oscillatory movements. Oscillatory movements have a positive & negative cycle. The positive portion of the cycle is one where impact of the force leads the accessory movement to sink into the tissues. Where as the negative portion of the cycle is one where, the therapist has to release the force to so that tissues can return to where it has started.

Types of oscillatory movements:

Oscillatory movements are administered in

1. Rhythmic manner or
2. With Irregular rhythm

Under most circumstances the treatment used is regular & rhythmical.

The informality about the treatment position:

1. For the purpose of learning the techniques various positions are adopted. These positions vary from physiotherapist to physiotherapist and not mandatory as similar positions many not suit all physiotherapist. Each physiotherapist should modify the position to suit her own circumstances.

2. Hence the whole attention is focused on learning the skill & feel of the joint movement so as to make them instinctive.

The bottom line that matches words from my heart
Advice to novice manipulators

Many authorities including Maitland emphasized the fact that “Brute strength is not essential to the use of manipulative treatment- rather, what is required are perceptive hands & an agile, methodological mind".

excerpt from my manual therapy class 9

Monday, September 14, 2009

Kaltenborn’s Approach to Joint Play Testing

Key points

1. In contrast to Maitland, Kaltenborn developed his joint play testing with an emphasis on straight line, translatoric movement within a joint.

2. The use of CCR (concave convex rule) for joint play testing.

3. The examiner feels for abnormal resistance to motion with a particular emphasis on end-feel testing.

4. This testing is not truly oscillatory although it is often repeated several times using different speeds of movement.

Points to focus

• Bone rotation = Joint Roll-glide = Physiological movement
• Bone translation = Joint gliding, Traction, Compression = Joint play

Rotation = curved movement around an axis,
Translation = straight-line movement

Kaltenborn’s 3 Point Scale

Kaltenborn developed a 3 point scale to describe the amount of movement and perceived resistance during manual joint testing and treatment.

Slackness available can be referred as the mid point form feeling point of view. When slackness is taken-up stretching (Gr-III) starts. Before onset of the slackness there is cancellation of joint compressive forces i.e. muscle tension, cohesive forces, atmospheric pressure. Hence the exact amount of force required for cancellation of compressive forces before entering into the slack zone is called Gr I.

Excerpt of my manual therapy class 8.

Friday, September 11, 2009

VCS-vacuum cleft sign

1. The intravertebral vacuum cleft sign (VCS) is an uncommon radiological sign.
2. VCS is characterized by a radiolucent zone in the vertebral body.
3. This zone is composed of 95% nitrogen and small amounts of oxygen and carbon dioxide.

4. Cause:

a. Post-traumatic ischemic necrosis (main cause) but other causes are (point b onwards)
b. osteoporosis,
c. corticosteroid therapy,
d. diabetes,
e. arteriosclerosis,
f. alcoholism,
g. multiple myeloma,
h. bone metastasis and
i. osteomyelitis.

The broad diagnosis is made by AP X-ray. However DD encompasses CT scan and MRI.


Sarli M et al; Osteoporos Int. 2005 Oct;16(10):1210-4. Epub 2005 Feb 25.

The Ultimate Frozen shoulder physical therapy recommendations

1. Pain reduction by Grade I cephalo-caudal glide recommended (Wardsworth CT; Physical therapy, Vol.66, dec.1986)

2. Mid-range mobilization II, II(-), II (+) (no specific effects claimed up to yet except as a progression of grade I)

3. End- range mobilization Increase in mobility & functional ability by grade III,IV (Henricus MV et al, PHYS THER, Vol. 80, No. 12, December 2000, pp. 1204-1213 and PHYS THER,Vol. 86, No. 3, March 2006, pp. 355-368)

4. Mulligan’s mobilization with movement (MWM) correct scapulohumeral rhythm significantly better than end range mobilization (Yang JL et al Phys Ther. 2007 Oct;87(10):1307-15)

5. PNF techniques for shoulder (Joseph JG et al; J Orthop Sports Phys Ther; Vol.33, dec. 2003 )- for scapulo-humeral alterations

6. PNF for upper trunk (My recommendation: Satyajit Mohanty, MSPT- not supported by research i.e. on clinical experience only) for scapulo-humeral alterations + upper trunk kyphosis

Wednesday, September 9, 2009

Challenging the CCR (concave-convex rule) mobilization convictions

Our peer’s classes on mobilization start with explanation of articular anatomy & McConnell joint classifications. It is followed by CCR with technique applications obeying the CCR.

For shoulder mobilization it goes like this:

1. To regain ER – Anteriorly directed glides.
2. To regain ABD – Inferiorly directed glides
3. To regain IR – posteriorly directed glides

Many times conventional wisdom is challenged when the research reports are contra posed. A paper JOSPT (2007) claimed that posteriorly directed joint mobilization technique was more effective than an anteriorly directed mobilization technique for improving external rotation ROM in subjects with adhesive capsulitis. However in groups comprised of both anterior directed glides compatible to CCR and posterior glides opposite to CCR recommendation had a significant decrease in pain.


Johnson AJ et al; J Orthop Sports Phys Ther. 2007 Mar;37(3):88-99.

Which is better for clinical application of posterior capsule stretch- The Sleeper stretch or the Cross body stretch?

Launder KG et al evaluated the acute effects of "sleeper stretches" on shoulder ROM. In their study sleeper stretches produced a statistically significant acute increase in posterior shoulder flexibility. However these authors explain that these acute changes in motion may not be clinically significant.

Because of this recently expressed the belief that the sleeper stretch is better than the cross-body stretch to address glenohumeral posterior tightness because the scapula is stabilized McClure P et al compared changes in shoulder internal rotation range of motion (ROM), for 2 stretching exercises, the "cross-body stretch" and the "sleeper stretch," in individuals with posterior shoulder tightness. The sample consisted of 54 asymptomatic subjects (20 males, 34 females).

The groups:
1. The control group (n=24) consisted of subjects with a between-shoulder difference in internal rotation ROM of less than 10 degrees.

2. Experimental groups ware those subjects with more than a 10 degrees difference. 2 intervention groups are formed i.e. the sleeper stretch group (n=15) or the cross-body stretch group (n=15).

1. The cross-body stretch in individuals with limited shoulder internal rotation ROM appears to be more effective than no stretching in controls.

2. Improvement in internal rotation from the cross-body stretch was greater than for the sleeper stretch and of a magnitude that could be clinically significant.


1. J Orthop Sports Phys Ther. 2007 Mar;37(3):108-14.

2. J Athl Train. 2008 Jul-Aug;43(4):359-63.

Sunday, September 6, 2009

Differences in major joint play testing grades

The pioneers of joint play testing

The two principal pioneers of joint play testing in manual therapy are Geoffrey Maitland of Australia, and Freddy Kaltenborn of Norway. Both individuals developed techniques for the extremities and spine, and both developed different scales for describing the force and movement used during testing and treatment.

Essential Differences between the Australian and the Nordic Approach

During the development of his approach, Maitland was strongly influenced by the neurophysiologic principles relating to pain. Kaltenborn on the other hand was influenced by the joint based mechanical approaches advocated by Cyriax, Mennel, and Stodard.

1. Basic differences in approaches:
Maitland’s approach (non-diagnostic approach): Maitland’s approach uses angular motions in the extremities when looking at joint play. Logically, angular movements of the long bones may be used to identify abnormal resistance due to muscle guarding, muscle tone, or articular restriction. However, because of its gross nature, it is difficult to judge whether articular or neuromuscular impairments are causing a particular movement restriction.

Kalternborn’s approach: Drawing from simple mechanical principles Kaltenborn reasoned that there are two types of movement available in a joint: rolling and gliding. Understanding that, excessive loading (sheer and compression) leads to articular cartilage degeneration Kaltenborn chose to emphasize straight-lined, translational (gliding) movements during joint examination, mobilization, and manipulation. His techniques are performed using very small amplitudes of movement with forces applied close to the joint line.

2. The scales developed: The scales developed by Maitland and Kaltenborn are equally dissimilar. Kaltenborn’s scale looks at resistance within the range while Maitland’s scale looks at the amplitude of oscillations within the range. Some manual therapy systems integrate these two scales which causes confusion for the novice manual therapist.

3. Kaltenborn & Maitland’s Initial Treatment Directions: Kaltenborn and Maitland target their initial treatments differently. Maitland advocated treating patients with pain by directing oscillations towards the direction of movement causing pain (but not into pain). Kaltenborn on the other hand emphasized treating to improve function using directions that cause the least amount of pain.

(excerpt from my manual therapy class:8)

Saturday, September 5, 2009

Grades of accessory movement

Grades of accessory movement

This following article is about introducing the novice manual therapist to grades of applying passive accessory movement.

Variables of Passive accessory movement administration

1. Direction
2. Grade
3. Speed & Rhythm
4. Duration of administration

Aim of grading of passive accessory movements

1. To assess: Different abnormalities of spine & periphery presents with different amount of pain & resistance to passive movements. Our approach to palpation can not be the same to all of them as there may be different grades of tolerance to forces due to either mechanical faults or inflammation.
a) Hence first of all force identified into different grades provides a rational explanation to approach tissue faults.

b) It also helps to find out localized & referred pattern of pain (especially in spinal conditions).

c) It further indicates tissue condition accessible at different depth of penetration (feel of the tissue).

d) It also helps to assess the reaction of pain to that of force. Pain reaction to passive force indicates the receptive capacitance of the tissue.

e) At other end of the finding, we are able to compare the normal to abnormal mobility (hypo-mobile, Hyper- mobile etc).

2. To treat:
a) It is an established fact that graded passive forces of different depth produce different mechanical impacts on the peripheral mechanoreceptors that further affects the pain gait. However, many other hypotheses for explanation are there in vogue.

b) The bottom line is graded forces suitable to the tolerance can be administered to produce reduction of pain or change in local and over all mobility.

c) It is seen that after pain centralization in spine the local tissue can tolerate more mobilizing force (higher grades).

The bottom line of grading passive accessory movements:

There are varying international practices for the description of the grades of technique application. Treatment techniques are usually graded for easier communication between therapists. The grades describe how the technique was applied in terms of amplitude and where in the range it was applied. This allows another therapist to take over a treatment and perform similar techniques on the patient. It also makes recording of treatment easier. One of the more common ways of describing the grades of Passive Accessory Intervertebral Movement application is the 4 grades of classification developed by Maitland 2001.