- Grade 1: Small movements of the spine performed within the spines resistance
- Grade 2: Larger movements of the spine but still performed within the spines resistance
- Grade 3: Large movements of the spine performed into the spines resistance
- Grade 4: A small movement of the spine performed into the spines resistance
- Grade 5: A high velocity movement performed into the spines resistance
How does the maitland concept help?
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| Maitland Cconcept |
The type of mobilisation used depends on the severity, irritability and nature of the spinal pain. The mobilisations create movement within the joints of the spine which reduces stiffness and makes movement easier. The increased ease of movement also reduces pain.
Decisions Which Need to be Made
- The Direction - of the mobilisation 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.
- The Desired Effect - what effect of the mobilisation is the therapist wanting? Relieve pain or stretch stiffness?
- 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 localised effect.
- The Method of Application - The position, range, amplitude, rhythm and duration of the technique.
- The Expected Response - Should the patient be pain-free, have an increased range or have reduced soreness?
- How Might the Technique be Progressed - Duration, frequency or rhythm?
How to Choose the Direction
To make sure you settle on appropriate mobilisations it is important to get the type of glide, the direction and speed correct.
Different Types of Mobilisation: 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; this is where the Concave Convex Rule comes into use, but for now consider the number of possible glides a clinician may use:
- A-P (Anteroposterior)
- P-A (Posteroanterior)
- Longitudinal Caudad
- Longitudinal Cephalad
- Joint Distraction
- Medial Glide
- Lateral Glide
Concave Convex Rule: Up, down, Left or Right?
Choosing the direction of the mobilisation 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).
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.
Examples:
To improve shoulder flexion you would perform an A-P mobilisation due to the way the convex humerus articulates with the concave glenoid fossa.
An easier way to visualise this is to try and show this rule with your hands. (Picture from)
How to Choose the Grade: How Far into Range and Quickly or Slowly?
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:
- 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 which support and stabilise the joint so increase range of movement.
The rate of mobilisation should be thought of as an oscillation in a rhythmical fashion at:
- 2Hz - 120 movements per minute
- For 30 seconds - 1 minute
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 mobilisations, 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, 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:
- α-Beta fibres - Large diameter and myelinated - touch and pressure - Fast (50m/s)
- α-Delta fibres - Small diameter and myelinated - temperature and pain (well localised, sharp/prickly) - Medium (15m/s)
- C fibres - Small diameter and un-myelinated - pain (dull, poorly localised, persistent) - Slow (1m/s)
The size of the fibres 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 fibres are the quickest of the 3 types followed by α-Delta fibres and finally C fibres.
The interplay between these nerves is important but it is not the whole story, as you can see only two of these nerves are pain receptors α-Delta fibres are purely sensory in terms of touch. All of these nerves synapse onto projection cells which travel up the spinothalamic tract of the CNS to the brain where they go via the thalamus to the somatosensory cortex, the limbic system and other areas. In the spinal cord there are also inhibitory interneurons which act as the 'gate keeper'. 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'. When the smaller fibres are stimulated the inhibitory interneurons do not act, so the gate is 'open' and pain is sensed. When the larger α-Delta fibres are stimulated they reach the inhibitory interneurons faster and, as larger fibres inhibit the interneuron from working, 'close' the gate. This is why after you have stubbed your toe, or bumped your head, rubbing it helps as you are stimulating the α-Delta fibres which close the gate.
