Learning objectives

 To understand terminology guiding peripheral

manipulation
 To understand and describe the various concepts in
peripheral manipulation
 To understand the theory of conducting an assessment
 To identify red flag patients

Introduction
 Peripheral: anything that is away from the centre

 Mobilization: is the treatment technique that involves the

clinician applying a force to mimic the gliding that occurs
between bones. It is a passive movement, the goal of which
is to produce a slide or glide.

 Manipulations: aggressive, high velocity techniques, or

thrusts. They occur very fast, and at the end of available
joint play.

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Joints
 Diarthroses
 Synoival joint.

Types of Joints

Cont…
 Amphiarthrosis (cartilaginous):Slightly movable
joints. In this type of joint, the bones are connected by
hyaline cartilage or fibrocartilage.

 Synarthrosis (fibrous): immovable joints. the bones

come in very close contact and are separated only by a
thin layer of fibrous connective tissue.

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Phases of Healing
 Inflammatory
 Repair/ Regeneration Phase/ Proliferation stage
 Remodeling Phase

 Inflammatory stage:
 Lasts up to 5 – 7 days
 Characterized by inflammation and hemostasis
 Formation of a platelet plug
 Attraction of neutrophils and macrophages

 Proliferation Phase:
 Begins day 3 (or after the inflammatory phase end
 Fibroblast cells - peak around day 7 responsible for
angiogenesis, epithelialization and collagen formation.
 Can last up to 6 weeks

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 Remodeling Phase:
 Increased collagen production and breakdown lasts 6
months to a year.

CONCEPTS

Kaltenborn
If the moving joint surface rolls on another joint without
simultaneously gliding, the surfaces would separate (gap or
subluxate) in some places and impinge in others. Roll and
glide must occur simultaneously to preserve joint integrity =
concave-convex rule.

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 Articulating Surfaces
concave/convex rule
(Kaltenborn concept)

 When a convex surface moves on a stable concave

surface the movement occurs in the opposite direction
to the bony lever
 When a concave surface is moving on a stable convex
surface the sliding occurs in the same motion as the
bony lever.
http://youtu.be/9pCbnvpyLvs

Mulligan
 Based on Kaltenborn concept (1989)

 He proposed “that injuries or sprains might result in a

minor positional fault to a joint thus causing
restrictions in physiological movement”

 The concept thus of mobilizing the spine whilst the

spine is in a weight bearing position and directing the
mobilisation parallel to the spinal facet planes was
born

 Passive oscillatory mobilisations called ‘NAGs’ (natural

apophyseal glides) and sustained mobilisations with
active movement ‘SNAGs’ (sustained natural
apophyseal glides) are the mainstay of this concept’s
spinal treatment

 Mobilization with movement (MWM’s ) is what is

used when applying this concept to peripheral joints.

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Cyriax
 Focused more on soft tissue
 Promoted the breakdown of scar tissue using deep
transverse frictions to promote collagen orientation
during the healing process.

Butler and Shacklock

 Butler: Focused on adverse mechanical tension in the
nervous system, based on pathology, biomechanics
and clinical experience.
 Can be integrated into the Maitland concept
 Shacklock: focused on the mobilization of the nervous
system as a treatment technique.

Richardson and Sahrmann

 Richardson: spinal stability can be enhanced by
facilitating a co-contraction of muscles surrounding
the lumbar spine.

 Sahrmann: postural alignment and muscle

imbalances.

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 McConnell
 McConnell: the use of taping/strapping to correct the
joint dysfunction.

Maitland
 Maitland Concept
emphasizes a specific way of thinking, continuous evaluation and assessment and the art of
manipulative physiotherapy (“know when, how and which techniques to perform, and adapt these
to the individual Patient”) and a total commitment to the patient.

Permeable ‘brick wall’: decide which side of the brick wall is being used during clinical reasoning.

Theoretical Clinical
Diagnosis History

Prevent theory from overriding the clinicians decision making processes and does not inhibit the
clinician from discovering the patient’s disorder in terms of its history.

Subjective Examination
 Aim:
 Decide the source of the symptoms and/ or the
dysfunction (* sign)
 What factors are contributing to the decision
 Whether there are any precautions and/or
contraindications to the physical examination
 The prognosis of the condition – this can be affected by
factors such as the stage and the extent of the injury as
well as the patient’s expectation personality and lifestyle
 How best to manage the patients conditions

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 Objective Examination
 Aim:
 Establish with *, the signs relevant to the patient’s disorder
 Test the clinical and theoretical hypotheses identified in the C/O
 Analyze movements in terms of their range/symptom response/
quality
 Apply an appropriate amount of examination
 Reproduce the symptoms
 Find comparable signs
 Establish the source, cause of the source and contributing factors to
the disorder\exclude factors not at fault
 Confirm or rule out the need for caution with special testing
 Follow a logical, methodical, comprehensive relevant and
integrated format
 Record in a logical methodical way
 Follow – up examination not completed at the initial consultation
during subsequent visits.

Definitions
 Hypermobility : an excessive range of movement is
possible and there is complete muscular control, thus
allowing for stability.
 Instability: there is and excessive range of abnormal
movement for which there is no protective muscle
spasm
 Quick tests: these are active, usually antigravity tests
and are the first tests used during the objective
examination .

Cont…
 Clear Joint: A clear joint is a joint which has full range
painless movement, which is also painless on
overpressure, compression or special tests. It the
movement is normal the joint is recorded √√
 The first √ denotes that the range is normal and painfree
 The second √ denotes that it is also painless with
overpressure.

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Cont…
 Special Test: Passive tests consisting of a combination of
two physiological movements or one physiological mvt
and 1 accessory mvt used to test if a joint is normal.
 Special Questions: specific questions asked to be aware
of any precautions or contra-indications.
 Comparable sign:
 Joint sign: any facet of movement that is abnormal –
musculoskeletal (pain, stiffness or muscle spasm)
 Comparable joint sign: refers to combinations of pain,
stiffness and spasm which the examiner finds in
examination and considers to be comparable with the
patients symptoms.

The Body Chart

 What to do first??

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 Body Chart
 Area of symptoms
 Areas relevant to the region being examined
 Quality of pain
 Intensity of pain
 Depth of pain
 Abnormal sensation
 Constant or I/M symptoms
 Relationship of symptoms

Behaviour of Symptoms
 Aggravating Factors
 Easing Factors
 Twenty – four hour behaviour of symptoms
 Function
 Stage of the Condition

 Severity, Irritability and Nature of symptoms (SIN)

Special Questions
 General Health
 (DEARTH)
 Weight Loss
 Medication
 Steroid use
 Anticoagulants
 Neurological symptoms
 Saddle anaesthesia
 Urinary incontinence
 Urinary retention
 Constant bilateral pins and needles
 Disturbances in gait

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 Dizziness/ nausea
 Vertebrobasilar insufficiency (VBI)
 X-Ray and Medical Imaging

History of the Present

Condition
 Which area was affected
 How long the symptoms has been present
 Whether there was a sudden or slow onset of the
symptoms
 Whether there was a known or unknown cause that
provoked the onset of the symptom

Past medical History

 Any medical information relevant to the patients
condition
 History of previous episodes
 When did it occur
 Duration
 Did they fully recover
 Past treatments
 Did it assist

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Social and Family Responsibility
 Employment
 Home environment
 Family history of condition?

Physical Examination
 Observation
 Informal
 Formal
 Observation of posture
 Observation of muscle form
 Observation of soft tissues
 Observation of patients attitudes and feelings

Summary
 There are different joint types – basic rules and
concepts that guide the assessment and treatment.

 3 phases of healing

 2 main aspects to assessment:

 Subjective assessment
 Objective assessment

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References
 Kaltenborn, F.M. (1989). Manual Mobilization of the Extremity Joints (4th ed.)

 Maitland.G.D., Peripheral Manipulations 3rd Edition

 Petty J.N. & Moore A.P., Neuromuscular Examination and Assessment

 Hunter, G. (1998). Specific soft tissue mobilization in the management of soft tissue
dysfunction. Manual Therapy, 3(1), 2 -11.

 Shacklock, M. (1995). Neurodynamics. Physiotherapy, 81(1), 9-16.

Structure Pain
Bone Deep, nagging, dull
Muscle Dull ache
Nerve Root Sharp shooting
Nerve Sharp, bright, lightening like
Vascular Throbbing, diffuse
Visceral Diffuse

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