MANUAL

This article is the second in a series

from our Manual Therapy Student
Handbook (see the
‘Contents panel’ for

THERAPY: further details). It

discusses the terms
‘mobilisation’,

Definitions – ‘manipulation’ and

‘massage’. As these
terms are used commonly,
mobilisation, although not always
consistently, it is important

manipulation and that their meanings are

clearly defined. Read this online

massage
http://spxj.nl/1Le22Ft

15-10-SPORTEX BY JULIAN HATCHER GRAD DIP PHYS

FORMATS MPHIL, MCSP FOM
WEB MOBILE
PRINT MOBILISATION of amplitude of the movements and oscillatory mobilisations are created
There is a degree of confusion the range of movement in which the relative to this point of onset of
around the terms ‘mobilisation’ and movements take place. The movement resistance.
‘manipulation’. For the purposes of is performed at slow velocity and is
these articles we will use the following always within the control of the patient. Definitions are as follows:
definitions based around the definitions n Grade I A small amplitude passive
used by Maitland: Manipulations are movements that oscillatory movement within the
are forceful passive movements resistance-free range.
Mobilisations are movements of just beyond the range of normal n Grade II A large amplitude passive
joints performed either as oscillatory physiological range. They are done oscillatory movement within the
movements of varying amplitude, at high velocity and hence outside of resistance-free range.
or as sustained stretches. They the control of the patient. They are nG  rade III A large amplitude passive
are passive movements done commonly known as high velocity oscillatory movement going into the
as physiological or sometimes thrusts of low amplitude. resistance range.
accessory movements. nG  rade IV A small amplitude passive
Maitland Grades oscillatory movement going into the
Maitland himself actually grades these Maitland Grades are described resistance range.
movements with respect to the size relative to the overall available nG  rade V A small amplitude, high
movement at any joint (however velocity thrust performed at the end
large or small this may be). The of full available range (ie. at the end of
concept can be easily visualised by the pink box in Figure 1).
referring to Figure 1, where the overall
range of motion is represented by the Various orthopaedic medicine
pink box; specifically along the educational groups have similarly
horizontal axis. The section labelled attempted to apply this grading for
‘R’ is the point where resistance is treatments that are not just passive
experienced when performing a movements, but exercises too. These
passive movement. The ‘depth’ of this are simplified in that they map easily to
resistance section may be relatively Maitland’s grading structure thus:
‘thin’ in joints with firm elastic capsular nG  rade A A movement or exercise
end-feels, and ‘thicker’ in joints performed within the pain-free range.
where soft tissue is opposed. From nG  rade B A movement or exercise
Figure 1: The Maitland Grades of mobilisation
that concept, the notions of passive performed into the resistance range.

44 sportEX journal 2015;66(October):44-47

 MANUAL THERAPY STUDENT HANDBOOK

some may become mechanical joint

MAITLAND GRADES THE movement.

MOBILISATION MOVEMENTS Concave–convex rule

WITH RESPECT TO THE At this point, we should remind ourselves
of the ‘concave–convex’ rule:
SIZE OF AMPLITUDE OF THE
MOVEMENTS AND THE RANGE When the convex surface is fixed,
and the concave surface moves, the
OF MOVEMENT IN WHICH THE component of glide that accompanies

MOVEMENTS TAKE PLACE the component of roll is in the same

direction as the angular movement of
the limb or the overall movement of
the joint.

When the concave surface is fixed,

and the convex surface moves, the
component of glide that accompanies
the component of roll is in the opposite
direction to the movement of the joint
or limb.

Essentially this means that use of

accessory mobilisations should match
these rules to be effective. If moving the
convex joint surface to increase range
nG
 rade C A small amplitude, high believed to have the effect of reducing of movement, the choice of direction is
velocity thrust performed at the end the perception of pain. The actual opposite to the limited movement. The
of full available range. mechanism of how this is achieved is converse is true if moving the concave
not precise; however, the effect may surface.
Grade As are similar to Grades I and II, bombard the central nervous system In summary, mobilisation of joints
Grade Bs are the same as Grade III and with afferent signals that block out has an effect both on pain and stiffness,
IV, and Grade C is identical to Grade V. the pain signals (pain gate theory). in that it can cause a reduction in both.
In addition to this, it is believed that The actually mechanisms of how this is
What occurs during mobilisation? movement of joint capsule may achieved are not fully known.
Having decided upon our definition of decrease its viscoelastic properties or
joint mobilisation, what actually occurs? mechanical resistance (what we may MANIPULATION
What are the biomechanical movements call stiffness). As stated in the section on ‘Mobilisation’,
at the joint surfaces? It has certainly been shown that there is a good deal of confusion over the
Well, firstly there is movement there is a measurable variation of terms, ‘manipulation’ and ‘mobilisation’. For
defined as ‘gliding’ of joint surfaces. force with time, which may have effect the purposes of this series of articles we
However, do both joint surfaces move or on both pain and stiffness. It appears will use the definitions used by Maitland
is one the prime mover and the other that repetitive movement of the joint as stated in the section on ‘Mobilisation’,
more fixed? Generally speaking, the aim causes a reduction in the joint stiffness where ‘manipulation’ occurs at the
of mobilisation is to have a causative (in the biomechanical sense) so that Maitland Grade V level.
effect at the joint by holding one joint less force is required to produce
surface fixed, and making the other joint the same amount of movement (or nG rade V A small amplitude, high
surface move in relation to it. In reality, displacement). It has also been shown velocity thrust performed at the end of
it is near impossible to hold one joint that manual therapists are able to vary full available range (ie. at the end of the
actually fixed perfectly, and undoubtedly the amount of displacement caused by pink box in Figure 1).
there will be some movement. It is likely, the technique of choice. Therapists may
though, that any movement occurring grade movement as Maitland or Cyriax Again, we now have a definition for joint
is likely to be opposite to the moving would, however, how good and accurate manipulation, but what really happens in
segment, which may enhance the effect. therapists are in terms of these grades biomechanical terms? Movement of joint
So what is being achieved by this is not known. What is known, though, surfaces (which?) causing:
movement of two adjacent segments? is that energy is transferred from n correction of joint position (static)
It is believed that the movement therapist to client. This energy may be n correction of abnormal vertebral
causes the stimulation of joint transferred from mechanical to heat movement (dynamic)
mechanoreceptors. This, in turn, is caused by resistance and friction, and n release of soft tissue abnormalities

Co-Kinetic.com 45
 (tenderness, spasm, trigger points) stroke with the hand, press softly. sympathetic nervous system, which
n c orrection of muscle imbalance In the 18th and 19th centuries, in turn reduces blood pressure and
or contraction in opposing muscle massage was used in Europe by a induces relaxation. More specifically, the
groups. Swede, Per Henrik Ling; hence the term purported physiological effects include
‘Swedish massage’. This became an the following:
There is also evidence to show extremely popular medical treatment 1. Cardiovascular and lymph
that manual therapists can produce by the end of the 19th century. Johann - improved circulation
consistent sudden application of force Mezger, a Dutch Physician, introduced - improved delivery and removal of
following pre-load force causing capsular terminology that described different products in blood
distension. Another interesting point to techniques of massage: - decreased blood pressure and heart
raise here is the issue of ‘cracks’. Are n effleurage rate
cracks necessary to gain results in n petrissage - increased stroke volume
manipulation? n tapotment - increase in white blood cells and
The answer most therapists n frictions, etc. other elements of immune system
would give would be ‘no’. The scientific - stimulates circulation in lymph
evidence on the other hand is Unfortunately for bona fide masseurs, system
inconclusive. However, many therapists the word ‘massage’ was also a term - improved removal of waste products
actually feel they get a better result if freely used by prostitutes to hide other 2. Nervous and endocrine systems
cracks are heard, and nearly all agree activities. Unfortunately there is still - stimulates or soothes nervous
that cracks are beneficial to the patient. some evidence that this may still be system through activation of
Whether the latter is a psychological the case in some establishments of sensory receptors
benefit or not is unclear. There is also ill repute! Indeed, back in 1894, eight n reduction in pain through release of
some debate as to the source of these women banded together to form the endorphins
cracks. Nothing yet has been proven, Society of Trained Masseurs. They were n suppression of pain
but two main schools of thought exist. the founders of what is now known as n stimulation of parasympathetic
The first uses the explanation that the Chartered Society of Physiotherapy. system promoting relaxation and
nitrogen gas dissolved in the synovial There are many more contemporary improved sleep
fluid forms a gas bubble due to the forms of massage such as: n increased dopamine and serotonin
decrease in volume as a result of the n Rolfing levels
distension of the joint. The noise heard n deep tissue massage 3. Muscular and connective tissue
is something to do with the sudden n sports massage n relieves muscular stiffness, soreness
formation of these bubbles. The second n reflexology and spasms – direct pressure and
explanation is explained by the sudden n neuromuscular massage reflex response
return of the capsule to its original n connective tissue massage n enhanced blood circulation –
position after the release of negative n lymphatic massage. increased oxygen and nutrients
pressure. The latter does not, however, available to tissue
explain how the pressure is released. The philosophies behind these different n increased flexibility
One thing that has been proven techniques may be somewhat varied; n rapid disposal of waste products
by scientific experimentation is that however, they can all be summarised helps reduce soreness
release of muscle spasm is not directly as being effective in two ways: the n breakdown of fibrous adhesions.
related to cracking of joints. It is mechanical and the reflexive response.
seemingly independent of the cracking The scientific evidence behind the Two main forms of massage will be
phenomenon. effectiveness of massage is somewhat addressed in this article series; effleurage
limited. Clinical observations are much and frictions. Effleurage is a type of
MASSAGE more extensive. It is generally accepted deep stroking, often used to apply oil to
Massage is probably one of the most that this anecdotal evidence is at least skin and to prepare the body for more
popular styles of manual therapy that based on sound clinical reasoning and vigorous techniques. It is often performed
is commonly used by all sorts of physiological principles. in specific directions in order to move
people. A definition of massage could fluid towards lymph nodes such as the
be the manipulation of soft tissue for Mechanical response popliteal fossa or femoral triangle. It is
therapeutic purposes. This is the direct response brought on often reported to have relaxational effects
Like all other forms of manual by force or pressure increasing blood and may help reduce swelling. Frictions
therapy, massage has a long history. It circulation, softening and breaking up are an uncomfortable massage technique
is probably the oldest form of medical scar tissue. often performed in either unidirectional
treatment. It has been used throughout or circular directions. Deep transverse
history by all cultures, including Greek, Reflexive response frictions are performed in a unidirectional
Chinese, Indian, Egyptian and Roman. This is the reaction to a stimulus that manner and are purported to stimulate
The word massage comes from the is governed by the nervous system. mechanoreceptors which reduces pain,
Arabic word ‘masah’ – which means The effect is decreased arousal of the may cause breakdown of scar tissue by

46 sportEX journal 2015;66(October):44-47

 MANUAL THERAPY STUDENT HANDBOOK

weakening cross-linkages of scar while 6. Magee DJ. Orthopaedic

THE AUTHOR
promoting strong fibre formation. It may physical assessment, 6th ed.
JULIAN HATCHER Grad Dip Phys MPhil, MCSP
be used in preparation for manipulative Saunders 2014. ISBN 978-
FOM is a senior lecturer at the University of
techniques. 1455709779. Buy from Amazon
Salford and the programme leader for BSc
(£62.99). http://spxj.nl/1UAP1vN
Hons Sport Rehabilitation programme, having created
RECOMMENDED READING 7. Hengeveld E, Banks
it 1997. Previously he was senior physiotherapist in
1. Anderson MK, Parr GP. K. Maitland’s Vertebral
Orthopaedic Medicine at Warrington Hospital Trust from
Fundamentals of Sports Injury Manipulation: management
1987–1997. He also worked in Rugby League (including
Management. Lippincott, of neuromusculoskeletal disorders –
Great Britain BARLA Rugby League) for 7 years as well
Williams & Wilkins 2011. ISBN volume 1, 8th ed. Churchill Livingstone
running his own Sports Injuries Clinic in Warrington up
978-1451109764. Buy from Amazon 2013. ISBN 978-0702040665. Buy
until 1997.
(Print £60.30 Kindle £64.34) from Amazon (Print £61.19 Kindle
Julian became a Fellow of Orthopaedic Medicine
http://spxj.nl/1UANMg £58.13). http://spxj.nl/1g8VFWW
(FOM) in 2000, and Certified Strength & Conditioning
2. Cyriax J. Textbook of 8. Hengeveld E, Banks
Specialist in 2005. After starting with a Graduate Diploma
orthopaedic medicine, vol. 1: K. Maitland’s Peripheral
in Physiotherapy (Grad Dip Phys), he gained his Master of
diagnosis of soft tissue lesions, manipulation: management
Philosophy (MPhil) from the University of Salford in 2007
8th ed. Balliere Tindall 1982. of neuromusculoskeletal disorders –
and has several publications around the knee particularly
ISBN 978-0702009358 Buy from volume 2, 5th ed. Churchill Livingstone
concerning topics such as ‘ACL deficiency: detection,
Amazon (£17.70). http://spxj.nl/1JSrLz4 2013. ISBN 978-0702040672. Buy
diagnosis and proprioceptive acuity’ and ‘Osteoarthritis
3. Boyling J, Jull G. Grieve’s from Amazon (Print £61.19 Kindle
long-term outcomes’. Julian is also an Honorary Member
modern manual therapy: the £58.13). http://spxj.nl/1Np97ol
of British Association of Sport Rehabilitators and Trainers
vertebral column, 3rd ed. 9. Kapandji IA. The physiology of
(BASRaT).
Churchill Livingstone 2005. the joints, volume 3: the spinal
For more information see his profile at the University
ISBN 978-0443071553.Buy from column, pelvic girdle and head.
of Salford website: http://spxj.nl/1LlU2xW.
Amazon (£94.44). http://spxj.nl/1K73UdZ Churchill Livingstone 2008. ISBN
4. Higgs J, Jones A, et al. 978-0702029592. Buy from Amazon
Clinical reasoning in the (£317.58). http://spxj.nl/1K75GM7.
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health professions, 3rd ed.  orking in Sport: From Student to Practitioner
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Butterworth-Heinemann FURTHER RESOURCES http://spxj.nl/1WeWe2K
2008. ISBN 978-0750688857. Buy 1. Audible sounds associated with spinal Anatomy and Soft Tissue Review (animated)
from Amazon (Print £54.99 Kindle manipulation – a snap-shot summary http://spxj.nl/1RkC4B3
£42.39). report. National Council for Osteopathic
http://spxj.nl/1NhBpzM
5. Abrahams PH, McMinn RMH.
Research 2012 http://spxj.nl/1Ka0fMz
2. Bakker M, Miller J. Does an audible
Want to share on Twitter?
McMinn and Abrahams’ Clinical release improve the outcome of a HERE ARE SOME SUGGESTIONS
atlas of human anatomy, chiropractic adjustment? The Journal Tweet this: Repetitive movement of a joint
7th ed. Mosby 2013. ISBN 978- of the Canadian Chiropractic causes a reduction in joint stiffness.
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KEY POINTS CONTENTS PANEL

n ‘Mobilisations’ are movements of joints performed either as oscillatory ARTICLES IN THE MANUAL
movements of varying amplitude, or as sustained stretches. They are THERAPY STUDENT HANDBOOK INCLUDE:
passive movements done as physiological or sometimes accessory
1. Introduction to manual therapy
movements.
2. Definitions: mobilisation, manipulation and massage
n ‘Manipulations’ are movements that are forceful passive movements just
3. Musculoskeletal assessment
beyond the range of normal physiological range. They are done at high
4. Musculoskeletal diagnosis
velocity and hence outside of the control of the patient.
5. Assessment and treatment of the hip
n Maitland defined ‘grades’ of movement, but it is difficult to know how
6. Assessment and treatment of the knee
good or accurate therapists are in terms of these grades.
7. Assessment and treatment of the ankle and foot
n Mobilisation of joints causes a reduction in both pain and stiffness.
8. Assessment and treatment of the shoulder
n A definition of massage could be the manipulation of soft tissue for
9. Assessment and treatment of the elbow
therapeutic purposes.
10. Assessment and treatment of the wrist and hand
n There are many different massage techniques but they can all be
11. Assessment and treatment of the cervical spine
summarised as being effective in two ways: the mechanical and the
12. Assessment and treatment of the lumbar spine
reflexive response.
13. Assessment and treatment of the thoracic spine

Co-Kinetic.com 47
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