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Flashcards in Vertebral Manual Therapy Deck (113):

Small amplitude oscillation short of resistance (R1)

Grade I


large amplitude oscillation near beginning of R1

Grade II


a large amplitude oscillation 50% between R1 and R2.

Grade III


a small amplitude oscillation performed at the limit of range (R2)

Grade IV


A small amplitude, high speed, thrust at the end of available range.

Grade V: High Velocity Thrust; also called a manipulation


Physical examination findings related to the chief complaints that are reproduced during an examination/treatment.

Comparable Sign


A manual therapy technique used to selectively influence the joint soft tissues depending on the technique or direction of translation

Joint Mobilization


Why make a diagnosis? (2 Main Objectives)

  1. To be able to EXPLAIN to the patient what is happening in their joints and thereby:
    • (a) produce relief through reassurance
    • (b) empower them to manage their symptoms
  2. To be able to PREDICT:
    • (a) what will happen to the affected part
    • (b) the risk of future problems in other places
    • (c) useful treatment


Clinical Decision making focuses on:

  • Patient's:
    • comparable sign
    • (symptoms)


Abnormal joint movement (that may be observed or felt)

  • (for example: stiffness, spasm, instability)

Joint Sign


Joint sign (felt by therapist) that reproduces the patient’s symptoms

Comparable sign


A joint cannot be considered clear or normal unless:

firm overpressure can be applied without pathological signs


Physical joint signs found on examination of an abnormal synovial joint and its supportive structures will consist of:

  • pain
  • pain at rest or with movement
  • stiffness
  • muscle spasm


True or False: Osteokinematic movement cannot occur without appropriate arthrokinematic movement



What are Mobilizations:

Passive Movements:

  • Oscillatory Movements
  • Physiological Movements
  • Accessory Movements


Oscillatory Movements:

Consist of the joint’s accessory movements and/or its physiological movements


Physiological Movements:

movements which the patient carries out actively


Accessory Movements

Movements that are not under voluntary control and can only be produced passively


Passive Physiological Spinal Movements (2 groups)

  1. (PPIVM) Passive Physiological Intervertebral Movements
  2. (PAIVM) Passive Accessory Intervertebral Movement


Passive Physiological Intervertebral Movements (PPIVMS)

  • Examines the movement at each segmental level of the spine
    • useful adjunct to identify segmental hypomobility or hypermobility


Passive Accessory Intervertebral Movement (PAIVMs)

  • Gentle movements that can help direct the therapist to identify:
    • Location, Nature, Severity or Irritability of symptoms
    • check for hyper/hypomobility, instability, spasm


3 Roles of Mobilization:

  1. RESTORE JOINT ALIGNMENT to normal positions or pain-free positions
    • allows for a painless full-range movement
  2. STRETCHING a stiff painless joint to restore range
    • use treatment movements that include the spin, roll, and slide normal for that joint
  3. RELIEVE PAIN by using special passive movement techniques
    • Mobilization and manipulation show to best effective when directed at mechanical problems
    • If the mechanical treatment eliminates the mechanical irritating cause, the patient loses his pain



  • Severe pain

  • Irritable conditions

  • Acute nerve root pain/irritation

  • Peripheralization
  • Any patient’s condition which is worsening


Non-severe patient condition is indicated by:

  • The patient is able to sustain a position that reproduces the symptoms
    • overpressures can be applied in this case


Severe patient condition is indicated by:

  • The patient is unable to sustain the position that produces the symptoms
    • no overpressures should be attempted



The presence of pain on movement



Initial Resistance



Limit of resistance



Onset of pain



intensity/ irritability/ nature, and limit of pain



Physiologic Limit



Pathologic Limit


The ______ of the patient’s condition will indicate the diagnosis and also provide facts on which the prognosis and possibility of recurrence can be assessed.



(Assessment) (Relationship between irritability and pathology) Information can be obtained by:

  • RANGE OF MOVEMENT in a joint
    • The presence of pain on movement
  • "ENDFEEL" produced by gently forcing the joint to the end of its range.


The Maitland treatment approach primarily uses _______ _________ movements to normalize function

passive accessory


The primary aim in the examination of a joint movement is to find a __________ ____ in an appropriate joint.

comparable sign


Pain Dominant presentation (4 characteristics)

  1. Range: often afraid to move
  2. Pain: Resting, early, and midrange
  3. Spasm: usually present
  4. Repeated movements: aggravate pain unless preferred direction is used


Stiffness dominant presentation:

  1. Range: limited
  2. Pain: Often end range only
  3. Spasm: seldom present
  4. Repeated movements: often increase the range


A Pain Component at Rest or With Movement:

  • pain associated with stiffness/hypomobility
  • often referred to as “intracapsular” pain
  • loose-packed mobilizations achieve relief


A Stiff and Painless Component:

  • “periarticular” or “end-range” pain
  • end range (closed packed) mobilizations and manipulation can achieve relief
    • a reduction of deformation is the key
    • increase range to restore function


Grade I and II mobilizations to:

Reduce, centralize, and eliminate pain


Grade III and IV mobilizations for:

  • produce the pain in the stiff dominated disorder
  • move the pain farther out into range
  • increase range by reducing stiffness


Contraindications to higher grade mobilizations:

- Any active systemic disease - Malignancy - Inflammatory Conditions - Recent Fracture or Non-union - Severe Osteoporosis - Cord Compression - Instability or Excessive Hypermobility - Spondylolisthesis - Gross Foraminal Encroachment


Precautions to higher grades of movement:

  • Acute Nerve Root Irritation or Compression
  • Recent Whiplash
  • Last trimester of pregnancy (unless acute locked joint)
  • Fusions (at same level)
  • Psychogenic disorders
  • Children/Teenagers prior to puberty
  • Practitioner lack of ability, skills, or training
  • Undiagnosed pain
  • When the S/E and P/E don’t agree


Straight Leg Raise:

  • Hip: Flexion
  • Knee: Extension
  • Ankle:
  • Toes:

  • Straight Leg Raise
    • Sciatic Nerve Bias


Straight Leg Raise:

Hip: Flexion and medial rotation

Knee: Extension

Ankle: Plantarflexion

Foot: Inversion


  • Straight Leg Raising:
    • Common peroneal nerve bias



Straight Leg Raise:

Hip: Flexion

Knee: Extension

Ankle: Dorsiflexion

Foot: Eversion

Toes: Extension

  • Straight Leg Raise:
    • Tibial Nerve Bias


Straight Leg Raise:

Hip: Flexion

Knee: Extension

Ankle: Dorsiflexion

Foot: Inversion


  • Straight Leg Raise
    • Sural Nerve Bias


Unilateral thoracic pain radiating along the line of the rib is usually indicative of pathology affecting the:


  • nerve root


Deep central back pain radiating through the chest may be indicative of:

  • Intervertebral Disc


Unilateral thoracic pain radiating horizontally around the chest wall is likely emanating from:


  • Unilateral joints:
    • Facet joints
    • Costovertebral Joints
    • Costosternal joints


T4 Pathology may produce what type of headache?

  • Cap-type headache
    • (although headaches may also be produced from C1 to C3)


Thoracic spine pathology at T1 may produce symptoms in:

  • Anterior or posterior arm


Thoracic spine pathology at T10-T12 may produce symptoms in:

  • The groin and posterior thigh


Severe biomechanica lesions of the thoracic spine (such as disc protrusion or dynamic facet defect) frequently involve activities of:

  • thoracic rotation and extension


Thoracic Vertebral Fractures:

  • most commonly what type?
  • most commonly occur where?
  • Why?

  • Compression Fracture
  • At T12
  • Junction between thoracic and lumbar spine and transition point between lumbar lordsis and thoracic kyphosis.


Indications for Inspiration Glides RIbs 2-11

  • Increase motion into bucket handle inspiration
    • Correction faulty positional space at rib joints

    • Improve periarticular muscle performance

    • Decrease pain


Indications for Expiration Glides RIbs 2-11

  • Increasing ROM into pump-handle expiration of ribs

    • Increase periarticular muscle performance

    • decrease pain

    • correcting faulty positional rib joint space-impairment


What is the PT implication of ribs having low stiffness against superior or inferior loading?

  • A force placed too far laterally can easily sprain one or more costovertebral and/or costotransverse joints


Pain pattern for a mid-thoracic rib subluxation:

  • Pain that radiates down the arm laterally
    • aggaravated during inspiration when trunk is flexed


Slump Test Variation

  • Cervical Spine: Flexion
  • Thoracic and Lumbar Spine: Flexion (slump)
  • Hip: Flexion (90o+), abduction
  • Knee: Extension
  • Ankle: Dorsiflexion
  • Foot:
  • Toes:

  • Slump Test (ST2)
    • Obturator Nerve Bias


Long Sitting Slump Test Variation

  • Cervical Spine: Flexion, Rotation
  • Thoracic and Lumbar Spine: Flexion (slump)
  • Hip: Flexion (90o+)
  • Knee: Extension
  • Ankle: Dorsiflexion
  • Foot:
  • Toes:

  • Long Sitting Slump Test (ST4)
    • Spinal Cord, cervical and lumbar nerve roots, sciatic nerve


Side Lying Slump Test Variation

  • Cervical Spine: Flexion
  • Thoracic and Lumbar Spine: Flexion (slump)
  • Hip: Flexion (20o)/(Hip in Extension?)
  • Knee: Flexion
  • Ankle: Plantar Flexion
  • Foot:
  • Toes:

  • Side Lying Slump Test (ST3)
    • Femoral Nerve Bias


Slump Test Variation

  • Cervical Spine: Flexion
  • Thoracic and Lumbar Spine: Flexion (slump)
  • Hip: Flexion 90+ degrees
  • Knee: Extension
  • Ankle: Dorsiflexion
  • Foot:
  • Toes:

  • Slump Test (ST1)
    • Spinal Cord
    • Cervical and lumbar nerve roots
    • Sciatic nerve



You can use a Grade V manipulation to relieve a muscle in spasm.

  • False
    • Never attempt to manipulate (Grade V) a muscle in spasm, gentle passive movements may relieve the spasm.


Effects of Rotations (cervical):

  • closes same side, opens other side
  • affects upper C-spine more than lower


Effects of Lateral Flexion (cervical):

  • Closes same side, opens other side
  • Affects lower C-spine more than Upper C-spine


A negative (-) finding of the Alar Ligament Stress Test is when:

  • The transverse process of C2 rotates opposite the direction of the side bend of the head.


What is a positive finding of the Sharp-Purser test and what does it mean?

  • Positive Findings:  demonstration of a sliding motion of the head backwards in relation to the spine of the axis
    • Indicates that a subluxation of the atlas on the axis has been reduced
    • Implicates dysfunction of the Transverse Ligament


Neck related disorders are more common in (men vs. women):

  • Women
    • prevalence increases after 50 yrs of age


Upper Cervical vs. Lower Cervical division components:

  • Upper Cervical: C1, C2
  • Lower Cervical: C3-C7


Features of atlanto-occipital joint:

  • Condyloid
  • Contributes to half of total neck flexion and extension
  • Common cause of headaches
  • Common cause chronic upper neck pain 2o to muscle tension


Features of atlanto-axial joint:

  • Synovial Joint (diarthrodial)
    • Pivot joint
  • Dens and atlas articulation
  • 1st intervertebral joint
  • Permit rotation of the skull
    • ½ total rotation of the neck comes from this joint


Primary restraint mechanism to prevent anterior sheer force of C1 on C2:

  • Transverse Ligament


Limits contralateral lateral flexion and rotation movement of the occiput on the cervical spine:

  • Alar Ligament


Resting Position of Cervical Spine:

  • Midway between flexion and extension


Close Packed Position of the Cervical Spine:

  • Full extension


Capsular Pattern of the Cervical Spine:

  • Side Flexion and rotation equally limited; extension


Facet Opening

  • Refers to the anterior and superior glide of the inferior articular process of the superior vertebra on the superior articular process of the vertebra below


Facet Closing

  • Refers to the posterior and inferior glide of the inferior articular process of the superior vertebra on the superior articular process of the vertebra below


  • Facet Gapping

  • Refers to the separation or distraction (traction) of the joint surfaces in a perpendicular direction


Arthrokinematic Movement in the cervical spine: Convex-Concave Rule

  • C0-C1 Motion Segment
    • The occipital condyles (convex surface) move on the concave surface of the atlas
  • C2-C7 Motion Segment
    • concave surface (superior vertebra) moving on a convex one (inferior vertebra)
    • Superior component:  rotation & translation in same direction
    • Inferior component:  rotates & translates in opposite direction



Mobilization [Maitland Definition]

  • Passive movement that is performed with a rhythm and a grade in a manner in which the patient is unable to prevent the technique from being performed


Contraindications to mobilization [11]

  • Bone disease/malignancy
  • Pregnancy
  • Vertebral artery insufficiency
  • Active ankylosing spondylitis
  • Rheumatoid arthritis
  • Spondylolisthesis
  • Gross foramina encroachment and/or ANR compression
  • Instability of the spine
  • Recent whiplash
  • Undiagnosed pain (psychological pain where signs do not match symptoms
  • Long-term steroid use (affects ligament laxity)


Central Posterior-Anterior (CPA) indications:

  • Best used for central & bilateral symptoms
    • Indicated when pain/ protective spasm is present in same direction


Unilateral Posterior Anterior UPA indications:

  • Best used for unilateral pain:
    • Symptoms on the side of the pain
    • Force directed against an articular process
  • Important technique for upper cervical disorders
    • same side symptoms
    • assess bilaterally, levels above and below on both sides of the motion segment


Characteristics of Low Back Pain (Burton et al. 2009):

  • Localized pain and discomfort
    • Below costal margin and above the inferior gluteal fold
  • May or may not have leg pain


Unilateral Anterior-Posterior (UAP) Indications:

  • Anterolateral signs & symptoms
    • Often has an effect on Neurodynamics
    • Carpal Tunnel Syndrome
    • Spondylolisthesis or intradiscal disorder


Transverse Glides indication:

  • Unilateral pain
    • usually push towards side of pain
    • provides a rotational component to the segment
    • used to centralize symptoms


Lateral Glide (Side Bending) indications

  • Best used for unilateral distribution of pain
    • Pain is diffused over a region of the spine
      • closure/compression on one side with opening on the other


Greatest stresses on the vertebral artery occur in these locations [3]:

  • C6-where it enters the transverse process
  • Between C1 and C2
  • Between C1 and the entry of the arteries into the skull


Assessment for the presence of symptoms and signs associated with VBI occurs at these four stages in the management of a patient with an upper quadrant disorder:

  1. History (subjective examination)
  2. Physical (objective) examination
  3. During treatment of the cervical spine
  4. Following treatment.


Risk Factors For Symptoms Related To Vertebrobasilar Insufficiency (Barker et al 2000)

  • Drop attacks, blackouts, loss of consciousness
  • Nausea, vomiting and general unwell feelings
  • Dizziness or vertigo
    • particularly if associated with head positioning
  • Disturbances of vision (e.g. decreased, blurred, diplopia)
  • Unsteadiness of gait (ataxia) and general feeling of weakness
  • Tingling or numbness (especially dysaesthesia, i.e. tingling around the lips, hemianaesthesia or any alteration in facial sensation)
  • Difficulty in speaking (dysarthria) or swallowing
  • Hearing disturbance (e.g. tinnitus, deafness)
  • Headache
  • Past history of trauma
  • Cardiac disease, vascular disease, altered blood pressure, previous cerebrovascular accident or transient ischemic attacks
  • Blood clotting disorders
  • Anticoagulant therapy
  • Oral contraceptives
  • Long-term use of steroids
  • A history of smoking
  • Immediately post partum


Precautions to Lumbar (vertebral) manual therapy related to nociception:

  • Pain occurs in a ‘stimulus-response relationship’
    • Hx and pain relationship
  • As pain reduces, function normalizes over time


Contraindications to vertebral manual therapy (lumbar):

  • No stimulus-response relationship to pain
  • Pain and activity intolerance seem to last longer than normal healing processes



You can rule out the sacral plexus as a source of pathology if symptoms radiate below the knee.

  • True
    • don't need to look at lower nerve roots in this situation


Specific Precautions to Examination and Treatment of the Sacroiliac and Pelvis:

  • Sexual dysfunction
  • Urinary frequency changes
    • Urinary incontinence developed over a relatively short period of time, may be indicative of a cauda equina lesion.


Add end-range overpressure to active test movements if:

  • FULL active movements are pain-free


The least threatening of the tension tests is:

  • Passive Neck Flexion
    • therefore should be executed first.


The prone knee bend only needs to be performed when:

  • a patient experiences neurological symptoms into the anterior thigh.


If the comparable sign (CS) was not elicited in active or passive physiological flexion, extension, lateral flexion, or rotation…..

  • ...the examiner needs to try the quadrant test.
    • This is a combination movement that consists of 3 separate motions: extension, side-bending, and rotation.
      • “super closed-packed position”


Stability of the pelvic girdle is acheived through:

  • Symphisis Pubis and the SI joints


Primary stabilizers of the pelvic girdle:

  • local muscles of the transversus abdominis
  • multifidi
  • Diaphragm
  • pelvic floor muscles


  • synergistic active timed co-contraction of these muscles produces stability


Factors that help produce dynamic stability and force closure of the pelvic girdle:

  • A strong ligamentous system
  • The wedge shape of the sacrum
  • Various muscle groups and fasciae crossing over the pelvic girdle


Force closure occurs by:

  • nutation movement of the sacrum in relation to the innominates (friction)
  • compression generated by the myofascial structures
    • Prevents shear forces and tolerance to vertical loading


Nutation (of the sacrum) is:

  • anterior sacral on iliac rotation
  • posterior iliac on sacral rotation
    • or both motions occurring simultaneously

A image thumb

Counternutation is:

  • Posterior sacral on iliac rotation
  • Anterior iliac on sacral rotation
  • or, both motions occurring simultaneously

A image thumb

Gaenslen's Test can indicate the presence or absence of:

  • SIJ lesion
  • Pubic symphysis instability
  • Hip pathology,
  • L4 nerve root lesion.
  • It can also stress the femoral nerve.


Mandibular deviation on opening:

  • The mandible often deviates toward the affected side due to muscle spasm or mechanical locking due to a displaced meniscus.


Indications for temporomandibular anterior glide:

  • Restrictions in mandibular depression, protrusion and contralateral lateral deviation of the TMJ.
    • Movement consists of slight downward distraction force followed by anterior gliding force applied through the thumb.


Componenents of clinical reasoning (5):

  • The Nature Or Kind Of Disorder
  • The Areas Of Symptoms
  • The Behavior Of The Symptoms
  • Present History
  • Past History


Factors relating to treatment by passive movement:

  • used to increase mobility of joints
  • used to decrease pain
  • performed at a speed in which it is not possible for patient to prevent the movement
  • may be "gentle-smooth" or "stretching"