Fundamentals Of Maitland Mobilizations

by Sara J Hall, SPT

The main focus of this site is on Maitland Mobilizations for the Vertebral Column.

About Maitland:

Geoffrey Douglas Maitland, born in 1924 in Australia, is the founder of the Maitland mobilization techniques.

He completed his training as a physiotherapist in 1949 and quickly developed an interest in “careful clinical examination and assessment of patients with neuro-musculo-skeletal disorders."¹

He studied from and learned the techniques of practitioners in the medical, osteopathic, chiropractic, and bonesetter fields.

His career led him to teach students and become a noteworthy contributor to medical and physiotherapy journals while still treating patients.

Maitland’s publishing and lectures addressed the importance of the subjective examination and specific passive movements that, at the time, did not play a large role in the treatment of patients.¹

Patient Evaluation:

The Subjective examination is complete when PT has identified what structures should be examined and how it should be done.
- kind of disorder, history, area, behavior of symptoms (general, particular, special questions, history)¹

Listen!

The Objective examination supports/ negates PTs hypothesis from the subjective exam¹

- clear proximal joints

Active Movements:

• Flexion. Extension. Rotation. Side Flexion. Combined movements/ Quadrants - (flexion/ side flexion/ rotation) or (extension/ side flexion/ rotation)

• All are performed with overpressure - "slight oscillatory movement at the end of AROM". Check for end feel, ROM, reproducion of symptoms²

Palpation:

• check skin for sweating, temperature, soft tissue changes

• PAIVMs (Passive Accessory Intervertebral Movements and PPIVMs (Passive Physiological Intervertebral Movements) are gentle movements that can help direct the therapist identify location, nature, severity, and irritability of symptoms.

- checking for hyper/hypomobility, instability, spasm

• Central PAs on spinous process or Unilateral PAs on articular pillar, transverse process, or facet to identify comparable sign¹

Movement Diagrams

Intended to convey information to other therapists such as initial(R1) and end resistance (R2), onset (P1), intensity/ irritability/ nature, and limit of pain (P2)¹

Neurological Testing:

• Dermatome and Myotome testing will help the Physical Therapist determine what level (vertebrae) of the spine to treat

Things to Consider:

• It is imparative to identify the active and/or passive movements that provoke or ease the symptoms of the patient.¹

• Once the movements are identified, a choice of treatment to provoke or relieve the symptoms must be made.¹

• Nature –refers to the type of issue that is causing the symptoms (i.e.: mechanical, inflammatory, etc.)

• Severity - refers to the intensity of the pain provoking activity. Caution is necessary during the examination and treatment.

• Irritability - refers to the pain level, how far into a movement pain is provoked, and how long it takes to subside after the movement is withdrawn²

• Is the patient pain dominant? Or stiff dominant?

• In 1995, a research report created a spinal moblization model to measure force and displacement during mobilizaitons. It was discovered that therapists "consistently underestimated the amount of force that they were applying", meaning their force was truely a lot more than they thought they were applying.²

For What Part of the Body are Mobilizations Used?

• Mobilizations can be used for every joint in the human body.

• His main focus was on the movements of the vertebral column and the interaction between the nerves, discs, and joints.

What are Mobilizations?

* passive movements

* used to increase mobility of joints

* used to decrease pain

* performed at a speed in which it is possible for patient to prevent the movement

* may be "gentle-smooth" or "stretching-staccato"¹

Passive Accessory Movement: joint movement, performed by the PT, patient cannot reproduce³

Types of Passive Accessory Movements:

• CPA - Central Posterior Anterior
  

- best used for pain evenly distributed on both sides
- indicated when pain/ protective spasm is present in same direction¹

• UPA - Unilateral Posterior Anterior

- best used for unilateral pain
- in cervical region, when pain is reproduced in AP direction, referred pain to ear/throat/ anterior shoulder/ scapula/ headache¹

• CAP - Central Anterior Posterior

- best used for spondylolisthesis or intradiscal disorder¹

• UAP - Unilateral Anterior Posterior

- used mostly in cervical region¹

• Rotation (General or Localized)
  

- Maitland feels this is most useful for lumbar spine
- best used for unilateral pain whether referred to leg or not¹

• Transverse
  

- best used for unilateral distribution
- push towards the painful side¹

• Longitudinal

- in cervical region, it helps the patient to gain confidence in the therapist
- in the lumbar spine, double leg method for even distribution, gentle for acute localized pain
- single leg methog for unilateral below the 4th lumbar vertebra ¹

Bouts of treatment should be performed for 30 seconds. The physical therapist will reasses the patient's symptoms after each bout. The therapist should pay close attention to how assessment questions are worded as to not lead. Questions such as "any change?" or "how does it feel?" are non-leading. Whereas, questions such as "any better?" or "less pain?" are leading.⁴

Never attempt to manipulate a muscle in spasm, gentle passive movements may relieve the spasm⁴

Contraindications to Mobilization:

1. bone disease
2. malignancy
3. pregnancy¹
4. vertebral artery insufficiency
5. active ankylosing spondylitis
6. rheumatoid arthritid
7. spondylolisthesis
8. gross foraminal encroachment
9. acute nerve root irritation or compression
10. instability of the spine
11. recent whiplash
12. undiagnosed pain
13. psychological pain where signs do not match symptoms⁵
14. steroid use affects ligament laxity
    

According to Maitland, the word manipulation can be used to describe all forms of mobilization.¹

Grades

For Pain Relief (Irritable):

Grade I: before R1, small amplitude

Grade II: before R1, large amplitude

For Stiffness (Non-irritable):

Grade III: between R1 and R2, large amplitude

Grade IV: at end near R2, small amplitude

Grade V: this is typically termed as manipulation - small amplitude, high speed, thrust.
for this grade, a patient may not be able to prevent the movement.¹

Which Treatment Do I Choose?

• Chiradejnant et al. revealed that "lumbar mobilization treatment has an immediate effect in relieving low back pain, however the specific technique used seems unimportant".⁶

• Maitland (2005) says “Techniques as they apply to the concept proposed in this book, are never ending and they never will have an ending. So long as patients present with different symptoms and examination signs, there will have to be changes in techniques to free the patients of those symptoms.”¹

• A UCLA Neck Pain study concluded that "equally effective results with less risk of adverse side effects" may be acheived through mobilzations rather than manipulations. In some cases manipulation may be more effective depending on the specific clinical indications.⁷

What Do Mobilizations Look Like?

Special Tests to Keep In Mind:

Vertebral Artery Insufficiency Test

Alar Ligament Test

Transverse Ligament Test

Slump Test (could imply neural tension)

Straight Leg Raise (could imply discogenic issue or neural tension)

Additional information:

• 2 main manipulative therapy organizations in UK:

Manipulation Asociation of Chartered Physiotherapists (MACP) - focuses on techniques of G.D. Maitland

and

Society of Orthopedic Medicine (SOM) - focuses on techniques of r. James Cyriax⁸

• A questionnaire from Britain and Ireland revealed that 813 of 1548 physiotherapists practice in settings where Maitland mobilizaion and McKenzie techniques were used in the treatment of low back pain.⁹

Where Can I Find More Information?

Click here for Google Scholar Search

Click here for Maitland-Australian Physiotherapy Seminars

Click here for WebMD (unspecified mobilizations)

Footnotes

1. Maitland GD. Maitland's Vertebral Manipulation. 7th ed. Philadelphia, PA. Elsevier. 2005.

2. Simmonds MJ, Kumar S, Lecheit E. Use of a Spinal Model to Quantify the Forces and Motion That Occur During Therapists' Tests of Spinal Motion. Physical Therapy.1995;75(3)212-222.

3. Koury MJ, Scarpelll E. A Manual Therapy Approach to Evaluation and Treatment of a Patient With a Chronic Lumbar Nerve Root Irritation. Physical Therapy.1994;74(6):548-560.

4. Sprague RB. The Acute Cervical Joint Lock. Physical Therapy.1983;63(9):1439-1444.

5. South Australia School of Physiotherapy. List of Contraindications for Manipulations: Graduate Diploma Course in Advanced Manipulative Therapy. 1978.

6. Chiradejnant A, Maher CG, Latimer J, Stepkovitch N. Efficacy of "therapist-selected" versus "randomly selected" mobilisation techniques for the treatment of low back pain: A randomised controlled trial. Australian Journal of Physiotherapy.2003;49:233-241.

7. Hurwitz EL, Morgnenstern H, Harber P, Kominki GF, Adams AH. A Randomized Trial of Chiropractic Manipulation and Mobilization for Patients with Neck Pain: Clinical Outcomes from the UCLA Neck-Pain Study. American Journal of Public Health.2002;92(10)1634-1641.

8. Hurley DA, McDonough SM, Baxter GD, Dempster M, Moore AP. A descriptive study of the usage of spinal manipulative therapy techniques within a randomized clinical trial in acute low back pain. Manual Therapy. 2005;10:61-67.

9. Foster NE, Thompson KA, Baxter GD, Allen J. Management of Nonspecific Low Back Pain by Physiotherapists in Britain and Ireland: A Descriptive Questionnaire of Current Clinical Practice. Spine.1999;24(13):1332.