Introduction

Research Corner: Sacroiliac Joint 

Sacroiliac Joint Motion

Testing

SIJ Manipulations

Combining Manipulations with Other Interventions

Comparing Manipulation Techniques

Systemic Response to SIJ Manipulation

Pubic Symphysis Manipulation

Research Summary

Lumbar Pain

Comparing Manipulation to Other Interventions

Comparing Manipulation and Mobilization Techniques

Kinematics of Manipulation

Systemic Effects of Manipulations

Adverse Events

Joint Manipulation: Lumbar Spine, Sacroiliac Joint and Pubic Symphysis

PACE

<h3>Introduction</h3>
<p>This course describes joint manipulation techniques for the lumbar spine, sacroiliac joint (SIJ), and pubic symphysis. Various synonyms and definitions have been used to describe the term &quot;manipulation&quot;. The Brookbush Institute uses one conventional definition of the term &quot;manipulations;&quot; implying low-amplitude (relatively small motions), high-velocity (quick) techniques, intended to target and reduce the stiffness of <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> joints or segments, that exhibit a decrease in passive accessory range of motion (a.k.a. stiffness during <a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic</a> motion; specifically <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a>). Research does imply that manipulations affect multiple joints simultaneously; however, the Brookbush Institute asserts that efforts to target the stiffest joints or segments will increase the likelihood that the stiffest segments are included in the &quot;multiple joints&quot; affected.</p>
<p>The Brookbush Institute has carefully selected manipulation techniques with the intent to increase the probability of practitioner success. That is, techniques have been chosen that are relatively easy to teach, reliably improve outcomes, and are the most commonly used. The Brookbush Institute does not wish to assert that these manipulation techniques are the only techniques that are effective, and/or that these are the best techniques for every outcome measure. It is possible that a highly complex, and/or advanced technique, may result in better outcomes, or that a particular pathology is better addressed with a rarely used technique.&#xA0;</p>
<p>Note, that the term &quot;mobilization&quot; is reserved for low-velocity techniques that are taught in a separate set of courses.&#xA0;&#xA0;</p>
<p>This course includes manipulation techniques that intend to reduce excessive stiffness of the lumbar spine (low back), SIJ, and the pubic symphysis (lumbopelvic manipulations), improve spine range of motion (ROM), improve lumbopelvic alignment, and potentially reduce hip dysfunction. For example, research has demonstrated a correlation between asymmetrical SIJ stiffness, asymmetrical hip range of motion, and a correlation between low back pain, and future lower extremity injury. These techniques may also be used in an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> approach for improving <a href="https://brookbushinstitute.com/courses/lumbo-pelvic-hip-complex-dysfunction-lphcd" title="LPHCD" target="_blank" rel="noopener">lumbopelvic hip complex dysfunction (LPHCD)</a> and <a href="https://brookbushinstitute.com/courses/lower-leg-dysfunction" title="LED" target="_blank" rel="noopener">lower extremity dysfunction (LED)</a> including sacroiliac joint pain (SIJD), lumbar radiculopathy, iliotibial band syndrome (ITBS), femoroacetabular impingement (FAI), patellofemoral pain syndrome (PFPS), etc. Additionally, due to the relationship between lumbopelvic alignment and hip <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a>, and the relationship between hip <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> and ankle motion during gait, these techniques may aid in the treatment of pes planus, Achilles tendinopathy, and plantar fasciitis.</p>
<p>The techniques in this course are recommended for all clinical human movement professionals (physical therapists, physical therapy assistants, athletic trainers, massage therapists, chiropractors, occupational therapists, etc.) to develop an <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a>, systematic, <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a>, patient-centered, patient-centered, and outcome-driven approach.&#xA0;</p>
<h3>Techniques Covered in this Course:</h3>
<ul>
  <li><a href="https://brookbushinstitute.com/video/lumbar-spine-joint-manipulation-high-velocity-thrust" target="_blank" rel="noopener">Lumbar Manipulation</a></li>
  <li><a href="https://brookbushinstitute.com/video/sacroiliac-joint-chicago-technique" target="_blank" rel="noopener">Sacroiliac Joint Manipulation</a></li>
  <li><a href="https://brookbushinstitute.com/video/shotgun-pubic-symphysis-manipulation" target="_blank" rel="noopener">Pubic Symphysis (Shotgun) Manipulation</a></li>
</ul>
<ul>
  <li style="list-style-type: none;">
    <ul></ul>
  </li>
</ul>
<h3>Sample Intervention: Left Asymmetrical Weight Shift</h3>
<ul>
  <li>
    <h4><strong>Manual Release</strong></h4>
    <ul>
      <li>Right <a href="https://brookbushinstitute.com/video/adductor-magnus-static-manual-release" target="_blank" rel="noopener">Adductor Magnus Manual Static Release</a></li>
      <li>Right <a href="https://brookbushinstitute.com/video/biceps-femoris-manual-static-release" target="_blank" rel="noopener">Biceps Femoris Manual Static Release</a></li>
      <li>Right <a href="https://brookbushinstitute.com/video/piriformis-static-manual-release" target="_blank" rel="noopener">Piriformis Manual Static Release</a></li>
    </ul>
  </li>
  <li><strong>Mobilization or Manipulation</strong>
    <ul>
      <li>Right Side Down <a href="https://brookbushinstitute.com/video/lumbar-spine-joint-manipulation-high-velocity-thrust" target="_blank" rel="noopener">Lumbar Spine Manipulation</a></li>
      <li>Right Side <a href="https://brookbushinstitute.com/video/sacroiliac-joint-chicago-technique" target="_blank" rel="noopener">Sacroiliac Joint Manipulation</a></li>
    </ul>
  </li>
  <li><strong>Manual Lengthening</strong>
    <ul>
      <li>Right <a href="https://brookbushinstitute.com/video/manual-adductor-stretch" target="_blank" rel="noopener">Adductor Magnus</a></li>
      <li>Right <a href="https://brookbushinstitute.com/video/piriformis" target="_blank" rel="noopener">Piriformis</a></li>
    </ul>
  </li>
  <li><strong>Activation</strong>
    <ul>
      <li>Left <a href="https://brookbushinstitute.com/article/gluteus-maximus-activation" target="_blank" rel="noopener">Gluteus Maximus Activation</a></li>
      <li>Left <a href="https://brookbushinstitute.com/article/gluteus-medius-activation-progression" target="_blank" rel="noopener">Gluteus Medius Activation</a></li>
    </ul>
  </li>
  <li><strong>Integration</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">Posterior Oblique Subsystem</a></li>
    </ul>
  </li>
</ul>
<h3>Related Courses</h3>
<p><strong>Additional Joint Mobilization Courses</strong></p>
<ul>
  <li><a href="https://brookbushinstitute.com/courses/manipulations-cervical-spine" title="Cervical manipulation" target="_blank" rel="noopener">Joint Manipulation: Cervical Spine</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-manipulation-thoracic-spine" title="Thoracic Manipulation" target="_blank" rel="noopener">Joint Manipulation: Thoracic Spine</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-manipulation-lumbar-spine-sacroiliac-joint-and-pubic-symphysis" title="Lumbar Manipulation" target="_blank" rel="noopener">Joint Manipulation: Lumbar Spine, Sacroiliac Joint, and Pubic Symphysis</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-manipulation-wrist-and-elbow" title="Elbow Manipulation" target="_blank" rel="noopener">Joint Manipulation: Elbow (Radial Head) and Wrist</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-manipulation-foot-ankle-and-tibiofibular-joint" title="Foot Manipulation" target="_blank" rel="noopener">Joint Manipulation: Ankle, Midfoot, and Tibiofibular Joint</a></li>
</ul>
<p><strong>For an introduction to joint mobilizations and manipulations:</strong></p>
<ul>
  <li><a href="https://brookbushinstitute.com/courses/introduction-joint-mobilizations-joint-manipulations" title="Introduction to Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Introduction</a></li>
  <li><a href="https://brookbushinstitute.com/courses/mobilization-and-manipulation-reliability-of-palpation-and-assessment" title="Reliability of Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Reliability</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" title="Effects of Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: Effects</a>&#xA0;</li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Risk of Adverse Effects</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilizations-and-manipulations-evidence-based-teaching-and-learning" title="Evidence-based Teaching and Learning" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: </a><a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">Evidence-based</a> Teaching and Learning</li>
</ul>

Course Description:  Lumbar Spine, Sacroiliac Joint, and Pubic Symphysis Joint Manipulation

<h2>For <a href="https://brookbushinstitute.com/article/lumbo-pelvic-hip-complex-dysfunction-lphcd" target="_blank" rel="noopener">Lumbo Pelvic Hip Complex Dysfunction</a> and <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction</a>:</h2>
<p><strong>For an introduction to joint mobilizations and manipulations:</strong></p>
<ul>
  <li><a href="https://brookbushinstitute.com/courses/introduction-joint-mobilizations-joint-manipulations" title="Introduction to Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Introduction</a></li>
  <li><a href="https://brookbushinstitute.com/courses/mobilization-and-manipulation-reliability-of-palpation-and-assessment" title="Reliability of Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Reliability</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" title="Effects of Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: Effects</a>&#xA0;</li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Risk of Adverse Effects</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilizations-and-manipulations-evidence-based-teaching-and-learning" title="Evidence-based Teaching and Learning" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: </a><a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">Evidence-based</a> Teaching and Learning</li>
</ul>
<h3>Techniques Covered in this Course:</h3>
<ul>
  <li><a href="https://brookbushinstitute.com/video/lumbar-spine-joint-manipulation-high-velocity-thrust" target="_blank" rel="noopener">Lumbar Manipulation</a></li>
  <li><a href="https://brookbushinstitute.com/video/sacroiliac-joint-chicago-technique" target="_blank" rel="noopener">Sacroiliac Joint Manipulation</a></li>
  <li><a href="https://brookbushinstitute.com/video/shotgun-pubic-symphysis-manipulation" target="_blank" rel="noopener">Pubic Symphysis (Shotgun) Manipulation</a></li>
</ul>
<h3><strong>Signs of correlated dysfunction:</strong></h3>
<ul>
  <li><strong><a href="https://brookbushinstitute.com/article/introduction-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat Assessment:</a></strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-9-anterior-pelvic-tilt-excessive-lordosis" target="_blank" rel="noopener">Anterior Pelvic Tilt</a></li>
      <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-17-sign-clusters-posterior-pelvic-tilt-butt-wink-and-inadequate-forward-lean-breakdown" target="_blank" rel="noopener">Inadequate Forward Lean</a></li>
      <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-15-sign-clusters-asymmetrical-weight-shift" target="_blank" rel="noopener">Asymmetrical Weight Shift</a></li>
      <li><a href="https://brookbushinstitute.com/video/knees-bow-in-breakdown" target="_blank" rel="noopener">Knees Bow In</a></li>
      <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-7-knees-bow-out" target="_blank" rel="noopener">Knees Bow Out</a></li>
    </ul>
  </li>
  <li><strong><a href="https://brookbushinstitute.com/article/special-tests-sacroiliac-joint" target="_blank" rel="noopener">Sacroiliac Joint: Special Test</a></strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-stork-gillet-test" target="_blank" rel="noopener">Gillet Test</a></li>
    </ul>
  </li>
  <li><strong><a href="https://brookbushinstitute.com/article/introduction-to-goniometry" target="_blank" rel="noopener">Goniometry</a></strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/goniometry-hip-internal-rotation-in-prone" target="_blank" rel="noopener">Hip Internal Rotation </a><a id="goniometry" data-tip="1523" target="_blank" href="/glossary-term/goniometry" class="glossary">Goniometry</a> in <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">Prone</a> &lt;40 - 50&#xB0;</li>
      <li><a href="https://brookbushinstitute.com/video/goniometry-hip-internal-rotation-at-90-degree-of-hip-flexion-9090-hip-ir" target="_blank" rel="noopener">Hip Internal Rotation </a><a id="goniometry" data-tip="1523" target="_blank" href="/glossary-term/goniometry" class="glossary">Goniometry</a> in <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">Supine</a> &lt;35 - 45&#xB0;</li>
      <li><a href="https://brookbushinstitute.com/video/goniometry-hip-external-rotation-in-prone" target="_blank" rel="noopener">Hip External Rotation </a><a id="goniometry" data-tip="1523" target="_blank" href="/glossary-term/goniometry" class="glossary">Goniometry</a> in <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">Prone</a> &lt;40 - 50&#xB0;</li>
      <li><a href="https://brookbushinstitute.com/video/goniometry-hip-external-rotation-at-90-degrees-of-hip-flexion-9090-hip-er" target="_blank" rel="noopener">Hip External Rotation </a><a id="goniometry" data-tip="1523" target="_blank" href="/glossary-term/goniometry" class="glossary">Goniometry</a> in <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">Supine</a> &lt;35 - 45&#xB0;</li>
      <li><a href="https://brookbushinstitute.com/video/hip-extension-goniometry" target="_blank" rel="noopener">Hip Extension Goniometry</a> &lt;0 - 10&#xB0;</li>
    </ul>
  </li>
  <li><a href="https://brookbushinstitute.com/article/introduction-manual-muscle-testing-active-population" target="_blank" rel="noopener"><strong>Manual </strong></a><strong><a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> Testing MMT:</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/video/gluteus-maximus-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">Gluteus Maximus Manual </a><a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> Testing (MMT) - Weak or With Compensation (Lumbar extension and/or knee flexion)</li>
      <li><a href="https://brookbushinstitute.com/video/gluteus-medius-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">Gluteus Medius Manual </a><a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> Testing (MMT) - Weak or With Compensation (Lumbar <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> flexion and/or hip flexion)</li>
    </ul>
  </li>
</ul>
<table>
  <tbody>
    <tr>
      <td>
        <p><strong>Brookbush/Grieve Sacroiliac Joint (SIJ) Movement Cluster:</strong></p>
        <h4><strong>Assess:</strong></h4>
        <ul>
          <li><a href="https://brookbushinstitute.com/article/sign-clusters-compensation-patterns-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat </a><a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> (OHSA): Stiff SIJ on the side opposite of an <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-15-sign-clusters-asymmetrical-weight-shift" target="_blank" rel="noopener">asymmetrical shift with &quot;heel rise&quot;</a>
            <ul>
              <li>&quot;Top tier exam&quot; used to identify asymmetry and imply further SIJ assessment</li>
            </ul>
          </li>
          <li><a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">Unilateral</a> Pelvic Tilt: <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> tilted innominate correlated with stiffer side</li>
          <li><a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-stork-gillet-test" target="_blank" rel="noopener">Gillet Test</a>: Less motion on the stiffer side</li>
          <li><a href="https://brookbushinstitute.com/article/lower-body-goniometry" target="_blank" rel="noopener">Hip Rotation Range of Motion</a>: Less motion on the stiffer side</li>
        </ul>
        <h4><strong>Treat:</strong></h4>
        <ul>
          <li><a href="https://brookbushinstitute.com/article/joint-manipulation-lumbar-spine-sacroiliac-joint-and-pubic-symphysis" target="_blank" rel="noopener">Mobilize/Manipulate</a>: Stiff SIJ</li>
          <li><a href="https://brookbushinstitute.com/article/gluteus-maximus-activation" target="_blank" rel="noopener">Glute Activation</a>: <a id="mobility" data-tip="1457" target="_blank" href="/glossary-term/mobility" class="glossary">Mobile</a> Side</li>
        </ul>
      </td>
    </tr>
  </tbody>
</table>
<h3>Sample Intervention: Left Asymmetrical Weight Shift</h3>
<ul>
  <li>
    <h4><strong>Manual Release</strong></h4>
    <ul>
      <li>Right <a href="https://brookbushinstitute.com/video/adductor-magnus-static-manual-release" target="_blank" rel="noopener">Adductor Magnus Manual Static Release</a></li>
      <li>Right <a href="https://brookbushinstitute.com/video/biceps-femoris-manual-static-release" target="_blank" rel="noopener">Biceps Femoris Manual Static Release</a></li>
      <li>Right <a href="https://brookbushinstitute.com/video/piriformis-static-manual-release" target="_blank" rel="noopener">Piriformis Manual Static Release</a></li>
    </ul>
  </li>
  <li><strong>Mobilization or Manipulation</strong>
    <ul>
      <li>Right Side Down <a href="https://brookbushinstitute.com/video/lumbar-spine-joint-manipulation-high-velocity-thrust" target="_blank" rel="noopener">Lumbar Spine Manipulation</a></li>
      <li>Right Side <a href="https://brookbushinstitute.com/video/sacroiliac-joint-chicago-technique" target="_blank" rel="noopener">Sacroiliac Joint Manipulation</a></li>
    </ul>
  </li>
  <li><strong>Manual Lengthening</strong>
    <ul>
      <li>Right <a href="https://brookbushinstitute.com/video/manual-adductor-stretch" target="_blank" rel="noopener">Adductor Magnus</a></li>
      <li>Right <a href="https://brookbushinstitute.com/video/piriformis" target="_blank" rel="noopener">Piriformis</a></li>
    </ul>
  </li>
  <li><strong>Activation</strong>
    <ul>
      <li>Left <a href="https://brookbushinstitute.com/article/gluteus-maximus-activation" target="_blank" rel="noopener">Gluteus Maximus Activation</a></li>
      <li>Left <a href="https://brookbushinstitute.com/article/gluteus-medius-activation-progression" target="_blank" rel="noopener">Gluteus Medius Activation</a></li>
    </ul>
  </li>
  <li><strong>Integration</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">Posterior Oblique Subsystem</a></li>
    </ul>
  </li>
</ul>

<ul>
  <li><strong>Manual Release</strong>
    <ul>
      <li>Right <a href="https://brookbushinstitute.com/video/adductor-magnus-static-manual-release" target="_blank" rel="noopener">Adductor Magnus Manual Static Release</a></li>
      <li>Right <a href="https://brookbushinstitute.com/video/biceps-femoris-manual-static-release" target="_blank" rel="noopener">Biceps Femoris Manual Static Release</a></li>
      <li>Right <a href="https://brookbushinstitute.com/video/piriformis-static-manual-release" target="_blank" rel="noopener">Piriformis Manual Static Release</a></li>
    </ul>
  </li>
  <li><strong>Mobilization or Manipulation</strong>
    <ul>
      <li>Right Side Down <a href="https://brookbushinstitute.com/video/lumbar-spine-joint-manipulation-high-velocity-thrust" target="_blank" rel="noopener">Lumbar Spine Manipulation</a></li>
      <li>Right Side <a href="https://brookbushinstitute.com/video/sacroiliac-joint-chicago-technique" target="_blank" rel="noopener">Sacroiliac Joint Manipulation</a></li>
    </ul>
  </li>
  <li><strong>Manual Lengthening</strong>
    <ul>
      <li>Right <a href="https://brookbushinstitute.com/video/manual-adductor-stretch" target="_blank" rel="noopener">Adductor Magnus</a></li>
      <li>Right <a href="https://brookbushinstitute.com/video/piriformis" target="_blank" rel="noopener">Piriformis</a></li>
    </ul>
  </li>
  <li><strong>Activation</strong>
    <ul>
      <li>Left <a href="https://brookbushinstitute.com/article/gluteus-maximus-activation" target="_blank" rel="noopener">Gluteus Maximus Activation</a></li>
      <li>Left <a href="https://brookbushinstitute.com/article/gluteus-medius-activation-progression" target="_blank" rel="noopener">Gluteus Medius Activation</a></li>
    </ul>
  </li>
  <li><strong>Integration</strong>
    <ul>
      <li><a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">Posterior Oblique Subsystem</a></li>
    </ul>
  </li>
</ul>

Sample Intervention (Example, Left Asymmetrical Weight Shift) 

<h3>Lumbar Spine Manipulation Summary</h3>
<table style="font-family: -apple-system, BlinkMacSystemFont, &apos;Segoe UI&apos;, Roboto, Oxygen, Ubuntu, Cantarell, &apos;Open Sans&apos;, &apos;Helvetica Neue&apos;, sans-serif; background-color: #ffffff; color: #34363a; font-size: 0.9375rem; font-weight: 400; letter-spacing: 0px;">
  <tbody>
    <tr>
      <td><strong>Efficacy, Dose, and Risk</strong>
        <ul>
          <li><strong>Efficacy:</strong> Implementation of lumbar manipulation based on diagnosis alone is most often beneficial, but results are inconsistent.</li>
          <li><strong>Manipulations and Performance:</strong> Lumbar and SIJ manipulations may have a positive impact on performance when used as part of an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> warm-up to address assessed impairments. It is unlikely that manipulations will improve performance if an impairment has not been identified.</li>
          <li><strong>Dose-response:</strong> A single manipulation session may have a significant initial effect; however, research suggests that long-term benefits are better with 12 - 18 treatments, over 3-6 weeks, at a frequency of 3 - 4 sessions per week, with follow-up sessions needed at a lower frequency to maintain benefits.</li>
          <li><strong>Clinical Prediction Rules:</strong> Research suggests that the current clinical prediction rules (CPRs) are weak; however, this research suggests that correlations exist between assessed impairments and low back pain.</li>
          <li><strong>Risk of Adverse Events:</strong> Practitioners&apos; beliefs regarding the risk of manipulation do not match the available evidence. Many of the published cases reported likely represent a correlation between manipulations and patients seeking care for serious medical conditions in progress. The risks of serious complications from lumbar manipulations are likely 1 in several million and far lower risk than most other medical interventions for low back pain.</li>
        </ul>
        <strong>Comparison and Combination:</strong>
        <ul>
          <li><strong>Comparing Manipulation to Other Interventions:</strong> Studies suggest that manipulations may be more effective, or at least as effective as soft tissue therapy, TENS, <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> energy technique (MET), neural mobilizations, patient education, back school, physician care, prescription medications, chemonucleolysis, or surgery, with the potential advantage of larger initial improvements.</li>
          <li><strong>Comparing Manipulations to Exercise:</strong> Research has demonstrated that manipulations are as effective or more effective than therapeutic exercise based on pain and dysfunction; however, it is likely more accurate to suggest that outcomes are <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> to intervention, with manipulations resulting in larger effects on ROM and pain, and exercise having a larger effect on strength and endurance.</li>
          <li><strong>Studies suggest that the addition of manipulation to medical care, soft tissue therapy, therapeutic exercise, and/or therapeutic modalities is significantly more effective than any single intervention, both short-term and long-term. </strong></li>
        </ul>
        <strong>Systemic Effects</strong>
        <ul>
          <li><strong>Effect on Motion:</strong> It is likely that manipulations affect joint stiffness, which may or may not affect total range of motion.</li>
          <li><strong>Analgesic Effects:</strong> Lumbar manipulation has <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> analgesic effects, likely influenced by the patient&apos;s current level of pain, and mediated by locally innervated C-fiber activity and altered <a id="excitability" data-tip="1310" target="_blank" href="/glossary-term/excitability" class="glossary">excitability</a> of <a id="dorsal" data-tip="1554" target="_blank" href="/glossary-term/dorsal" class="glossary">dorsal</a> horn neurons.</li>
          <li><strong>H-Reflex/Stretch Reflex:</strong> Attenuation of H-reflex is greater following manipulation than mobilization, is locally mediated, lasts for approximately 30 seconds, is similar for symptomatic and asymptomatic individuals, and attenuation is larger following lumbar manipulations than cervical manipulations. Further, research suggests that the velocity of manipulations may be a primary factor influencing H-reflex/stretch reflex attenuation, may be the result of velocity <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> dominating over length <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> of <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> spindles, and that manipulations may improve H-reflex response in individuals with H-reflex latency resulting from herniation.</li>
          <li><strong>Transcranial Magnetic Stimulation (TMS) Studies:</strong> Although there are relatively few TMS studies, the initial findings confirm that the <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a> response to manipulations is primarily mediated by the spinal cord, but also involves supraspinal reflex response.</li>
          <li><strong>Muscle Activity:</strong> Lumbar manipulation results in a normalization of <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> activity in those exhibiting low back pain. This includes an increase in <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> and <a href="https://brookbushinstitute.com/article/external-obliques" target="_blank" rel="noopener">external oblique</a> thickness during activity, no change in <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a> or <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a> thickness, a reduction in <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> activity, and a transient effect on <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a> <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> activity.</li>
        </ul>
      </td>
    </tr>
  </tbody>
</table>
<h3>Sacroiliac Joint (SIJ) Manipulation Summary:</h3>
<table style="font-family: -apple-system, BlinkMacSystemFont, &apos;Segoe UI&apos;, Roboto, Oxygen, Ubuntu, Cantarell, &apos;Open Sans&apos;, &apos;Helvetica Neue&apos;, sans-serif; background-color: #ffffff; color: #34363a; font-size: 0.9375rem; font-weight: 400; letter-spacing: 0px;">
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          <li><em>Focus should be placed on addressing stiffness and asymmetry and not sacral position or range of motion.</em></li>
        </ul>
        <strong>Pain, Motion, and Assessment</strong>
        <ul>
          <li><strong>SIJ Pain:</strong> Research using SIJ anesthetic or saline injection provides strong evidence that SIJ dysfunction may be responsible or contribute to 15 &#x2013; 30% of low back pain cases.</li>
          <li><strong>Total Motion:</strong> The SIJ is capable of approximately 1.6 - 6&#xB0; of rotation, and 0.1 - 2.0 mm of translation.</li>
          <li><strong>Palpation:</strong> SIJ motion is similar in amplitude lumbar facet motion, and well within the limits of fingertip <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>.</li>
          <li><strong>Defining Dysfunction: </strong>Asymmetrical stiffness likely alters motion and results in dysfunction and pain; it is unlikely that dysfunction is the result of a change in total ROM.</li>
          <li><strong>Ineffective Testing:</strong> Imaging may be <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> but not <a id="sensitivity" data-tip="1227" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitive</a>, subjective examination lacks <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and palpation of sacral position lacks <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a>.</li>
          <li><strong>Pain Cluster:</strong> Clustering pain provocation exams increases <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a>, as demonstrated by the <a href="https://brookbushinstitute.com/video/sacroiliac-joint-testing-item-cluster-lasletts-cluster-ii" target="_blank" rel="noopener">Laslett Cluster II</a>.</li>
          <li><strong>Gillet Test: </strong>The <a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-stork-gillet-test" target="_blank" rel="noopener">Gillet Test</a> is <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> when constrained to 2 or 3 possible outcomes (More stiff on right, More stiff on left, Even)</li>
          <li><strong>Movement Cluster:</strong> Grieve et al. demonstrated <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> and <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> when the <a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-stork-gillet-test" target="_blank" rel="noopener">Gillet Test</a> was combined with hip ROM asymmetry and palpation of the <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> ligament of the pubic symphysis.</li>
        </ul>
        <strong>Treatment</strong>
        <ul>
          <li><strong>Efficacy:</strong> SIJ manipulation results in improved SIJ symmetry, hip ROM symmetry, gait symmetry, pain, and disability.</li>
          <li><strong>Comparing Manipulation to Other Interventions: </strong>SIJ manipulation may be more effective than TENS, injections, and conventional physical therapy, although more consideration should be given to the expected outcomes (ROM vs. strength vs. <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity, etc) and less to direct comparison of each modality.</li>
          <li><strong>Combining Manipulation and Other Interventions:</strong> The combination of manipulation and dry needling is more effective than either technique alone, and slightly more effective than manipulation and traditional acupuncture. The combination of SIJ manipulation with <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> strengthening or stretching techniques is likely to result in better outcomes than using either intervention alone.</li>
          <li><strong>Optimal Practice:</strong> Research suggests that SIJ manipulation should be short-lever, small amplitude, and performed in conjunction with lumbar manipulation.</li>
        </ul>
        <strong>Systemic Effects</strong>
        <ul>
          <li><strong>Hormones:</strong> Initial studies suggest that SIJ manipulation results in an immediate <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> of various <a id="hormone" data-tip="1268" target="_blank" href="/glossary-term/hormone" class="glossary">hormones</a> and markers of <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a> activity, which likely play a significant role in the body&apos;s response to manipulation.</li>
          <li><strong>Cortical Response:</strong> Research suggests manipulation results in an increase in descending cortical drive that may aid in attenuating <a id="motor-unit" data-tip="1303" target="_blank" href="/glossary-term/motor-unit" class="glossary">motor unit</a> recruitment.</li>
          <li><strong>H-Reflex/Stretch Reflex:</strong> SIJ manipulation results in a decrease in H-reflex amplitude that is transient, does not affect M-wave amplitude, is <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> to the lower extremity of the side manipulated, and is not the result of confounding variables like body position or cutaneous input.</li>
          <li><strong>Quadriceps Activity:</strong> It is likely reasonable to assume that SIJ manipulation can have a small effect on <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a> <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment in individuals exhibiting signs of inhibition from pain, but the results may be transient and should be followed immediately by strengthening techniques. Results on asymptomatic patients may vary.</li>
          <li><strong>Systemic Effect on Motor Activity:</strong> Based on current research, it seems likely that CNS-mediated motor recruitment changes reverse the inhibition resulting from pain, i.e. &quot;disinhibition.&quot;</li>
        </ul>
      </td>
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<h3>Pubic Symphysis</h3>
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          <li><strong>Motion:</strong> Pubic symphysis exhibits 1.4 mm of motion in men, 1.6 mm in nulliparous (never given birth) women, and 3.1 mm in multiparous women.</li>
          <li><strong>Efficacy is Plausible:</strong> Research suggests that the inclusion of pubic symphysis shotgun manipulation being effective is plausible; however, limited research forces reliance on clinical outcomes.</li>
          <li><strong>Suggestions based on Clinical Outcomes:</strong> Clinical outcomes suggest that the pubic symphysis manipulation should be used in conjunction with SIJ manipulation, when SIJ techniques are not completely effective, or when the patient complains of <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor</a>,<a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener"> rectus abdominis</a>, or &quot;FAI-like&quot; symptoms, and/or pubic symphysis stiffness as assessed via manual mobilization.</li>
        </ul>
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</table>

Research Corner: Lumbar Spine Manipulation

<h3>Lumbar Pain</h3>
<p>There is a relatively large body of research investigating the efficacy of lumbar manipulation for lumbar spine pain. An RCT by Walker et al. demonstrated that chiropractic manipulation was more effective than sham treatment; however, effects were also correlated with patient satisfaction (1). An RCT by Licciardone et al. demonstrated that manipulation and sham manipulation both provided similar benefits when incorporated into usual osteopathic care, suggesting that the effects of manipulation may be due in part to placebo (2). A prospective RCT by Doughtery et al. demonstrated that older veterans receiving manipulation demonstrated a significant decrease in disability when compared to sham, despite both groups reporting similar levels of pain reduction at 12 weeks (3). Oh et al. demonstrated that high-velocity manipulation reduced pain, improved function, and increased ROM in spinal stenosis patients; however, manipulation did not have a significant impact on disc herniation index (MRI) (4). Annen et al. demonstrated that manipulations benefited a larger percentage of individuals with MRI confirmed modic changes (deleterious changes to bones and joints of the spine) when compared to individuals who had less evidence of modic changes (5). And, a study by Kuo et al. investigated the outcomes of 517 patients admitted between 1975 -1983 with MRI confirmed lumbar disk herniation who received manipulative treatment - 76.8% of these patients reported satisfactory results, 14.1% had a recurrence during the 2 month to 12-year follow-up, and less than 10% reported no results from the treatment (6). These initial studies suggest that gross implementation of manipulations based on diagnosis alone is likely most often beneficial, but the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of outcomes are likely moderate. Further, research is needed to aid in the optimization of implementation.</p>
<h3>Dose-response Relationship:</h3>
<p>One issue that may be affecting outcomes is the dose of manipulations necessary to optimize treatment effects. An RCT by Glover et al. demonstrated significant improvements in low back pain immediately following a single manipulation; however, there was no difference between the treatment and control groups (de-tuned ultrasound) at the 3-day and 7-day follow-ups (7). This study likely implies that manipulations have large immediate effects; however, a single manipulation session is not sufficient for long-term improvement. An RCT by Schwerla et al. demonstrated that 4 manipulations over 8 weeks resulted in significant improvements in postpartum low back pain and disability when compared to controls (8). In a study by Shokri et al., patients with MRI-confirmed lumbar disc herniation received 5 sessions of manipulations for the sacroiliac joint and lumbar spine during a 2-week period, resulting in a significant mean improvement in back and leg pain at the 5th session and 1-month follow-up (9). These studies likely suggest that more initial sessions result in a significant improvement of treatment effects. In a double-blind RCT by Santilli et al. a total of 64 men and 38 women (19&#x2013;63 yo) were randomized to manipulation or simulated manipulation groups, treatments were performed 5 days per week for up to 20 sessions, and findings demonstrated that manipulations were more effective, based on the percentage of pain-free cases, number of total days with pain, and number of days with moderate or severe pain (10). Burton et al. demonstrated that lumbar manipulation resulted in an increase in <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> and a reduction in pain during the first month of treatment; however, no further changes in ROM were noted. Further, changes in ROM were not predictive of symptom resolution during follow-up at 1-year, suggesting any positive effects related to manipulation may not be related to changes in ROM (11). Based on these studies, it might be suggested that manipulation treatments result in large initial effect sizes and that 2-weeks to 2-months of subsequent sessions are necessary to improve upon or maintain results. Two studies by Haas et al. specifically investigated the dose-response relationship of lumbar manipulations (12, 13). The first study compared days-per-week and the total number of weeks to symptom resolution and determined the most significant benefits from chiropractor care were achieved by patients receiving 3-4 sessions per week for about 3 - 4 weeks (12). In a subsequent RCT, Haas et al. demonstrated that the number of manipulation treatments had a modest, but significant effect on chronic low back pain up to about 18 visits, with 12 visits generally yielding most of the results. Note, in this study the author did state that the dose-response relationship was not as well-distinguished as previously thought (13). Despite the less-distinguished relationships in the RCT (which may be due to sample size), based on the studies above (7 - 13) a general guideline of approximately 12 - 18 sessions, over 3-6 weeks, with about 3 -4 sessions per week, may be a good general guideline. Further studies suggest follow-up is crucial. In a prospective, observer-blinded, RCT with a 1-yr follow-up by Bronfort et al., combinations of manipulation, strengthening, stretching, and NSAIDs were compared with little clinical difference between the groups throughout the study; however, the continuance of home exercise during the follow-up year, regardless of the type, was associated with better outcomes (14). Further, Senna et al. demonstrated that treatments must continue (likely at a much lower frequency) after an initial period of frequent manipulative therapy to achieve long-term benefits that are <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to a sham or control group (15). In summary, a single manipulation session may have a significant initial effect; however, research suggests that long-term benefits are better with 12 - 18 treatments, over 3-6 weeks, at a frequency of 3 - 4 sessions per week, with follow-up sessions needed at a lower frequency to maintain benefits.</p>
<h3>Clinical Prediction Rules:</h3>
<p>Clinical prediction rules (CPRs) may aid in refining manipulation implementation and further enhance outcomes. Fritz et al. and Childs et al. demonstrated that a subgroup of patients who had at least 4 out of 5 of the following criteria achieved substantially better outcomes following 4 weeks of manipulative therapy when compared to exercise alone. The criteria included: less than 16 days since symptoms began, no symptoms <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> to the knee, Fear-Avoidance Beliefs Questionnaire (FABQ) score less than 19, one or more <a id="hypomobility" data-tip="1676" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobile</a> segments in the lumbar spine, and one or both hips exhibiting less than 35&#xB0; of hip internal ROM (16, 17). In a complimentary clinical prediction rule to Fritz et al. and Childs et al., the same group of researchers determined factors that decrease the likelihood of successful treatment with manipulations, including longer symptom duration (more than 16 days), having symptoms in the buttock or leg, absence of lumbar <a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a>, less hip rotation range of motion, less difference between left and right hip internal rotation range of motion, and a negative <a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-gaenslens-test" target="_blank" rel="noopener">Gaenslen&apos;s sign</a> (18). It is interesting that positive outcomes from lumbar manipulation are not as strongly correlated with hip internal rotation ROM restriction as they are with hip rotation ROM asymmetry. Unfortunately, follow-up studies have failed to confirm the CPRs utility. An RCT by Hancock et al. was unable to predict differences between manipulation and placebo groups at 1-week post-treatment based on identification using the CPR (19). Further, an RCT by Dougherty et al. could not validate the CPR, demonstrating no difference between a therapeutic exercise group and a manipulations group (20). Although this research suggests that the current CPR is weak, the evidence does suggest that correlations exist between assessed impairments and low back pain. Further research is needed to refine the CPR criteria and develop a strong <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> tool for indicating the use of manipulations. It is the author&apos;s belief that <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of the CPR may increase by simplifying the criteria; for example, no sign of radicular symptoms, signs of lumbar stiffness or ROM loss, and asymmetry in hip rotation ROM.</p>

<p>Lumbar manipulations have been compared to a variety of interventions. Generally, studies have demonstrated that outcomes from lumbar manipulation are equal or <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to standard medical care. A double-blind RCT by Von Heymann et al. demonstrated that high-velocity manipulation was significantly more effective than diclofenac or sham treatment during the initial 48 hours of low back pain (21). An RCT by Hondras et al. demonstrated that the addition of either lumbar manipulation or mobilization was <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to standard physician care alone, for older healthy adults (22). In an older study by Doran et al., 456 patients with low back pain from various medical centers were allocated to one of four treatments groups -manipulation, conventional physiotherapy, corset, or analgesic tablets. As may have been predicted based on previously mentioned studies, patients were more likely to respond quickly to manipulation; however, the long-term effects were near equal for all treatments except the analgesics group which fared slightly worse (23). An RCT by Bishop et al. compared <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a> clinical practice guidelines (EBPCare) to standard family physician care, demonstrating EBPCare resulted in larger improvements in pain, disability, and function, for the duration of treatment and during 24-week follow-up (24). Note, EBPCare = reassurance, and avoidance of passive treatments, acetaminophen, 4 weeks of lumbar manipulation, and return to work within 8 weeks. In a multi-armed RCT by Hancock et al., 240 patients who had seen their general practitioner, had been diagnosed with acute low back pain, and had been given paracetamol and basic advice were randomly allocated to one of four equally sized groups: diclofenac 50 mg twice daily and placebo manipulative therapy; spinal manipulative therapy and placebo drug; diclofenac 50 mg twice daily and spinal manipulative therapy; or double placebo. In this study there was no difference in the recovery time (12 days) of all groups; however, it should be mentioned that only days to recovery was measured, with no other outcomes included in the study (25). A pilot and full-scale RCT by Giles et al. compared manipulation, acupuncture, and anti-inflammatory drugs, demonstrating that manipulation was the only treatment option to reach statistically significant improvements in pain and function at the end of 30 days of treatment (26, 27). An RCT by Juni et al. demonstrated that the addition of manipulation to standard physician care (general advice, paracetamol, diclofenac, or dihydrocodeine as required) did not result in significantly better outcomes for acute low back pain, following a 14-day treatment period or during a 6-month follow-up (28). Note, this study likely failed to meet the guidelines for manipulation dosage discussed above. Manipulation has also been compared to higher-risk medical procedures. A single-blind RCT by Burton et al. demonstrated that manipulation was at least as effective as chemonucleolysis for the treatment of symptomatic lumbar disc herniation based on follow-up at 12 months (29). McMorland et al. demonstrated that patients with sciatica who had failed conventional interventions benefited as much from spinal manipulation as from surgery (approximately 60% success rate), suggesting that conservative treatment including manipulation should likely be attempted prior to higher risk surgical interventions (30). These studies suggest that manipulations are at least as effective, if not more effective than many common medical interventions. Considering the risk of adverse events associated with prescription medications, chemonucleolysis, and surgery, manipulations should likely be considered as a safer initial treatment option.</p>
<p>Lumbar manipulation has also been compared to a variety of modalities conventionally used by rehab professionals. An RCT by Hurley et al. demonstrated that for acute low back pain the combination of patient education, manipulation, and TENS inferential therapy, was as effective as education when combined with either manipulation alone or TENS alone - based on improvements in pain, disability, and quality of life in both short and long-term follow-ups (31). An RCT by Hsieh et al. failed to demonstrate a difference in outcomes for subacute low back pain between joint manipulation, myofascial therapy, a combination of joint manipulation and myofascial therapy, or back school (32). Hoehler et al. compared manual soft-tissue therapy to lumbar manipulation in a group of low back patients who had no previous experience with manipulations; demonstrating that manipulations were more likely to result in immediate improvement; however, there was large improvements in both groups and no difference between groups at discharge (32). A double-blind RCT by Behrangrad et al. demonstrated that ischemic <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> of VMO <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> was more effective than lumbar manipulation for reducing PFPS symptoms; however, both techniques demonstrated efficacy (112). These studies suggest that manipulation is as effective or nearly as effective as soft tissue therapy, TENS, and back school when these techniques are performed alone. One notable exception may be the potential for larger immediate improvements as highlighted by the study by Hoehler et al. (33) (as well as other studies discussed above.)</p>
<p>Several studies have compared manipulations to exercise for the treatment of low back pain. A prospective RCT by Bronfort et al. demonstrated that supervised exercise was <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to home exercise for all outcomes in both the short and long-term, and was better than manipulations for improving strength and endurance; however, manipulation resulted in larger improvements in pain (34). Ferreira et al. demonstrated that manipulation and <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> exercise were <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to general exercise for improving function and pain in low back patients in the short term; however, results during 6 and 12-month follow-ups were similar (35). An RCT by Dougherty et al. could not validate the use of the previously mentioned CPR for deciding on manipulations as a treatment option, demonstrating that therapeutic exercise and manipulations were equally effective (20). Hawk et al. demonstrated no significant difference between manipulation and a mind-body approach known as bioenergetic synchronization technique, in chronic musculoskeletal pain following 4-weeks of treatment and a 3-week non-treatment period (36). Nwuga et al. compared manipulations to conventional therapy (heat, pelvic tilt exercises, <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> education, and lifting instructions); demonstrating manipulations required less total treatment time to achieve larger improvements in lumbar ROM and the <a href="https://brookbushinstitute.com/video/straight-leg-raise-test-and-well-leg-raise-test" target="_blank" rel="noopener">straight leg raise test</a> (37). Based on these studies it may be reasonable to conclude that manipulations are as effective, or more effective than exercise alone; however, it may be more accurate to assume that manipulations are likely to have a larger effect on ROM and pain, and exercise may have a larger effect on strength and endurance.</p>
<p>Additional interventions have been compared to manipulations. El Gendy et al. demonstrated that manipulation and <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> energy technique (MET) resulted in similar changes in stiffness; however, manipulations resulted in larger decreases in pain (38). Mahmoud, W. demonstrated that patients with radicular chronic low back pain exhibited larger improvements in pain, disability, and <a id="nerve-cell" data-tip="1361" target="_blank" href="/glossary-term/nerve-cell" class="glossary">nerve</a> root <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> (MRI) following lumbar manipulation when compared to neural mobilization (39). An RCT by Cherkin et al. demonstrated that one month of manipulation or McKenzie method of physical therapy treatments resulted in better outcomes than an educational booklet in the short term, and during 1 and 2-year follow-ups (40). In an RCT by Gibson et al., no difference was noted between manipulation, diathermy, and placebo for non-specific low back pain (41). Similarly, the study mentioned above by Hancock et al. demonstrated similar times to recovery (12 days) comparing 4 groups - placebo manipulative therapy; spinal manipulative therapy and placebo drug; diclofenac 50 mg twice daily and spinal manipulative therapy; or double placebo (25). An RCT mentioned earlier by Hsieh et al. failed to demonstrate a difference in outcomes between joint manipulation and back school for subacute low back pain (32); however, an RCT with 1-year follow up by Cecchi et al. demonstrated that manipulation resulted in larger improvement in pain and function than either conventional physiotherapy or back school (42). These studies likely suggest that manipulation has a larger effect on low back pain than MET, neural mobilizations, or patient education; however, determining a &quot;superior intervention&quot; when comparing combinations of treatments options is more difficult, as was the case in studies investigating physician care, back school or conventional physiotherapy.</p>

<p>Although comparing treatment options can aid in refining technique selection, <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> practice likely results from a combination of interventions. Several studies have investigated the benefits of combining manipulation with standard physician care and/or medications. Dougherty et al. demonstrated that an epidural injection followed immediately by mobilization and manipulation of the affected area, resulted in a significant improvement in outcomes (without adverse reactions) both immediately and during a 14-month follow-up (43). An RCT by Goertz et al. demonstrated that individuals 18-35 years of age with acute low back pain improved more when manipulation was added to standard medical care (44). Further, the RCT by Bishop et al. mentioned earlier compared the combination of reassurance, acetaminophen, 4 weeks of lumbar manipulation, and early return to work (8 weeks), to standard family physician care, demonstrating that the former resulted in larger improvements in pain, disability, and function, both during treatment and during a 24-week follow-up (24). These studies suggest that the addition of manipulation to medical care has a significant positive impact on outcomes for the treatment of lumbar dysfunction.</p>
<p>Studies have also demonstrated the efficacy of combining manipulation and exercise. An RCT by Bronfort et al. demonstrated that adding spinal manipulation to home exercise and education resulted in greater reductions in leg pain at 12 weeks, improvements in global pain and patient satisfaction, and reductions in medication use at 1-year follow-up for individuals with back-related leg pain (45). An RCT by Balthazard et al. demonstrated that the combination of manipulation and <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> exercise, was more effective than placebo and <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> exercise, for the reduction of pain and disability in chronic non-specific low back pain patients (46). A prospective RCT by Mohseni-Bandpei et al. demonstrated that the combination of manipulation and exercise resulted in larger improvements in pain, disability, ROM, and mean EMG activity of the <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> when compared to the combination of exercise and ultrasound (47). An RCT by Bronfort et al. compared various combinations of manipulation, strengthening, stretching and NSAIDS, noting little difference between the groups throughout the study; however, the continuance of exercise during the follow-up year, regardless of type, was associated with better outcomes (14). This study reinforces the importance of developing and insisting on compliance to home exercise programs. In a double-blind RCT by Rasmussen et al., the addition of manipulation to extension exercises did not improve outcomes for low back patients when compared to extension exercises alone (48); implying these two interventions may have similar effects. An RCT by Selhorst et al. demonstrated that the addition of lumbar manipulation to therapeutic exercise did not improve outcomes for adolescents with acute low back pain (49). However, Evans et al. demonstrated that the combination of spinal manipulation and exercise was more effective than exercise alone for long-term improvements in acute low back pain in adolescents (50). The conflicting results of these two studies likely demonstrate a relatively low level of impairment and stiffness accompanying adolescent low back pain. In summary, studies suggest that the addition of manipulation to therapeutic exercise is significantly more effective than either intervention alone; however, manipulations may not provide additional benefit when the exercise used is similar to lumbar manipulation. Note, self-administered lumbar mobilization should be part of a home-exercise program, and patients should be informed of the importance of compliance to attain long-term benefits from therapy.</p>
<p>Other <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> approaches have also been investigated. Murphy et al. demonstrated that the combination of lumbar manipulation and neural mobilization was effective in the majority of cases of spinal stenosis, without any serious adverse reactions or complications (51). Another study by Murphy et al. demonstrated that an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> approach, including both chiropractic and physical therapy services, improved outcomes for the treatment of lumbar radiculopathy with MRI confirmed herniated disk, including improvements in global pain, fear-avoidance behavior, disability, and patient satisfaction, both short and long-term (14.5 months) (52). Beyerman et al. demonstrated that the combination of chiropractic care and heat was more effective than heat alone for treating osteoarthritic low back pain, including more rapid and larger improvements in pain, ROM, and function (53). And, an RCT by Rosner et al. implied that orthotics may not provide additional benefits for back pain when added to manipulations; however, the data also indicated that there may be a relationship between outcomes and the amount of time wearing the orthotics (further research is warranted) (54). In general, the addition of lumbar manipulation to other modalities is likely to enhance both short-term and long-term outcomes; however, further research is needed to decide on the <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> combination of treatment options.</p>

<p>Studies indicate that the outcomes from manipulations and mobilizations are likely similar. An RCT by Xia et al. demonstrated that manipulation and mobilization resulted in similar short-term improvements in pain and disability for individuals with chronic low back pain, and both interventions were <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to &quot;waiting list&quot; controls (55). An RCT by Sims-Williams et al. demonstrated that both mobilization and manipulation groups resulted in similar short-term improvements and were <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to placebo controls (56). An RCT by Cook et al. demonstrated that there was no difference in pain or function between two groups of low back pain patients treated with either manipulation or mobilization, assessed during the second visit and at discharge (57). In an RCT mentioned above, Hondras et al. demonstrated that lumbar manipulation and mobilization were equally effective for older adults, and both were <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to standard physician care alone (22). Despite the rigorous methods of the research above, some studies have implied <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> outcomes from either manipulations or mobilizations, which may be in part attributable to differences in <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> responses to the two techniques. A study by Perry et al. demonstrated that skin conductance changed more and in a larger percentage of participants following manipulation when compared to mobilization. Further, manipulation performed in either direction resulted in the same change in skin conductance (58). An RCT by Cleland et al. demonstrated that the clinical prediction rule (CPR) described earlier correlated with improvements in low back pain when manipulation techniques were followed by supervised exercise; however, a correlation was not observed when lumbar mobilizations were followed by unsupervised exercise (<a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> was performed at the end of treatment and during a 6-month follow-up) (59). Conversely, a study by Carrasco-Mart&#xED;nez et al. demonstrated that flexion/distraction with mobilization technique resulted in larger immediate changes in pain and ROM than lumbar manipulation (60). Further, Thomson et al. demonstrated that mobilization, but not manipulation, had a significant effect on pain pressure threshold when compared to controls (61). In summary, there may be some <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> differences in response to mobilizations and manipulations; however, it may be reasonable to conclude that the group of studies implies there is little difference in outcomes for low back patients treated with either technique.</p>
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        <h3>Lumbar and Sacroiliac Joint Manipulation and Performance</h3>
        <p>Several studies have investigated the impact of lumbar and SIJ manipulation on asymptomatic athletes. Ward et al. demonstrated that lumbar manipulation did not have an impact on heart rate, rate of perceived exertion, blood lactate concentration, or time to volitional exhaustion in healthy individuals performing a treadmill exercise <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> (62). An RCT by Olson et al. demonstrated that asymptomatic cyclists showed no sign of improvement in hip flexibility or <a id="power" data-tip="1399" target="_blank" href="/glossary-term/power" class="glossary">power</a> output following lumbar manipulation, acupuncture sham, and no-treatment control groups (63). Although these studies seem to imply that manipulations do not improve performance, the studies lacked movement <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>. Two additional studies, demonstrate potential for an increase in performance when impairment is assessed. A prospective RCT by Alveranga et al. demonstrated that spinal manipulation had a significant impact on symmetry in asymptomatic young athletes as measured with a force plate during static <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, squats, and vertical jump (64). An RCT by Gong et al. demonstrated that manipulation and massage had a significant effect on joint position sense in individuals who demonstrated lower initial joint position sense; note, massage alone did not have an effect (65). Last, two dissertations, one a multi-armed RCT, demonstrate that the use of manipulations during a warm-up deserves further consideration. A doctoral dissertation by Sood demonstrated spinal manipulation resulted in a significant increase in cricket bowling speed in asymptomatic athletes (66). This dissertation did not include movement assessment; however thoracic stiffness is a very common impairment. A dissertation with multi-armed RCT design by Kretsmann et al. investigated the effects of manipulations as part of the normal warm-up of soccer players, demonstrating the lumbar manipulation group exhibited increased lumbar ROM, the sacroiliac joint manipulation group exhibited increased SIJ motion but not lumbar ROM, and all 3 groups demonstrated increases in kicking speed, with the largest increases seen in the combination SIJ and lumbar manipulation group (237). The increase in lumbar ROM may be further <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> that manipulations can be beneficial for performance when restrictions/impairments are noted. Based on these studies it may be reasonable to consider manipulation techniques as part of a well-designed movement preparation warm-up based on assessed impairments. However, it is unlikely that manipulation will improve performance when there is no indication for it.</p>
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<p>Only a few studies have investigated the mechanics of manipulations. A study by Zhang et al. demonstrated impulse speed and magnitude of pressures of facet joints was greater during manipulation than that during mobilizations. Zhang et al. also demonstrated that during mobilization and manipulation, pressures of <a id="ipsilateral" data-tip="1550" target="_blank" href="/glossary-term/ipsilateral" class="glossary">ipsilateral</a> facet joints decreased first and then increased, while pressures of <a id="contralateral" data-tip="1549" target="_blank" href="/glossary-term/contralateral" class="glossary">contralateral</a> facet joints increased first and then decreased (67). An RCT by Cramer et al. used MRI to demonstrate that side-positioning resulted in greater gapping of facet joints than controls, and that lumbar manipulation resulted in greater gapping than side-positioning (68). A study by Xu et. al demonstrated that rotational manipulations (like the one taught below) to the same side were more likely to displace a disk bulge toward the <a id="nerve-cell" data-tip="1361" target="_blank" href="/glossary-term/nerve-cell" class="glossary">nerve</a> root, implying that it may be safer to perform rotational manipulations to the <a id="contralateral" data-tip="1549" target="_blank" href="/glossary-term/contralateral" class="glossary">contralateral</a> side (69). Haussler et al. demonstrated that manipulation increased vertebral <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> and decreased stiffness, as evidenced by an approximately 15% increase in vertebral displacement during gait (70). Xia et al. demonstrated that disability was correlated with decreased flexion/extension ratio and an increase in global stiffness; however, improvements following 6 weeks of therapy were not correlated with improved flexion/extension ratio or mechanical <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of stiffness. Interestingly, they were correlated with manual assessed stiffness (71). A study by Stamos-Papastamos et al. also suggests that some measures of stiffness may not be affected by manipulation, demonstrating that neither mobilization or manipulation had a significant effect on bending stiffness or ROM; however, this study was also performed on asymptomatic individuals (72). Although it seems unlikely that asymptomatic individuals would exhibit significant differences in stiffness following mobilizations, the discrepancies between Haussler et al., Xia et al. deserve further attention. More research is needed to determine the ideal outcome measures for range of motion and stiffness, and perhaps more consideration is given to the effects of mid-range stiffness as described by Panjabi et al.&apos;s neutral zone <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> (73, 74).</p>

<p>Similar to claims made about adverse events from <a href="https://brookbushinstitute.com/article/manipulations-cervical-spine/" target="_blank" rel="noopener">cervical spine manipulation</a>, adverse events following lumbar spine manipulation have been significantly exaggerated. Unfortunately, the exaggerated risks associated with these techniques have resulted in inaccurate beliefs by many clinicians. A study by Puentedura et al. collected surveys from 1000 physical therapists, demonstrating that the gross majority (90%+) believe that thoracic and lumbar manipulations are safe and effective, with a smaller percentage (68.9%) believing <a href="https://brookbushinstitute.com/article/manipulations-cervical-spine/" target="_blank" rel="noopener">cervical spine manipulation</a> are safe and effective (110). Hincapi&#xE9; et al., using a belief elicitation design with 47 clinicians demonstrated that chiropractors expressed the most optimistic beliefs, physicians expressed neutral beliefs; and spine surgeons expressed slightly more pessimistic beliefs. In general, clinicians with the most optimistic views believed that chiropractic manipulations reduced the incidence of acute herniation by about 60%, while those with the most pessimistic views believed that chiropractic manipulations increased the incidence of herniations by about 30% (111). Note, these beliefs are not close to the actual estimations of injury or recovery rates. Boucher et al. reviewed 6 court cases of aggravated lumbar herniation symptoms following chiropractic care. Based on the rather alarming conclusion of the Canadian Court, it may be reasonable to conclude that these beliefs have influenced legislation as well: &quot;<em>1) informed consent is an ongoing process that cannot be entirely delegated to office personnel; 2) when the patient&apos;s history reveals risk factors for lumbar disc herniation the chiropractor has the duty to rule out disc pathology as an <a id="etiology" data-tip="1489" target="_blank" href="/glossary-term/etiology" class="glossary">etiology</a> for the symptoms presented by the patients before beginning anything but conservative palliative treatment; 3) lumbar disc herniation may be triggered by spinal manipulative therapy on vertebral segments distant from the involved herniated disc such as the thoracic spine</em>&quot; (112). If the court had acted in good faith, they may have referred to a comprehensive lit review and recommendations based on the interpretation of that research by experts. These studies suggest that despite the level of education and pursuit of <a id="evidence-based-practice" data-tip="1532" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based practice</a>, many clinicians have beliefs that do not reflect the findings of current best evidence regarding lumbar herniations.</p>
<p>The exaggeration and beliefs of clinicians and legislators are likely due to various case reports of serious injury. Yang et al. presented a case of cauda equina syndrome immediately following vigorous low back massage and spinal manipulation, requiring emergency surgical intervention to achieve full recovery. (113) In separate publications by Solheim et al. and Cheng et al., a case is discussed of lumbar epidural hematoma following spinal manipulation. The symptoms were similar to cauda equina syndrome, required emergency assistance, but emergency surgical evacuation resolved symptoms (114, 115). Morandi et al. reported a case of cauda equina ischemia following lumbar manipulation that was not the result of herniation or bony fragment, which may imply microvascular trauma (116). Kornberg, E. published a case of a 44-year old man, whose sequence of pathology appears to be acute aortic occlusion, following a lumbar artery aneurysm, following a chiropractic manipulation (117). Case reports like these are important for identifying symptoms that are indicative of rare complications; for example, loss of leg strength, loss of bowel and bladder control, and loss of sensation are &quot;red flags&quot; that should prompt immediate referral to emergency care. However, it should also be noted in all of these cases that the condition of the disks, vessels, and neural structures was unknown prior to intervention, and these cases may be representative of complications in progress that were identified during manipulation and not caused by manipulation.</p>
<p>Published case series may be a little more representative of practice. In a review of the literature between 1911 and 1989, Haldeman et al. found ten reported cases of cauda equina syndrome following lumbar manipulation, that resulted in poor outcomes due to chiropractor and physician failing to identify the severity of the issues and a delay of several days in emergency treatment (118). These cases reinforce the need for education on &quot;red flag&quot; issues that imply immediate emergency care is recommended. Herbert et al. performed a systematic search of the literature up to 2012; 2046 studies were screened, and 41 studies reporting on 77 cases were included. Adverse events consisted of cauda equina syndrome (29 cases); lumbar disk herniation (23 cases); fracture (7 cases); hematoma or hemorrhagic cyst (6 cases); and other serious adverse events (12 cases, 16%) including neurologic compromise, vascular compromise, soft tissue trauma, <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> abscess formation, disrupted fracture healing, and esophageal rupture (119). Again it must be noted that these cases were pulled from databases comprised of decades of research; however, this list of cases may aid in refining a list of &quot;red flags&quot;. In a case series, Oppenheim et al. reviewed 16 cases of cervical, thoracic and lumbar spine manipulations that resulted in immediate worsening of symptoms; 89% required surgery, outcomes were excellent in 50%, good in 37.5%, and 3 of the patients died from unrecognized malignancies (120). Again, we have to be careful not to assume a correlation between manipulations and events as the deaths in these cases imply; these individuals were likely seeking medical care for symptoms from complex medical issues. Kim et al., a group who generally publishes conservative conclusions made the unfortunate misstep of publishing the statement, &quot;However, we assumed that cauda equina syndrome or disc rupture is far more common than the literature would reflect&quot;, without any <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> for the claim and in direct opposition to their study which could only locate 61 case studies over a time period of 85 years (121). In an interesting study by Gorrell et al., it was demonstrated that articles were more likely to report on adverse events if they possessed larger sample sizes, were published after the 2010 CONSORT statement, had a low risk of bias, and involved multiple intervention sessions (122). This is certainly important to keep in mind for future studies. Although these case series aid in creating a list of complications, a list of red-flag issues, and aid in determining which complications are most likely, the following studies on risk show how irresponsible the statements by Kim et al. are.</p>
<p>Proposed mechanisms have been refuted, the risk of complications is low, and the relative risk of complications suggests this issue is again over-exaggerated. Ianuzzi et al. used cadaver specimens to demonstrate that lumbar manipulation forces were far less than the amount of force necessary to result in damage to facet joint capsules (123). An older study by Chrisman et al. performed myelogram before and after manipulation in individuals with lumbar intervertebral-disc syndrome, demonstrating no change in myelogram findings for any participant (124). Oliphant et al. performed a systematic review and risk <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> based on current data. Their conclusions were the risk of manipulation causing a clinically worsened disk herniation or cauda equina syndrome was less than 1 in 3.7 million (125). Hincapie et al. used a self-controlled case series design and population-based healthcare databases in Ontario, Canada, to investigate all adults with acute lumbar disc herniation (LDH) requiring emergency department (ED) visit and early surgical intervention between April 1994 and December 2004, and determined that the events were as strongly correlated with physicians visits as with chiropractic visits (126). In summary, these studies suggest that complications do arise and that recognizing symptoms of complications is essential to full recovery. However, these studies also suggest that the risk and relative risk of injury are so low that suggesting manipulation as a treatment option should be considered safe and effective.</p>

<h3>Does Sacroiliac Joint (SIJ) Dysfunction Contribute to Low Back Pain?</h3>
<p>Sacroiliac joint (SIJ) manipulation is a controversial topic, primarily due to false notions regarding SIJ motion and SIJ <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>. Several studies have used injection to demonstrate that SIJ dysfunction contributes to low back pain. In a study by Fortin et al. on asymptomatic individuals, injection into the SIJ immediately revealed an area of buttock hyperesthesia extending approximately 10 cm caudally and 3 cm laterally from the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> iliac spine (Fortin area) (127). In a follow-up study, 16 patients were selected whose pain most closely matched the &quot;Fortin area&quot;, of these patients 10 benefited from therapeutic injection (128). Van der Wurff et al. mapped the area and intensity of chronic low back pain patients and then compared responder and non-responders to double diagnostic SIJ injection. The findings suggest that there were no significant differences in area; however, the intensity of <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> areas did differ; with 100% of SIJ injection responders exhibiting more intense pain in the &quot;Fortin area&quot; and only 10% of SIJ injection responders with more intense pain at the ischial tuberosity (129). Maigne et al. demonstrated that nearly 20% of individuals with low back pain and diagnosed SIJ dysfunction, experienced at least temporary relief from fluoroscopic guided SIJ anesthetic block (130). Slipman et al. demonstrated that fluoroscopic guided injections effectively reduced pain, disability, and increased time at work during a 2-year follow-up of patients diagnosed with SIJ dysfunction (131). Soneji et al. demonstrated no significant difference between ultrasound-guided and fluoroscopy guided SIJ injections, with both resulting in a significant reduction from baseline mean pain scores, as well as improvements in physical functioning, discomfort, opioid utilization, and patient satisfaction (132). Although more research is needed to aid in refining <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> and injection interventions, the effect of SIJ injection on low back pain provides strong evidence that SIJ dysfunction is a significant contributor to low back pain.</p>

<p>Several exacting methods of motion analysis have been used to determine the amount of motion of the SIJ. In studies by Jacob et al. and Kissling et al., using a three-dimensional stereophotogrammetric method with intraosseous markers, the transition from sitting to standing resulted in average values for rotation and translation of 1.8&#xB0;/0.7 mm for males and 1.9&#xB0;/0.9 mm for the females. Based on a couple of individual cases in the study, it was postulated that pathological sacroiliac joint <a id="stability" data-tip="1193" target="_blank" href="/glossary-term/stability" class="glossary">instability</a> may occur when values are more than 6.0&#xB0;/2 mm (133, 134). Egund et al. used roentgen stereophotogrammetry to demonstrate that during <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a> motions, the sacrum moved primarily around a transverse axis about 2&#xB0;, and the distance between the two <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> iliac spines varied at most by 0.4 mm during 7 different body positions (135). In a study by Wilke et al., Schanz screws were implanted in S1 and the ilium and measured continuously with a three-dimensional <a id="goniometry" data-tip="1524" target="_blank" href="/glossary-term/goniometry" class="glossary">goniometric</a> system. The maximum rotation angle in the sagittal plane was 1.3&#xB0; on the right and 1.6&#xB0; on the left for flexion plus extension. Extension of the hip always produced the largest motion in the sacroiliac joint (136). Cibulka et al. also demonstrated small reciprocal motions in straddle position using radiostereometric analysis that matched the amount of motion demonstrated in other studies (137). Additionally, two studies by Struesson et al. demonstrated that movement of the sacroiliac joint was small during the standing hip flexion <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> when compared to reciprocal straddle position, suggesting that standing may reduce SIJ motion due to muscular contraction or <a id="form-closure" data-tip="1452" target="_blank" href="/glossary-term/form-closure" class="glossary">form closure</a> (138, 139). These studies indicate that the SIJ is capable of approximately 1.6 - 6&#xB0; or rotation, and/or 0.1 - 2.0 mm of translation. Although the initial impression of these motions may result in jumping to a conclusion that they are small and insignificant, we must be careful not to impose a subjective value without reference.</p>
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      <td>
        <h4><strong>How much is 2 to 3mm?</strong></h4>
        <p>It is easy to see 1.6 - 6&#xB0; of rotation, or a translation of 0.1 - 2.0 mm and think that the motion of the SIJ is not worth consideration; however, these motions should be considered relative to other joint motions. Kozanek et al. demonstrated that during flexion-extension movements of the trunk, the lumbar facets rotated primarily along a mediolateral axis an average of 2&#xB0;&#x2013;6&#xB0;, and translated (<a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a>) in a cranial/caudal direction an average of 2&#x2013;4 mm (140). There are very few practitioners who would argue that motion of the lumbar facets is not palpable, and yet, the amount of motion is similar to the motion reported by studies on the SIJ. The next reasonable question to ask may be: &quot;How <a id="sensitivity" data-tip="1227" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitive</a> are the receptors in the fingertips, and what is the threshold amount of motion that can be reliably palpated?&quot;. A reasonable conclusion about fingertip <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> may be made by analogy, comparing the amount of SIJ motion to studies on the height of braille letters and reading speed/comprehension by the blind. Lei et al. demonstrated that when blind adults were tested with the lowest braille heights (0.04mm), more repeated motions over words and slower reading speeds occurred; however, repeated movements and reading speed were normal at medium and high braille heights (0.18 and 0.38mm) (141). This implies that it is possible to comfortably identify the difference in braille letters when heights are 1/5 of a mm, and reading could still take place at 1/20th of a mm. These heights are between 10 and 50 times smaller than the amount of motion of the SIJ. Although palpation and <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of SIJ motion may be more difficult than palpating <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> at the shoulder or hip, it may be reasonable to conclude that SIJ motion is as difficult to palpate as lumbar facet motion, and well within the limits of fingertip <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>.</p>
      </td>
    </tr>
  </tbody>
</table>
<h3>SIJ Dysfunction and Altered Motion</h3>
<p>Additional motion studies have investigated how SIJ motion is altered by pain and dysfunction. Kibsg&#xE5;rd et al. demonstrated that the straight let raise <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> resulted in 0.8&#xB0; of <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> rotation and 0.3&#xB0; inward tilt of the straight leg ilium on the sacrum in patients with long-standing severe sacroiliac joint pain (142). Sturesson et al. used roentgen stereophotogrammetry to investigate SIJ motion in 25 patients with SIJ disorders, in various normal and extreme physiologic positions, demonstrating a mean ROM of 2.5&#xB0; (0.8 degree-3.9 degrees), and mean translation of 0.7 mm (0.1-1.6 mm). There was no difference between symptomatic and asymptomatic joints (143). Adhia et al. demonstrated that when SIJ-negative low back pain patients were compared to SIJ-positive low back pain patients (diagnosed using <a id="test-item-cluster" data-tip="1209" target="_blank" href="/glossary-term/test-item-cluster" class="glossary">test cluster</a>), they exhibited significantly different innominate movement patterns and trends of rotation, but not innominate ranges of motion (144). Buyruk et al. demonstrated a correlation between asymmetric stiffness and pelvic pain using a novel Doppler imaging of vibration technique (145). In another study by the same group, Damen et al. demonstrated that using the vibration imaging technique to <a id="assessment" data-tip="1486" target="_blank" href="/glossary-term/assessment" class="glossary">assess</a> SIJ asymmetric laxity had a <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> of 65%,, <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a> of 83%, and a positive <a id="predictive-values" data-tip="1738" target="_blank" href="/glossary-term/predictive-values" class="glossary">predictive value</a> of 77% for pregnancy-related pelvic pain persisting postpartum (146). The studies by Adhia et al., Buyruk et al., and Damen et al. may suggest that asymmetric stiffness is the physical phenomenon leading to changes in motion and pain, and not changes in total ROM (144 - 146). Adding to the &quot;asymmetry hypothesis&quot;, Cibulka et al. demonstrated that patients with low back pain without evidence of SIJ dysfunction had more hip external ROM than internal ROM bilaterally, whereas those with evidence of SIJ dysfunction had significantly more hip external ROM than internal ROM unilaterally, specifically on the side of the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> innominate (147). These studies imply that determining how dysfunction affects total SIJ ROM may be the wrong <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> to investigate. Instead, these studies suggest that asymmetric stiffness likely alters motion during activity and is correlated with dysfunction and pain. The change in stiffness without a change in total ROM may be similar to the changes described in Panjabi et al.&apos;s neutral zone <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> for the lumbar spine (148, 149). The application of this <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> to both the lumbar spine and SIJ also increases congruence between hypothesized spine dysfunction, suggesting that changes in the motion of various segments of the spine may occur due to similar mechanisms.</p>
<h3>Changes in Motion Following Manipulation</h3>
<p>Studies have demonstrated some changes in pelvic motion and position post manipulation; however, based on research findings expectations should be modified. Tullberg et al. compared roentgen stereophotogrammetric analysis and position tests before and after manipulation in 12 individuals with <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> sacroiliac joint dysfunction, demonstrating that manipulation did not change the position of the sacrum in standing; however, manual sacral position tests did change from positive to normal (150). This may suggest that the effects of manipulation do not alter sacral position and that manual sacral position tests are not valid; however, these tests may still have diagnostic benefit if capable of identifying individuals who would benefit from sacral directed therapies. In an RCT by Cibulka et al., 20 patients who had sided low back pain and SIJ dysfunction were randomly assigned to control and experimental groups and pelvic tilt was measured. The experimental group was manipulated on the side of stiffness resulting in equal and opposing tilting toward normalization of both innominate during retesting (based on relative ASIS and PSIS height) (151). This may imply that while the sacral position is not palpable, innominate tilt may be palpable and used as a <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of manipulation success. In a <a id="quasi-experimental-research" data-tip="1159" target="_blank" href="/glossary-term/quasi-experimental-research" class="glossary">quasi-experimental study</a> by de Toledo et al. manipulation did not result in significant changes in SIJ mobility; however, the clear trend in the data may also suggest that this study was too small to reach statistical significance (152). Conversely, Mahmoud et al. demonstrated that <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> iliosacral joint manipulation increased SIJ ROM, reduced hyperlordosis of the lumbar spine, and decreased SIJ and low back pain (153). Based on these research studies, and the studies discussed below regarding treatment, manipulation should be expected to alter iliac position and not sacral position, improve asymmetry but potentially not SIJ <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a>, and reduce symptoms associated with SIJ dysfunction.</p>

<p>Several studies have investigated the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of imaging and medical examination for the diagnosis of SIJ dysfunction. Elegafy et al. demonstrated that computed tomography had a <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> of 57.5% and a <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a> of 69%, based on a comparison to the number of patients who tested positive using SIJ Injection (anesthetic block) (154). Slipman et al. demonstrated that of 31 patients, 19 responded to SIJ block, only 4 responders had signs of SIJ dysfunction on bone scans, and zero non-responders had signs on bone scans (155). These studies may suggest that imaging has high <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a>, but very low <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>. Additional studies using radiographs imply a correlation between SIJ dysfunction and femoral acetabular impingement syndrome (FAI). Krishnamoorthy et al. demonstrated a high percentage of SIJ abnormalities on radiographs (25.2%) in patients with FAI (156). Further, Morgan et al. demonstrated that a significant number of patients meeting strict criteria for SIJ pain had radiographic evidence of FAI or hip arthrosis (157). Arthrography may demonstrate some of the physical phenomena that may be contributing to SIJ pain. Fortin et al. demonstrated the extravasation of contrast medium during arthrogram of the SIJ, which may imply micro-damage of SIJ capsular structures and/or the potential of intra-articular fluids to aggravate adjacent neural structures (56). Schwarzer et al. demonstrated similar findings; of 13 low back pain patients (30%) who obtained relief from an anesthetic SIJ block, 9 exhibited tears of the <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> capsule during arthrography (158). Dreyfuss et al. demonstrated that the combination of medical history and physical examination was also not particularly beneficial for assessing the contribution of SIJ dysfunction to low back pain (160). And, Freburger et al. demonstrated that using calipers and inclinometers for determining SIJ motion and dysfunction was unreliable in a multicenter study (161). These studies demonstrated that imaging may be <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> but lacks <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>, that medical examination alone lacks <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, there appears to be a correlation between SIJ dysfunction and FAI, and arthrography may be used in aiding in further research.</p>
<p>Studies have demonstrated a <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> diagnosis of SIJ pain using clusters of the most effective SIJ special tests for pain provocation. A study by Laslett et al. in 1994 demonstrated that many of the pain provocation tests were <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> (162). In 2003 and 2005, Laslett et al. reported the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of a <a id="test-item-cluster" data-tip="1209" target="_blank" href="/glossary-term/test-item-cluster" class="glossary">test cluster</a> resulted in 94% <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> and 78% <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a>, using anesthetic SIJ block as the comparison criteria (163, 164). Further, in 2009, a meta-analysis by Szadek et al. demonstrated that the <a href="https://brookbushinstitute.com/video/thigh-thrust-test-sacroiliac-joint" target="_blank" rel="noopener">thigh thrust test</a>, the <a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-sacrul-thrust-compression-distraction-tests" target="_blank" rel="noopener">compression test</a>, and 3 or more positive stressing tests (as used in the <a href="https://brookbushinstitute.com/video/sacroiliac-joint-testing-item-cluster-lasletts-cluster-ii" target="_blank" rel="noopener">Laslett Cluster</a>) demonstrated discriminating <a id="power" data-tip="1399" target="_blank" href="/glossary-term/power" class="glossary">power</a> for diagnosing SIJ pain (165). The Laslett Cluster is covered in detail in the course, &quot;<a href="https://brookbushinstitute.com/article/special-tests-sacroiliac-joint" target="_blank" rel="noopener">Special Tests: Sacroiliac Joint</a>&quot;. The success of the pain provocation cluster may imply that clustering exams are a potential path to <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> movement <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>. An interesting comparison by Soleimanifer et al. demonstrated that there was no correlation between findings of SIJ motion special tests, and SIJ pain provocation special tests. It is important to note that most or the tests used were not part of any cluster currently supported by research (Sitting flexion, Standing flexion, <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">Prone</a> knee flexion, <a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-stork-gillet-test" target="_blank" rel="noopener">Gillet test</a>, <a href="https://brookbushinstitute.com/video/hip-special-test-faber-patricks-test" target="_blank" rel="noopener">FABER</a>, <a href="https://brookbushinstitute.com/video/thigh-thrust-test-sacroiliac-joint" target="_blank" rel="noopener">Posterior shear</a>, Resisted abduction <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a>) (166). However, the idea that a <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> pain cluster and a <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> movement cluster should demonstrate correlation is likely an important goal in the development of a movement cluster. These studies demonstrate that there is a <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> approach for diagnosing SIJ pain and that clustering exams may be a viable option for improving SIJ movement <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a>.</p>
<p>Several studies have investigated the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of movement <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a>. Herzog et al. demonstrated that some palpation procedures demonstrated <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, but not others; which implies that more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> training protocols should be developed to teach motion palpation (167). Lueck et al demonstrated inter- and intra-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> at a single clinic was variable for SIJ motion exams, noting that intra-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was higher than inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and that it was the amount of daily practice and not years of experience that affected <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (168). Hungerford et al. demonstrated that the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of the <a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-stork-gillet-test" target="_blank" rel="noopener">Gillet Test</a> was high when findings were reduced to a 2-point scale (PSIS remained neutral or moved <a id="cephalad" data-tip="1560" target="_blank" href="/glossary-term/cephalad" class="glossary">cranially</a>), and were still moderate when a 3-point scale was used (PSIS neutral, <a id="cephalad" data-tip="1559" target="_blank" href="/glossary-term/cephalad" class="glossary">cranial</a>, or <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a>) (169). Levangie et al. demonstrated that a positive <a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-stork-gillet-test" target="_blank" rel="noopener">Gillet Test</a> had a relatively high <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a> for low back pain (presumably related to SIJ <a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a>), but only weak association with PSIS height, and no correlation with standing forward flexion <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a>, sitting forward flexion <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a>, or supine-to-sit <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a> (170) Interestingly, Cibulka et al. demonstrated 82% <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>, 88% for <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a>, 86% positive predictive and 84% for negative <a id="predictive-values" data-tip="1738" target="_blank" href="/glossary-term/predictive-values" class="glossary">predictive value</a> for a combination of many of the same tests mentioned above, including the standing flexion <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a>, sitting posterior-superior iliac spine palpation, <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a> long-sitting <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a>, and <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> knee flexion <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a> (171). Considering the relatively high <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of the <a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-stork-gillet-test" target="_blank" rel="noopener">Gillet Test</a> and the relatively high <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of the tests investigated by Cibulka et al., it seems likely that these <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> are testing different phenomena correlated with SIJ dysfunction. An interesting study by Grieve et al. should have inspired further research. Grieve et al. demonstrated that a <a id="test-item-cluster" data-tip="1209" target="_blank" href="/glossary-term/test-item-cluster" class="glossary">test cluster</a> including the <a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-stork-gillet-test" target="_blank" rel="noopener">Gillet Test</a> revised by the author (alternate hip and knee flexion in supported standing), passive <a href="https://brookbushinstitute.com/video/goniometry-hip-internal-rotation-at-90-degree-of-hip-flexion-9090-hip-ir" target="_blank" rel="noopener">hip rotation ROM in </a><a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a> with 90&#xB0; of hip and knee flexion, and palpation of the <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> ligament of the symphysis pubis were <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> for identifying individuals referred by a physician who responded to SIJ manipulation in conjunction with education on living modification and a progressive walking program (172). What is interesting about this cluster is the use of the most <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> movement <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a>, a focus on identifying asymmetry, pain with palpation which research has demonstrated has high <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a> for other joints and correlation with the success of the implied treatment. These concepts and many of the same <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> were used in the cluster recommended below. These studies suggest that most SIJ movement <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> are likely unreliable and inaccurate alone; however, a cluster of <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> may be more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> and accurate. The <a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-stork-gillet-test" target="_blank" rel="noopener">Gillet Test</a> when constrained to 2 or 3 possible outcomes is likely the most <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> individual <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>. Further, based on the studies above, it may be reasonable to conclude that a movement cluster should focus on identifying asymmetrical stiffness and asymmetrical motion, with the intent of predicting best practice for improving stiffness and asymmetry.</p>
<table>
  <tbody>
    <tr>
      <td>
        <p><strong>Brookbush/Grieve (172) Recommended Cluster:</strong></p>
        <h4><strong>Assess:</strong></h4>
        <ul>
          <li><a href="https://brookbushinstitute.com/article/sign-clusters-compensation-patterns-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat </a><a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> (OHSA): Stiff SIJ on the side opposite of an <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-15-sign-clusters-asymmetrical-weight-shift" target="_blank" rel="noopener">asymmetrical shift with &quot;heel rise&quot;</a>
            <ul>
              <li>&quot;Top tier exam&quot; used to identify asymmetry and imply further SIJ assessment</li>
            </ul>
          </li>
          <li><a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">Unilateral</a> Pelvic Tilt: <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> tilted innominate correlated with stiffer side</li>
          <li><a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-stork-gillet-test" target="_blank" rel="noopener">Gillet Test</a>: Less motion on the stiffer side</li>
          <li><a href="https://brookbushinstitute.com/article/lower-body-goniometry" target="_blank" rel="noopener">Hip Rotation Range of Motion</a>: Less motion on the stiffer side</li>
        </ul>
        <h4><strong>Treat:</strong></h4>
        <ul>
          <li><a href="https://brookbushinstitute.com/article/joint-manipulation-lumbar-spine-sacroiliac-joint-and-pubic-symphysis" target="_blank" rel="noopener">Mobilize/Manipulate</a>: Stiff SIJ</li>
          <li><a href="https://brookbushinstitute.com/article/gluteus-maximus-activation" target="_blank" rel="noopener">Glute Activation</a>: <a id="mobility" data-tip="1457" target="_blank" href="/glossary-term/mobility" class="glossary">Mobile</a> Side</li>
        </ul>
      </td>
    </tr>
  </tbody>
</table>

<h3>SIJ Manipulations Improve Asymmetry</h3>
<p>Improving asymmetry may be the most well-supported benefit of SIJ manipulation. M&#xE9;ndez-S&#xE1;nchez et al. demonstrated that <a id="bilateral" data-tip="1552" target="_blank" href="/glossary-term/bilateral" class="glossary">bilateral</a> sacroiliac joint manipulation resulted in significant changes in forefoot and heel pressure in asymptomatic individuals (173). de Oliveira Grassi demonstrated a significant correlation between greater peak foot pressure on a force plate on the side of the stiff SIJ, and a reduction in total peak pressure following SIJ manipulation (174). Herzog et al. demonstrated that SIJ manipulation reduced low back pain and disability, and significantly changed foot contact forces during gait both early and late in the rehabilitation process (175). Robinson et al. demonstrated that SIJ manipulation improved gait symmetry, in those individuals who exhibited asymmetrical gait prior to manipulation (176). Zamanlou et al. demonstrated that sacroiliac joint manipulation significantly improved asymmetry and disability in a group of patients with assessed pelvic asymmetry; however, no significant differences were noted in lumbar ROM post-intervention (177). The studies by de Oliveira Grassi et al., Zamanlou et al. and Robinson et al. (174, 176, 177) may demonstrate an important point regarding the correlation between expected change and assessed impairment, noting that asymmetry was corrected in those individuals exhibiting asymmetry and lumbar ROM was not necessarily affected. Wojtowicz et al. demonstrated that <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> manipulation of the SIJ in healthy subjects altered gait parameters bilaterally, including longer steps and stride length, an increase in maximum midfoot pressure, and a decrease in heel pressure, all of which may imply an improvement in gait quality and economy (178). A prospective randomized study by Alveranga et al. demonstrated that spinal manipulation had a significant impact on symmetry when compared to controls, during static <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, squat, and vertical jump in a group of young healthy athletes (65). These two studies may suggest that SIJ manipulation for those with assessed SIJ stiffness may have an effect on the performance of daily tasks and sport. Stolinski et al. demonstrated that a single SIJ manipulation improved <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> symmetry in children as measured using the POTSI index (video technology) (179). Childs et al demonstrated that low back patients who received an SIJ manipulation exhibited better iliac crest and weight-bearing symmetry and that better symmetry was positively correlated with changes in pain scores at 3 - 4 day follow-up. The finding by Childs et al. correlating symmetry with pain is an important point validating the intent to improve symmetry as a treatment goal. A study Daly et al. further <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> the findings by Childs et al. (180), 23 of 100 consecutive pregnant patients with low back pain were selected based on strict criteria for sacroiliac joint dysfunction and randomized to treatment and control groups, 11 of whom were randomly assigned to a SIJ manipulation group (experimental), and 10 of the 11 exhibited no further signs of asymmetry or pain after treatment (181). Finally, an interesting doctoral dissertation by Bisset et al. demonstrated that SIJ manipulation increased hip internal rotation, but not external rotation, both immediately after and during 1-week follow-up in individuals with low back pain (182). These studies suggest that SIJ manipulation may have a positive effect on pelvic symmetry, hip ROM, and gait in those individuals with assessed impairment.</p>
<h3>SIJ Manipulation and Low Back Pain:</h3>
<p>Studies have also investigated the effect of SIJ manipulation on Low Back Pain. An RCT by Sipko et al. demonstrated that manipulation and self-mobilization increased pain pressure threshold (decreased pain) over the iliolumbar ligament and <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> in asymptomatic individuals (183). An RCT by Vaseghnia et al. investigating the effect of SIJ manipulation on low back pain, SIJ pain, and innominate tilt, demonstrated SIJ manipulation resulted in decreased pain (VAS scores), increased pain pressure threshold, and increased lumbar spine ROM, hip ROM, and active straight leg raise <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> ROM, both immediately following the technique and during a 24-hour follow-up (184). An RCT by Molins-Cubero et al. demonstrated that manipulation had a significant effect on low back pain, pain pressure <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>, mechanosensitivity of both SIJs when compared to sham, in a group of women with low back pain and primary dysmenorrhea (185). Ehrler et al. demonstrated that patients receiving manipulation with sequestered herniation reported significantly less leg pain and had a significantly larger proportion of improvement on other measures (186). In a retrospective case series, Lisi et al. demonstrated that of 17 cases of pregnant women with low back pain receiving chiropractic care (including manipulation), 16 cases demonstrated clinically important improvements, with an average decrease from 5.9 to 1.5 on a numeric pain rating scale (range 2 - 10), and an average time to important pain relief of 4.5 days, following 1.8 visits (range 0 - 13 days, and 1 - 5 visits, with no adverse events (187). In a study by Sasso et al., 69 patients with SIJ dysfunction were evaluated and treated with a structured physical therapy program, resulting in 95% rating their results as good or excellent during a 2-year follow-up (188). In a study by Shorki et al., patients with MRI-confirmed lumbar disc herniation received 5 sessions of manipulations for the sacroiliac joint and lumbar spine during a 2-week period, resulting in significant mean improvement in back and leg pain at the 5th session and 1-month follow-up (9). These studies demonstrate that even when SIJ manipulation is performed alone, it may be an effective treatment for low back and SIJ pain and dysfunction.</p>

<p>Several RCTs have been published attempting to compare various interventions to SIJ manipulation for the treatment of low back, SIJ, and knee pain. An RCT by Vaidya et al. demonstrated that the combination of SIJ manipulation and exercise was more effective than TENS and exercise for the treatment of pregnancy-induced <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> pelvic pain (189). In an RCT by Patel et al., 30 symptomatic subjects received short wave diathermy and exercise and were randomized to groups receiving either SIJ manipulation or <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> energy technique (MET). SIJ manipulation resulted in better outcomes at 1, 2, and 6-week <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> (190). An RCT by Visser et al. randomly allocated 51 SIJ patients with leg pain to conventional physiotherapy with a success rate of 3 out of 15 patients (20%), joint manipulation with a success rate of 13 of the 18 patients (72%), and intra-articular injection with a success rate of 9 out of 18 patients (50%), suggesting that manipulation may be the <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> intervention (191). An RCT by Kamali et al. compared SIJ manipulation and stabilization exercises for individuals with assessed SIJ dysfunction, demonstrating no significant difference between groups based on pain and the Oswestry Disability Index (ODI) (192). An interesting study by Herzog et al. demonstrated that back school resulted in better outcomes on clinical measures (pain, disability); however, manipulation resulted in better biomechanical outcome measures (193). An RCT by Behrangrad et al. demonstrated that ischemic <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> of the <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">vastus medialis obliquus (VMO)</a> resulted in better short-term and long-term benefits for the treatment of <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> patellofemoral pain syndrome than lumbopelvic manipulation (194). Although it is always problematic to compare modalities with varied intents on the basis of diagnosis alone, these studies suggest that SIJ manipulation is an effective treatment, and may be more effective than TENS, injections, and conventional physical therapy. The studies by Herzog. et al. and Behrangrad et al. (193, 194) may suggest that more consideration should be given to the <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a> of treatment effect and the outcome measures used by researchers, with the intent of comparing interventions less and understanding the best use for each individual intervention more.</p>
<p>Although manipulation has demonstrated <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> efficacy to many interventions, research continues to demonstrate the superiority of combining treatments. This includes the combination of manipulation techniques. Kamali et al. demonstrated that SIJ manipulation and lumbar manipulation was <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to lumbar manipulation alone, based on pain and ODI scores (195). Further, several studies have demonstrated the efficacy of combining SIJ manipulation and needling. Sun et al. demonstrated that the combination of acupuncture and manipulation was <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to either intervention alone, based on rates of resolution and improvement at 3-month follow-up (196). Sokunbi et al. demonstrated that the combination of manipulation, acupuncture, and exercise was more effective than only one or two of these treatment options (197). Zhou et al. demonstrated that the combination of dry needling and SIJ manipulation was more effective than traditional acupuncture and SIJ manipulation (198). Conversely, an RCT by Boff et al. demonstrated that the combination of myofascial <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> and manipulation was not more effective than manipulation alone for low back patients (199); however, this may be in part due to the application of myofascial <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> based on pre-determined muscles and not on <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>. In summary, these studies suggest that the combination of manipulation and needling is more effective than either technique alone. Dry needling may be <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to traditional acupuncture, and further research is needed on the combination of manipulation and manual <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> techniques.</p>
<p>Manipulation and exercise have demonstrated <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> efficacy to either technique alone in most studies. Sharma et al. demonstrated that the combination of manipulation and exercise was more effective than conventional physiotherapy exercises for the treatment of patients with low back pain and SIJ dysfunction (200). Wang et al. demonstrated that the combination of manipulation and &quot;<a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">subsystem</a> exercise therapy&quot; was <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to <a href="https://brookbushinstitute.com/article/posterior-oblique-subsystem-pos" target="_blank" rel="noopener">subsystem</a> exercise therapy alone by a relatively large margin, including large differences in strength, pain, and disability scores by the 3rd day and during a 3-month follow-up (201). Nemisto et al. demonstrated that manipulation, exercise, and physician consultation/education resulted in &quot;major recovery&quot; of 60% of patients compared to physician consultation/education alone which resulted in just 51% of patients reporting &quot;major recovery&quot; at 1-year follow-up (202). Despite this study strongly correlating psychosocial issues with failure to recover, the significant difference in recovery rate should be considered <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> for <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> treatment. An RCT by Frank et al. demonstrated that the patients who exhibited a loss of knee <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activation benefited more from a combination of lumbosacral manipulation and <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a> strengthening&#xA0;during a 6-week follow-up when compared to&#xA0;<a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a> strengthening alone (203). One study was found that suggested the combination of interventions was not more effective. An RCT by Nejati et al. demonstrated that there was no difference between manipulation, exercise, or the two modalities combined on patients with SIJ dysfunction during <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> immediately following treatment, during 12-week follow-up, or during 24-week follow-up (204). Although all groups improved, it is interesting to note that a lack of additional benefit from the combined intervention may be in part due to the exercise protocol already including a self-administered version of SIJ manipulation. In addition to strengthening, <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a>, and <a id="activation-technique" data-tip="1530" target="_blank" href="/glossary-term/activation-technique" class="glossary">activation exercises</a>, manipulation may also attenuate the benefits achieved from stretching. Cibulka et al. demonstrated that adding SIJ manipulation to therapy for hamstring <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strain that included moist heat and passive stretching resulted in a significant increase in hamstring peak <a id="torque" data-tip="1294" target="_blank" href="/glossary-term/torque" class="glossary">torque</a> during follow-up (205). This may suggest that SIJ manipulation is an effective addition to hamstring strain treatment, and perhaps that SIJ dysfunction is a contributing cause to hamstring strains. Further, Fox et al. demonstrated that manipulation and stretching may be more effective than stretching alone for increasing hamstring length in those with assessed ROM restriction (active straight leg raise) (206). These studies suggest that the combination of SIJ manipulation along with <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> strengthening or stretching techniques is likely to result in better outcomes.</p>

<p>A few studies have been published comparing manipulation techniques. Sutlive et al. demonstrated that both sacroiliac joint manipulation and rotational lumbar manipulation were equally effective for reducing low back pain and disability (ODI) during 48-hour follow-up (207). Kamali et al. demonstrated that the combination of SIJ manipulation and lumbar manipulation was <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to lumbar manipulation alone for reducing pain and disability (ODI) immediately following treatment, 48 hours post-treatment and at 1-month post-treatment (208). The study by Sutlive et al. may suggest that these manipulations have some overlapping effects; however, the study by Kamali et al. suggests that combining these manipulations may result in the best outcomes. Zhu et al. demonstrated that the short-lever manipulation (as taught in this course) resulted in larger decreases in pain and disability (ODI score) than long-lever manipulations (209). Based on the study findings it may be reasonable to conclude that although long-lever manipulations can be beneficial, the treatment itself is also more likely to cause some level of pain and inflammation. Shearer et al. compared mechanical manipulation using the &quot;Activator Adjusting Instrument&quot; to sacroiliac joint manipulation, demonstrating that both resulted in equal benefit for individuals with SIJ dysfunction (210). These findings are interesting as an RCT by Gorrell et al. demonstrated that the Activator was less effective than manual manipulation for the cervical spine (211). Based on these studies it may be reasonable to conclude that best practice for low back pain is short-lever manual SIJ manipulations in conjunction with manual lumbar manipulation; however, the Activator Adjusting Instrument may also be effective.</p>

<h4><strong>Hormones and Neurotransmitters</strong></h4>
<p>The systemic response to SIJ manipulation is similar to lumbar manipulation; in fact, many of the studies on lumbar and SIJ manipulation may be using the same technique but assuming motion of different segments based on the amount of spinal flexion or body position. Studies have started to investigate the effect of manipulations on <a id="hormone" data-tip="1268" target="_blank" href="/glossary-term/hormone" class="glossary">hormones</a> and other blood markers. An RCT by Molins-Cubero et al. demonstrated that manipulation had a significant effect on low back pain, pain pressure <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>, and mechanosensitivity of both SIJs, no effect on plasma levels of catecholamines or noradrenaline, but a significant effect on serotonin in a group of women with low back pain and primary dysmenorrhea (212). In an RCT by Kokjohn et al. side-lying manipulation resulted in a significant reduction in pain, level of menstrual distress, and a significant reduction in plasma levels of KDGPF2a in a group of women with primary dysmenorrhea; however, a similar, less significant decrease in KDGPF2a was also seen in the sham group (213). An RCT by Didehdar et al. demonstrated that spinal manipulation resulted in significant changes in brain metabolites when compared to baseline and a sham treatment group, including increases in N-acetyl aspartate in the thalamus, <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> cingulate cortex, insula, dorsolateral prefrontal cortex regions, increases in choline in the thalamus, insula, and somatosensory cortex regions, and glutamate and glutamine levels in the thalamus (214). These initial studies suggest that SIJ manipulation results in the <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> of various <a id="hormone" data-tip="1268" target="_blank" href="/glossary-term/hormone" class="glossary">hormones</a> and markers of <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a> response, which likely play a significant role in the body&apos;s immediate response to manipulation and any therapeutic effect that may follow. Further study is needed.</p>
<h4><strong>Reflex Activity</strong></h4>
<p>Studies have also demonstrated reflexive <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a> changes in response to SIJ manipulation. Studies have revealed that some of the changes are cortical, perhaps mirroring the results of the study by Didehdar et al. above (214). Lelic et al. demonstrated that a single session of manipulation to dysfunctional spinal segments in subclinical pain patients altered somatosensory processing at the cortical level (N30 amplitude), particularly within the prefrontal cortex (215). Haavik et al. demonstrated that spinal manipulation increased cortical <a id="excitability" data-tip="1310" target="_blank" href="/glossary-term/excitability" class="glossary">excitability</a>, as indicated by larger MEPmax for transcranial magnetic stimulation-induced input-output curves for both an upper and lower limb <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> with larger amplitudes of movement-related cortical potentials. Additionally, there were no changes in spinal measures (F-wave amplitudes) suggesting increases in strength following spinal manipulation are due to descending cortical drive and not spinal cord level changes (216). Similar to manipulation of other spinal segments, many studies have demonstrated attenuation of H-reflex. Suter et al. and Orakifar et al. demonstrated that SIJ manipulation had a transient effect on tibialis <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> H-reflex (217, 218). Azadvari et al. demonstrated that H-reflex amplitude to the tibialis <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> decreased following lumbosacral manipulation; however, had no significant effect on latency or M-wave amplitude (219). Niazi et al. demonstrated that manipulation resulted in increased maximal voluntary contraction (MVC) measured by EMG and force, increased V/M ratio, and a reduction in H-reflex threshold for the soleus <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> (220). An RCT by Murphy et al. demonstrated that sacroiliac joint manipulation resulted in a significant decrease in H-reflex of the <a id="ipsilateral" data-tip="1550" target="_blank" href="/glossary-term/ipsilateral" class="glossary">ipsilateral</a> leg, and no effect on H-reflex in the <a id="contralateral" data-tip="1549" target="_blank" href="/glossary-term/contralateral" class="glossary">contralateral</a> leg or sham groups. Further, the study was repeated with anesthetic cream over the SIJ to determine if the decrease in H-reflex was related to cutaneous afferent stimulation; the study results were similar suggesting cutaneous input does not contribute to H-reflex attenuation (221). Dishman et al. demonstrated that lumbar manipulation had a larger effect on the attenuation of <a href="https://brookbushinstitute.com/article/gastrocnemius-plantaris" target="_blank" rel="noopener">gastrocnemius</a> H-reflex than the side-lying loaded position used during set-up (81). These studies suggest that manipulation has a significant effect on cortical reflex, including an increase in descending cortical drive that may aid in attenuating <a id="motor-unit" data-tip="1303" target="_blank" href="/glossary-term/motor-unit" class="glossary">motor unit</a> recruitment. Further, a significant amount of research has been done on the effect of manipulation on H-reflex, suggesting that the decrease in H-reflex amplitude is transient, does not affect M-wave amplitude, is <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> to the lower extremity of the side manipulated, and is not simply the result of body position or cutaneous input.</p>
<h4><strong>Muscle Activity</strong></h4>
<p>Several studies have demonstrated that SIJ manipulation alters core <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity. Haavik et al. demonstrated that spinal manipulation on pregnant women in their second trimester resulted in increased levator hiatal area when compared to healthy non-pregnant controls, implying relaxation of the pelvic floor muscles due to pregnancy-related changes (222). de Almeida et al. demonstrated SIJ manipulation resulted in significant increases in phasic perineal contraction (PPC) and basal perineal <a id="tone" data-tip="1641" target="_blank" href="/glossary-term/tone" class="glossary">tonus</a> in healthy volunteers (223). The studies by Haavik et al. and Almeida et al. may contradict; however, they may also have assessed different pelvic floor muscles or demonstrated the effects of manipulation on pregnancy-related changes. Marshall et al. demonstrated that sacroiliac joint manipulation to the stiffer side resulted in a decrease in the latency of deep abdominal <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activation during a 6-month follow-up (224). And, Barbosa et al demonstrated that sacroiliac joint manipulation significantly increased <a href="https://brookbushinstitute.com/article/transverse-abdominis" target="_blank" rel="noopener">transverse abdominis</a> and <a href="https://brookbushinstitute.com/article/internal-obliques" target="_blank" rel="noopener">internal oblique</a> activity during upper extremity motion in individuals with assessed SIJ dysfunction (225). These studies demonstrate that SIJ manipulation has a significant effect on core <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity, likely optimizing recruitment via decreased latency and normalized activity.</p>
<p>Studies have also investigated the effect of lumbosacral manipulation on <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a> strength. Grindstaff et al. demonstrated that healthy individuals exhibited a small transient increase in <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a> force (3%) and activation (5%) immediately following lumbosacral manipulation, which was not present by a 20-minute follow-up (106). Suter et al. demonstrated that sacroiliac joint manipulation resulted in increased <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a> <a id="torque" data-tip="1294" target="_blank" href="/glossary-term/torque" class="glossary">torque</a> and <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activation of the <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a> in individuals with <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> knee pain, presumably from reducing inhibition, and then demonstrated the same findings using an RCT design the following year (226, 227). These findings are supported further by a dissertation by Sher et al., that used a blinded RCT design, demonstrating that chiropractic manipulation had a significant but transient effect on knee <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a> strength (228). However, the transient nature and small effect size demonstrated in these studies likely contributes to research demonstrating contradictory findings. An RCT by Sanders et al. demonstrated that lumbosacral manipulation did not improve <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a> strength in healthy asymptomatic individuals (237). It is likely reasonable to assume that SIJ manipulation can have a small effect on <a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a> <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment in individuals exhibiting signs of inhibition from pain, but the results may be transient and should be followed immediately by strengthening techniques. Results on asymptomatic patients may vary.</p>
<p>Studies have demonstrated changes in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity following SIJ manipulation that deserve further study. An RCT by Farazdaghi et al. demonstrated that SIJ manipulation did not affect <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> sway in static standing; however, there were increases in trembling and rambling velocity in the SIJ manipulation group which may imply an increase in neuromuscular activity (230). And, Pollard et al. demonstrated that both SIJ and upper cervical manipulation increased hip flexion ROM; however, upper cervical manipulation increased hip flexion more. Interestingly, a study by Pollard et al. done prior to this study demonstrated no changes in hip ROM following SIJ manipulation (231, 232). These studies likely imply that manipulation results in central <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a> changes that may have effects on global <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity. Based on current research, it seems likely that these CNS-mediated motor recruitment changes resulting from manipulation are related to reversing the inhibition resulting from pain, i.e. disinhibition.</p>

<p>The technique taught in this course is commonly observed in practice; however, there is almost no research on pubic motion or this technique. Garras et al. demonstrated that single-leg stance resulted in pubic motion of 1.4 mm of motion in men, 1.6 mm in nulliparous (never given birth) women, and 3.1 mm in multiparous women (233). Note these values are similar to the amount of motion described for the sacroiliac joint. Considering each innominate is one solid structure, the pubic symphysis and sacroiliac joint must move together, and similar motion may have been expected. An RCT by Hensel et al. demonstrated that pregnant women in their 3rd trimester benefited from an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> plan of care, including conventional physician care and 12 osteopathic techniques - including the shotgun pubic symphysis manipulation taught below. The <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> care plan resulted in significantly less low back pain than standard care, slower deterioration of low back pain function, no increase in the number of patients who experienced complications; however, there was no impact on outcome measures related to labor itself (234). Considering that the shotgun pubic symphysis manipulation was one of 12 techniques, it is impossible to determine the technique&apos;s contribution to the outcome. Although the amount of research on the pubic symphysis and manipulation is less than ideal, it may be reasonable to suggest that it supports the plausibility of its effective implementation.</p>
<p>In practice, pubic manipulation is most often attempted when SIJ dysfunction has been confirmed, and SIJ techniques alone do not completely resolve symptoms. However, certain symptoms may specifically indicate pubic manipulation. Subjective symptoms <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> to pubic symphysis dysfunction include <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor</a>/groin pain, feelings of <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor</a> tightness, <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a> tendonitis or pain, and symptoms similar to femoral acetabular impingement (FAI). Pubic symphysis <a id="caudal" data-tip="1557" target="_blank" href="/glossary-term/caudal" class="glossary">caudal</a> and <a id="cephalad" data-tip="1559" target="_blank" href="/glossary-term/cephalad" class="glossary">cranial</a> mobilizations may be used to aid in the <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of stiffness via palpation; however, this is a <a id="sensitivity" data-tip="1227" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitive</a> region for the patient, and the technique may have limited <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. In summary, research suggests that the effective inclusion of pubic symphysis shotgun manipulation is plausible; however, the limited amount of research results in reliance on clinical outcomes.</p>

Video Demonstration

<p><iframe src="https://player.vimeo.com/video/312177464" frameborder="0" allowfullscreen="allowfullscreen"></iframe></p>
<h4><strong>Patient and Practitioner set-up</strong></h4>
<ol>
  <li>The patient should be side-lying, facing the practitioner, with shoulders stacked, top leg flexed and bottom leg straight.</li>
  <li>The table should be low enough for the practitioner to comfortably reach over the patient and palpate the spinous process, as well as be able to lay their trunk over the trunk of the patient during the manipulation. The ability to use the weight of your trunk during this manipulation is almost mandatory, especially if the patient is considerably larger than you are.</li>
</ol>
<h4><strong>Passive Motion Assessment</strong></h4>
<ol>
  <li>Motion can be assessed using central or <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> to <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> lumbar mobilizations.
    <ul>
      <li>Note: this usually happens with the patient in <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> prior to this technique</li>
    </ul>
  </li>
  <li>During the set-up of this technique, the therapist may also notice that the spinous processes of two vertebrae move together during flexion, extension, or rotation, indicating stiffness of the facets between those segments.</li>
</ol>
<h4><strong>Lockout Position:</strong></h4>
<ol>
  <li>Place the fingertips of the hand closest to the patient&apos;s head over the spinous processes of the segment you wish to target with the manipulation.</li>
  <li>Place the knee of the patient&apos;s top leg in the crease under your <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> iliac spine (ASIS).</li>
  <li>Use your other hand and your ASIS, to move the patient&apos;s leg into hip flexion, to posteriorly tilt the pelvis, and flex the lumbar spine from the bottom up.</li>
  <li>Continue to flex the hip, until the lower vertebrae of the segment you are targeting starts to move. This indicates that you have &quot;locked-up&quot; all of the joints below that segment (ligamentous lock).</li>
  <li>Adjust the patient&apos;s bottom leg, top foot, and hip as needed to ensure you maintain ligamentous lock as you set the top knee on the table, turn slightly to face top half of the body and reset your ASIS to pin the top knee to the table and in position.</li>
  <li>Switching hands while successfully completing step 5 may be the trickiest step in this technique; carefully replace the fingers that were monitoring motion of the spinous process with the fingertips of the hand closest to the patient&apos;s feet.</li>
  <li>Using the hand closest to the patient&apos;s head, gently pull the bottom arm up and behind you to slowly rotate the patient&apos;s torso away from you. It may be helpful to cue the patient to allow their top shoulder to <a id="roll" data-tip="1602" target="_blank" href="/glossary-term/roll" class="glossary">roll</a> back as you pull the bottom arm forward and up.</li>
  <li>Continue to rotate the patient&apos;s torso until you feel the top vertebrae of the segment you are targeting start to move. This indicates &quot;facet lock&quot; of all the joints above this segment.</li>
  <li>Adjust the forearm of the arm closest to the patient&apos;s feet so that they are aligned over the patient&apos;s pelvis, and you feel you could use the friction between your forearm and the patient&apos;s pelvis to forcefully rotate it toward you.</li>
  <li>Place your other forearm over the patient&apos;s <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> <a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">pectoralis major</a>, slip your hand under their top arm, and hold your opposite wrist.</li>
  <li>Place your torso over your arms and adjust as needed to feel as though you are pressing and holding the patient in their end-range, i.e lock-out position.</li>
</ol>
<h4><strong>High-Velocity Thrust</strong></h4>
<p>Important Note: 90% of the manipulation technique is set-up. If you have not achieved lock-out in the previous steps, having great &quot;thrust technique&quot; will be rendered useless.</p>
<ol>
  <li>The motion is primarily toward the table, with the intent of rotating the spine. Most of the force is coming from the practitioner&apos;s body weight.</li>
  <li>Visualize the small, rapid motion (maybe 4 - 6&quot;&quot;.). You are trying to force &quot;one segment&quot; to rotate.</li>
  <li>Ensure the patient is not guarding.
    <ul>
      <li>Tip: have the patient take a deep breath or wiggle their toes. Your goal is to <a id="distraction" data-tip="1812" target="_blank" href="/glossary-term/distraction" class="glossary">distract</a> them so that they allow you to passively control their trunk with as little <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity as possible.</li>
    </ul>
  </li>
  <li>Quickly, thrust the patient into the new position by allowing a large portion of your body weight to depress into their torso while pulling back with the forearm on the pelvis, and pushing a bit forward and toward the table with forearm over the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> <a href="https://brookbushinstitute.com/article/pectoralis-major" target="_blank" rel="noopener">pectoralis major</a>. Again, you are depressing into the table with some intent to rotate. This generally takes a little practice before it can be performed at &quot;high velocity&quot;</li>
  <li>Slowly and gently <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> pressure, by standing up, tipping the patient back into side-lying, or gently performing physiological rotational mobilizations in side-lying to allow the patient a moment to &quot;catch their breath&quot;.</li>
</ol>

Lumbar Manipulation

<p><iframe src="https://player.vimeo.com/video/312189592" frameborder="0" allowfullscreen="allowfullscreen"></iframe></p>
<h4><strong>Patient and Practitioner set-up</strong></h4>
<ol>
  <li>The patient should be lying <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a>.</li>
  <li>The table should be low enough for the practitioner to press into the patient&apos;s opposite-side ASIS, with the practitioner&apos;s chest over the patient&apos;s torso and arm straight.</li>
</ol>
<h4><strong>Passive Motion Assessment</strong></h4>
<ol>
  <li>It is strongly recommended that the Brookbush/Grieve (172) Recommended Cluster is used to determine the side likely to be stiff.</li>
  <li>SIJ <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> to <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> mobilizations may be used as an additional <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> to confirm findings from the Brookbush/Grieve cluster.</li>
</ol>
<h4><strong>Lockout Position:</strong></h4>
<ol>
  <li>The patient is going to be asked to <a id="glide" data-tip="1815" target="_blank" href="/glossary-term/glide" class="glossary">slide</a> toward the practitioner on the table.</li>
  <li>The ankle closest to the opposite side of the table is going to be placed over the ankle closer to the practitioner, and the patient is side-bent away from the practitioner in &quot;smile away&quot; position.
    <ul>
      <li>This position theoretically &quot;lock&apos;s out&quot; or &quot;prepares&quot; the SIJ for manipulation from the bottom up. The torso is then rotated toward the practitioner to lock all of the segments above the SIJ.</li>
    </ul>
  </li>
  <li>The practitioner is then going to place the palm of the hand closest to the patient&apos;s feet, over the patient&apos;s opposite ASIS. It is important to attempt to use the softest part of the hand (inter-thenar groove) over a large area to reduce the amount of discomfort that can be felt from pressing directly into the ASIS</li>
  <li>The practitioner will then ask the patient to interlock their fingers and place their hands behind their head.
    <ul>
      <li>Note, it may be helpful if the patient chooses to interlace their fingers so that fingertips touch opposite hand web space, and not web space to web space. If the fingers are interlaced too far it may be impossible to <a id="glide" data-tip="1815" target="_blank" href="/glossary-term/glide" class="glossary">slide</a> the practitioner&apos;s arm through the arm and forearm of the patient.</li>
    </ul>
  </li>
  <li>The practitioner will then <a id="glide" data-tip="1815" target="_blank" href="/glossary-term/glide" class="glossary">slide</a> the hand closest to the patient&apos;s head, over the patient&apos;s arm closest to the opposite side of the table, and back through the gap between their arm and forearm, so that the back of the practitioner&apos;s hand lies on the patient&apos;s sternum. (This feels a little awkward at first, but it makes lock-out position more comfortable)</li>
  <li>Maintaining pressure over the ASIS, the practitioner will then rotate the patient&apos;s torso toward them, until any further rotation causes the patient&apos;s pelvis to press firmly into the practitioner&apos;s palm.
    <ul>
      <li>Note: At this point the practitioner&apos;s arm closest to the patient&apos;s head should be near straight and it may be possible to <a id="glide" data-tip="1815" target="_blank" href="/glossary-term/glide" class="glossary">slide</a> the practitioner&apos;s arm further through the patient&apos;s arm, and actually grab the side of the table to stabilize during the thrust portion of the technique.</li>
    </ul>
  </li>
  <li>Once, end-range rotation is reached, with the smile-away position of the body maintained, lock-out position has been achieved.</li>
</ol>
<h4><strong>High-Velocity Thrust</strong></h4>
<p>Important Note: 90% of the manipulation technique is set-up. If you have not achieved lock-out in the previous steps, having great &quot;thrust technique&quot; will be rendered useless.</p>
<ol>
  <li>The manipulation comes primarily from using the weight of the torso to press firmly into the ASIS with the straight arm, down toward the table. The arm that was used to rotate that torso must maintain that rotation; it may be necessary for the practitioner to simultaneously add a little force pulling the patient&apos;s torso toward them if they cannot hold onto the table for extra <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a>.</li>
  <li>Visualize the small, rapid motion (maybe 3 - 5&quot;.). The practitioner is trying to force the ilium to rotate or <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> on the sacrum.</li>
  <li>Ensure the patient is not guarding.
    <ul>
      <li>Tip: have the patient take a deep breath or wiggle their toes. The goal is to ensure that patient allows you to passively press through the resistance barrier created by the stiff joint.</li>
    </ul>
  </li>
  <li>Quickly, thrust the patient into the new position, attempting to use body-weight and not arm strength.</li>
  <li>Slowly and gently <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> pressure, by standing up, tipping the patient back into <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a>, and giving the patient a minute to &quot;catch their breath&quot;.</li>
</ol>

Sacroiliac Joint Chicago Technique Manipulation

<p><iframe src="https://player.vimeo.com/video/313285699" frameborder="0" allowfullscreen="allowfullscreen"></iframe></p>
<h4><strong>Patient and Practitioner set-up</strong></h4>
<ol>
  <li>The patient is <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">supine</a> in hook-lying (knees bent) position.</li>
  <li>The table should be high enough for the practitioner to comfortably place their forearm between the patient&apos;s knees.</li>
</ol>
<h4><strong>Passive Motion Assessment</strong></h4>
<ol>
  <li>Often pubic manipulation is attempted when SIJ dysfunction has been confirmed and SIJ techniques alone do not completely resolve symptoms.</li>
  <li>Subjective symptoms for pubic symphysis dysfunction may include <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor</a>/groin pain, feeling of <a href="https://brookbushinstitute.com/article/adductors" target="_blank" rel="noopener">adductor</a> tightness, <a href="https://brookbushinstitute.com/article/rectus-abdominis-pyramidalis" target="_blank" rel="noopener">rectus abdominis</a> tendonitis or pain, and symptoms similar to femoral acetabular impingement (FAI).</li>
  <li>Pubic symphysis <a id="caudal" data-tip="1557" target="_blank" href="/glossary-term/caudal" class="glossary">caudal</a> and <a id="cephalad" data-tip="1559" target="_blank" href="/glossary-term/cephalad" class="glossary">cranial</a> mobilization may also be used to &quot;assess&quot; stiffness via palpation, but obviously, this is a <a id="sensitivity" data-tip="1227" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitive</a> region for the patient and the technique may have limited <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>.</li>
</ol>
<h4><strong>Lockout Position:</strong></h4>
<p>You may notice that this technique is quite different from the other techniques included in the manipulations courses. That is because this is actually a <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> energy technique (MET) that often results in cavitation, and although not a true manipulation is the closest approximation of a manipulation available for this joint.</p>
<ol>
  <li>The patient is asked to isometrically abduct bilaterally in hook-lying position against practitioner resistance, 3 times for 3 - 5 seconds.</li>
  <li>There are several methods for applying resistance, but the Brookbush Institute prefers sequentially wider contraction, starting with knees together, then knees approximately 12&quot; apart, and then knees wide enough to allow the practitioner&apos;s forearm to fit length-wise between them.</li>
  <li>After the last isometric hold, the practitioner will slip their forearm between the patient&apos;s knees, with palm against the knee on one side and soft part of the arm above the elbow against the knee on the other side.</li>
  <li>The practitioner then immediately cues the patient to adduct against the patient&apos;s arm.
    <ul>
      <li>This should occur quickly, with a goal of immediately following the isometric abduction with a near-maximal isometric contraction of the adductors. The contraction of the adductors should <a id="distraction" data-tip="1812" target="_blank" href="/glossary-term/distraction" class="glossary">distract</a> the pubic symphysis, allowing the two sides of the pubis to &quot;realign&quot;, and an audible pop may occur. Note, as with all manipulations an audible cavitation is not necessary for the technique to be effective.</li>
    </ul>
  </li>
</ol>
<h4><strong>High-Velocity Thrust</strong></h4>
<ol>
  <li>Although the technique above does not often require a high-velocity thrust, a thrust may be added.</li>
  <li>If the same protocol above is followed, but the last step is replaced by placing both forearms between the knees with palms on <a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">medial</a> condyles, the practitioner can add a quick thrust into abduction as the patient is maximally adducting.</li>
  <li>The amount of motion is the same as other manipulations, relatively small and rapid (maybe 4 - 6&quot;).</li>
</ol>

Shotgun Manipulation (Pubic Symphysis)

Bibliography

<p>© 2019 Brent Brookbush</p>
<p>Questions, comments and critiques welcomed and encouraged</p>

Copyright

A-Band - Refers to the part of the muscle cell that looks darker under a microscope.  This area of the cell is darker due to parallel arrangement of thicker filaments (myosin) and overlap with the thinner filaments (actin).
<ul>
 	<li>As a muscle contracts, the A-band is where actin and myosin interact.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

<strong>Accuracy</strong> - the proportion of individuals correctly identified by the test results.
<ul>
 	<li>For example, a special test with perfect accuracy would imply a test has 100% specificity, 100% sensitivity, 100% positive predictive value and 100% negative predictive values.</li>
</ul>

Action Potential - A rapid change in voltage, resulting in a wave of excitation, that may result in stimulation of a nerve or muscle cell.
<ul>
 	<li>In order for an action potential to be initiated, the resting membrane voltage must exceed the excitation threshold, which then results in a cascade of depolarization and the "wave of excitation." Any stimulus below that threshold will not result in an action potential, and a stimulus greater than the threshold will not increase a single action potential, but may result in additional action potentials.  In this way, the action potential functions more like an on/off switch (all or none), and less like a dimmer switch.</li>
</ul>

A single-joint movement pattern (most often) designed to load a specific under-active muscle(s), while minimizing the contribution of over-active synergists via specific cues/joint motions.
<ul>
 	<li style="text-align: left;">Activation techniques/exercises are performed with the intent of addressing a muscle exhibiting a reduction in activity (tone) as a result of, or contributing to postural dysfunction.</li>
 	<li style="text-align: left;">Activation techniques/exercises cannot be multi-joint movement patterns due to relative flexibility, altered reciprocal inhibition, and synergistic dominance resulting in compensation patterns.</li>
</ul>
Example, <a href="https://brentbrookbush.com/articles/corrective-exercise-articles/activation/gluteus-medius-activation-progression/" target="_blank">gluteus medius activation</a> involves resisted hip abduction while minimizing the contribution of the TFL via hip extension.

Active stretching is a term used to describe a stretch that involves an active contraction of opposing musculature to lengthen a muscle to its end range. Generally these stretches are held for 2-5 seconds and repeated for 8-15 repetitions.

<strong>Adenosine triphosphatase (ATPase):</strong> is the enzyme responsible for catalyzing (initiating and accelerating) the decomposition of ATP to ADP.
<ul>
 	<li>This dephosphorylation (breakdown) reaction releases energy for processes like muscular contraction.</li>
</ul>

<b>Adenosine triphosphate (ATP): </b>The molecule that functions as a universal energy-transfer molecule, providing most of the energy associated with muscular contraction and human movement. ATP is composed of an adenine group, a ribose group, and three molecules of inorganic phosphates.
<ul>
 	<li>Energy is provided when hydrolysis results in the cleaving of a phophate group; resulting in adenosine diphosphate, an inorganigic phosphate group, and energy.</li>
</ul>

<strong>Algometry</strong> - measuring the amount of pressure to result in sensitivity or pain, using an algometer.
<ul>
 	<li>Generally, research uses algometry to establish a minimum pain pressure threshold (PPT), in which a lower PPT implies more sensitivity and pain, and a higher PPT implies less sensitivity and pain. PPT is a common outcome measure in trigger point research.</li>
</ul>
<a href="https://brentbrookbush.com/wp-content/uploads/2019/07/Algometer.jpg"><img class="aligncenter  wp-image-140177" src="https://brentbrookbush.com/wp-content/uploads/2019/07/Algometer.jpg" alt="Image of an Algometer" width="500" height="333" /></a>

<span class="_Tgc"><b>All-or-none</b> <b>principle</b> - a nerve or muscle cell's response to a stimulus is independent of the strength of the stimulus. If that stimulus exceeds the threshold potential (threshold of an action potential), the nerve or muscle fiber will respond completely; otherwise, there is no response.</span>

Example, when a motor unit in the biceps brachii is stimulated it contracts the same way whether a 10 lb or 50 lb dumbbell is lifted.  It is actually the number of muscle cells and the size of the motor unit that determines force output.

&nbsp;

The transition period between eccentric load and concentric contraction during a repetition of an exercise.  This term is most often used in reference to power/plyometric exercises, in which a shorter amortization phase is believed to be beneficial.  The shorter amortization phase may better use the stored energy from the elastic deformation of connective tissue and enhance synchronization of myotatic (stretch) reflex with maximum voluntary contraction.

Example, the athlete was cued to spend as little time as possible in the bottom of their squat stance (the amortization phase) during a set of box jumps.

Muscles that oppose the prime mover and synergists for a given joint action.

That is, all the muscles that can perform the opposing joint action.

Example: The triceps and anconeus are antagonists during elbow flexion.

An anatomical direction; toward the front

Example, the face is on the <em>anterior</em> aspect of the head

<strong>Appendicular Skeleton</strong> - referring to the bones the bones of the arms and legs, as well as the bones that support them. This includes the pelvis, clavicle and scapula. There are approximately 126 bones in the appendicular skeleton.
<ul>
 	<li>Etymology - Appendicular, as in appendage, "that which is appended to something as a proper part," 1640s, from <a class="crossreference" href="https://www.etymonline.com/word/append?ref=etymonline_crossreference">append</a> + <a class="crossreference" href="https://www.etymonline.com/word/-age?ref=etymonline_crossreference">-age</a>. - <a href="https://www.etymonline.com/word/appendage" target="_blank" rel="noopener">Etymology Online</a></li>
</ul>
"Appendicular skeleton" is a label referring to a set of bones whose function is distinct from the bones of the "<a href="https://brentbrookbush.com/glossary/axial-skeleton/" target="_blank" rel="noopener">axial skeleton</a>".

A reflexive decrease in muscle activity due to joint dyskinesis.
For example, a reduction in deep cervical flexor activity as a result of cervical spine dyskinesis.

<strong>Arthrokinematic Motion</strong> - Small amplitude motions between bone surfaces at a joint.  The arthrokinematic motions are roll, glide (slide or translation), spin, compression and distraction (traction). Arthrokinematic motions accompany osteokinematic motions to maintain joint congruence.
<ul>
 	<li>Example, arthrokinematic motion of the talus includes posterior glide on the tibia during ankle dorsiflexion.</li>
</ul>
Synonyms include: arthrokinematics, passive accessory motion, joint play and component motion

&nbsp;

<strong>Assessment</strong><em> -</em> is the act of assessing, i.e. determining the importance, size, or value of -

In most cases, the results of an assessment are compared to normative data. If the individual exhibits values that are within normal parameters, it may be assumed that the aspect of health or motion assessed is not contributing to the patient's complaint, symptoms or movement impairment. If the results fall outside of normal parameters, it may indicate that the aspect of health or motion assessed is contributing to, or being affected by the patient/client's complaint, symptoms, or movement impairment. In some cases, the results of an assessment are compared to an "ideal model." In this case, deviations from the ideal are noted as potential issues. For example, deviations noted in the <a title="Introduction to the Overhead Squat Assessment" href="https://brentbrookbush.com/online-courses/articles/assessment/introduction-overhead-squat-assessment/" target="_blank">Overhead Squat Assessment</a> are compared to an "ideal model" of posture and motion.

Assessments used by human movement professionals can be divided into three broad categories:
<ul>
 	<li><strong>"Clear" the Patient/Client for Intervention</strong> - These are tests, assessments and evaluations used to determine if a patient/client's issue may improve given the assessing professional's scope, skills, abilities and willingness to treat that individual.
<ul>
 	<li>For example, many of the special tests used in orthopedic medicine assist in determining the level of pathology or likelihood of a particular diagnosis. Certain issues and diagnoses are beyond the scope of the human movement professional, and are better treated by diagnostic professionals in the medical community (physicians, podiatrists, surgeons, etc.). A <em>Calf Squeeze (Thompson) Test</em> is one example, in which a positive sign may indicate a rupture of the Achilles tendon that may be better treated via surgical intervention.</li>
</ul>
</li>
 	<li><strong>Highlight Contraindications - </strong>Tests, assessments and evaluations used to stratify risk or preclude a professional from addressing certain tissues, motions or using a particular technique.
<ul>
 	<li>For example, the Vertebral Artery Test (VBI) is often used to determine if high velocity thrust mobilizations (manipulations) are safe for a patient with cervical dysfunction.</li>
</ul>
</li>
 	<li><strong>Refine Exercise/Intervention Selection</strong>: Tests, assessments and evaluations used to assist the professional in determining which techniques, modalities and exercises will best address a patient/client's complaints or desired goals.
<ul>
 	<li>Most movement assessments fall into this category. For example, a positive <a href="https://brentbrookbush.com/vimeo_videos/elys-test-rectus-femoris-flexibility-assessment/" target="_blank">Ely's Test</a> may indicate a need to release and/or lengthen the <a href="https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/rectus-femoris/" target="_blank">rectus femoris</a>.</li>
</ul>
</li>
</ul>
Note: An assessment, or assessment result, may fall into more than one category. For example, although goniometry is an assessment most often used to <em>Refine Exercise/Intervention Selection</em>, if a range of motion is significantly altered, with an abnormal end-feel, and/or causes the patient or client/pain, the individual may need to be referred to a physician for further testing and <em>Clearance</em> to resume rehab activities.  Further, that same patient may return to the human movement professional with a list of <em>Contraindicated Activities</em> from the physician. - <em>"When in doubt, refer out!"</em>

<strong>Axial Skeleton</strong> - referring to the bones of the head, neck, trunk and spinal column (does not include pelvis). There are approximately 80 bones in the axial skeleton.
<ul>
 	<li>Etymology - Axial, as in "axis", referring to "imaginary motionless straight line around which a body (such as the Earth) rotates," from Latin <span class="foreign">axis</span> "axle, pivot, axis of the earth or sky" - <a href="https://www.etymonline.com/word/axis" target="_blank" rel="noopener">Etymology Online</a></li>
</ul>
"Axial skeleton" is a label referring to a set of bones whose function is distinct from the bones of the "<a href="https://brentbrookbush.com/glossary/appendicular-skeleton/" target="_blank" rel="noopener">appendicular skeleton</a>".

<strong>Balance</strong> - The ability to maintain a body’s center of mass over its base of support. Balance can be static or dynamic.
<ul>
 	<li>For example, maintaining balance is harder on one leg because the center of mass must stay over a much smaller base of support.</li>
</ul>

A ball and socket joint (also called a spheroid joint or spheroidal joint) is a synovial joint in which the rounded or spherical end of one bone fits into a cup-like depression of another bone. The distal bone is capable of motion around an indefinite number of axes, which have one common center. Examples include the hip and shoulder (glenohumeral joint)

<strong>Base of support (BoS)</strong> - refers to the area beneath an object or person, and the area within the perimeter created by every point of contact that the object or person makes with the supporting surface. This may include the <a href="https://brentbrookbush.com/articles/anatomy-articles/muscular-anatomy/gluteus-maximus/" target="_blank" rel="noopener">glutes</a> of someone sitting on a chair, or the back of someone leaning against a wall.
<ul>
 	<li>For example, during a single leg balance the BoS is the area of the foot in contact with the surface; however, when a person is standing on two feet, the BoS is the area of both feet and the surface between them.</li>
</ul>

Pertaining to both sides

Example, bilateral rows are performed with both arms at the same time.

<strong>Case-control Study</strong> - a particular form of retrospective study that samples a matched group of people who have, and do not have the outcome being studied. A case-control study is a quasi-experimental design, often used in medicine to aid in determining potential contributing factors (cannot determine causality). In this study type exposure is the dependent variable and outcome is independent.
<ul>
 	<li>Example, in this retrospective case-control, medical records were investigated for trends correlated with cervical pain (1).
<ol>
 	<li>Mäkela, M., Heliövaara, M., Sievers, K., Impivaara, O., Knekt, P., &amp; Aromaa, A. (1991). Prevalence, determinants, and consequences of chronic neck pain in Finland. <i>American journal of epidemiology</i>, <i>134</i>(11), 1356-1367.</li>
</ol>
</li>
</ul>

An anatomical direction; toward the tail, relative to humans this term is often used to refer to "in the direction of the tale (toward the feet)".

Example, to release the trapezius muscle the therapist used a force directed<em> caudally</em>.

<strong>Center of mass (CoM)</strong> - an object's mean position of mass; that is, a point that is perfectly surrounded by an equal amount mass in all directions.

<b>Center of gravity (CoG)</b> - point where <b>gravity</b> appears to act. Since the human body is so small compared to the earth, we can assume gravity acts uniformly on the body, and that CoG and CoM are the same.
<ul>
 	<li>Example, the CoM of the human body while lying down or standing straight up is close to our navel. However, it is possible that during a resistance exercise, the combination of the body's weight and the weight of the resistance will place the combined CoM outside the body. For example, during the mid-portion of a <a href="https://brentbrookbush.com/vimeo_videos/back-squat/" target="_blank" rel="noopener">back squat</a> the CoM would be several anterior to the naval.</li>
</ul>

An anatomical direction; toward the head (synonym: cranial)

Example, hip pain was felt with any force directed <em>cephalad</em>.

<strong>Cohort Study</strong> - a particular form of longitudinal study that samples a cohort (a group of people who share a defining characteristic), performing a cross-section at intervals through-out a period of time. A cohort study is a quasi-experimental design often used in medicine to aid in determining etiology or a cause-and-effect relationship. In this study type exposure is the independent variable and outcome is dependent.
<ul>
 	<li>Example, the study by Cholewicki et al. (1) investigated Yale Varsity Athletes (the cohort) with 2 and 3 year follow up (longitudinal design) and found that trunk muscle response time to off-loading was predictive of future low back injury.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/core/increased-trunk-muscle-latency-may-cause-rather-than-result-from-low-back-pain/" target="_blank" rel="noopener noreferrer">Cholewicki, J., Silfies, S., Shah, R., Greene, H., Reeves, N. Alvi, K., Goldberg, B. (2005). Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 30(23), 2614-2620</a></li>
</ol>

<strong>Comparable Sign:</strong> A combination of pain, stiffness and/or spasm during examination that is comparable to the patients symptoms.
<ul>
 	<li>One common error made during evaluation with special tests is attention given to any discomfort or pain, rather than attempting to identify the pain/discomfort related to the patient's complaint (concordant/comparable sign). Many special tests purposefully test tissue limits and are at least mildly uncomfortable in every individual. Basing your assessment on positive tests that resulted in "concordant/comparable signs" will improve your chances of arriving at the correct diagnosis.</li>
</ul>

An alternative movement pattern that has been adopted to compensate for dysfunction/impairment in the human movement system.
Example: A lack of calf extensibility may limit dorsiflexion, leading to the knees bowing inward (functional valgus) and excessive forward lean of the torso during a squat.

An arthrokinematic motion - the approximation of joint surfaces; that is, a force that directs one bone surface into another resulting in a reduction in intra-articular volume. Although widely thought of as a "destructive force", it is likely best to consider compression as a naturally occurring, stabilizing force. Any arthrokinematic force in excess (spin, glide, roll, traction) may be viewed as potentially deleterious.

For example, during a squat the femoral head is compressed into the acetabulum by muscular forces, bodyweight and any additional external load.

<strong>Concave (Concavity)</strong> - Having an outline or surface curved like the interior surface of a bowl or sphere - to cave-in or curve inward.
<ul>
 	<li>Example, the internal surfaces of the pelvis is concave, holding some of the bodies viscera.</li>
</ul>

<strong>Concordant Sign</strong> - The patient's specific pain, symptom or complaint.<span style="color: #ff0000;"> </span>
<ul>
 	<li>One common error made during evaluation with special tests is attention given to any discomfort or pain, rather than attempting to identify the pain/discomfort related to the patient's complaint (concordant/comparable sign). Many special tests purposefully test tissue limits and are at least mildly uncomfortable in every individual. Basing your assessment on positive tests that resulted in "concordant/comparable signs" will improve your chances of arriving at the correct diagnosis.</li>
</ul>

<strong>Conductivity</strong>: Stimulation results in more than a local effect (1).
<ul>
 	<li>For example, in a muscle cell the stimulation of a motor endplate results in a change in cell membrane polarity that rapidly propagates (is conducted) along the entire length of the muscle cell, stimulating all sacromere.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

A condyloid joint (also called condylar, bicondylar, ellipsoid, or ellipsoidal) is an ovoid articular surface, or condyle, that is received into an elliptical cavity.  These joints permit movement in two planes.  Examples include the knee, metacarpophalangeal joints and metatarsophalangeal joints.

Connective Tissue Cell - One of the four basic types of animal tissue, consisting mostly fibers and ground substance.  These cells are specialized to binds organs together, holds them in place, protect them from external forces, and may fill space in the body's cavities.

Example, the body's muscles are enclosed in durable connective tissue sheets known as the "epimysium", "perimysium", and "endomysium," which and in support and transmitting force.
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

<strong>Contractility: </strong>The ability to shorten (1).
<ul>
 	<li><strong>Contractility</strong>: Muscle cells are unique in the amount they can shorten when stimulated; this is this largerly due to the highly organized and unique arrangement of myofilaments (actin and myosin).</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Pertaining to the opposite side

Example, the external oblique muscle performs contralateral rotation; rotation to the opposite side.

<strong>Convex (Convexity)</strong> - Having an outline or surface curved like the exterior of a circle or sphere - to bulge or curve outward.
<ul>
 	<li>Example, the top of your head is shaped by the convex exterior surface of your skull.</li>
</ul>

<strong>Correlational Research</strong> - Non-experimental <a href="https://www.questionpro.com/blog/what-is-research/">research</a> method in which the statistical relationship between two variables is investigated.
<ul>
 	<li>In this research by Kwon et al., a correlation was noted between a decrease in extensibility during a hamstring length test (goniometry) and current knee pain (1).</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/correlation-patellofemoral-pain-syndrome-pfps-hamstring-activity/" target="_blank" rel="noopener">Kwon O, Yun M, and Lee W. (2014). Correlation between intrinsic patellofemoral pain syndrome in young adults and lower extremity biomechanics. <em>J. Phys. Ther. Sci. </em>26: 961-964</a></li>
</ol>

<strong>Counter-nutation</strong> - posterior rotation of sacrum relative to ilium, and/or anterior rotation of ilium relative to sacrum.
<ul>
 	<li>The pelvic floor muscles are examples of muscle that may counter-nutate the sacrum.</li>
</ul>
[caption id="attachment_126335" align="aligncenter" width="400"]<a href="https://brentbrookbush.com/wp-content/uploads/2018/10/Nutation.png"><img class=" wp-image-126335" src="https://brentbrookbush.com/wp-content/uploads/2018/10/Nutation.png" alt="Nutation and Counter-nutation of the Sacroiliac Joint" width="400" height="967" /></a> Nutation and Counter-nutation of the Sacroiliac Joint[/caption]

&nbsp;

<strong>Crossover (Study) Design</strong> - A type of longitudinal, repeated measures quasi-experimental design in which each group receives both treatments, but at different times. It is named "crossover" due to the patients "crossing-over" to the other treatment or sham group after a specified period of time.
<ul>
 	<li>This type of study has the advantage of every individual serving as their own control, which may reduce the influence of confounding variables.</li>
 	<li>Unfortunately, the design itself introduces the chances that anyone receiving the experimental variable in the first period will continue to be effected in the second period.</li>
</ul>
In a study by Senna et al., a cross-over design was used to investigate the difference load made on inter-set rest intervals (1).
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/strength-training-research-corner/heavy-vs-light-load-single-joint-exercise-performance-with-different-rest-periods/" target="_blank" rel="noopener">Senna, G.W., Rodrigues, B.M., Sandy, Scudese, Bianco, A, &amp; Dantas, E.H.M. (2017). Heavy vs light load single-joint exercise performance with different intervals. <em>Journal of Human Kinetics, 58, 197-206.</em> </a></li>
</ol>

Cross-sectional Study - a research design that involves gathering data from a population or representative subset at a specific point in time.
<ul>
 	<li>Example, the study by Karimi-Mobarake et al.(1) investigated the prevalence of genu varum and genu valgum among school children 7-11 years old in Iran.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/low-prevalence-of-genu-varum-and-valgum-among-elementary-school-children/" target="_blank" rel="noopener noreferrer">Karimi-Mobarake, M., Kashefipour, A., Yousfnejad, Z. The prevalence of genu varum and genu valgum in primary school children in Iran 2003-2004. (2005) <em>Journal of Medical Science</em> 5(1). 52-54</a></li>
</ol>

<strong>Cytokine</strong> - A broad and loose category of small proteins that act through receptors, and are especially important to immune function (inflammation).
<ul>
 	<li>Cytokines include substances such as interferon, interleukin, and growth factors, which are secreted by certain cells of the immune system and have an effect on other cells. Their definite distinction from hormones is a topic of continued research.</li>
</ul>
&nbsp;

Dependent variable - in research, this is the variable that is changed by the independent variable, most often this is the "outcome" of the study.
<ul>
 	<li>Example, in the study by Cleland et al. (1), the independent variable is "thoracic manipulation," and the dependent variable is "lower trapezius muscle strength."</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/short-term-effects-lower-thoracic-manipulation-lower-trapezius-muscle-strength/" target="_blank" rel="noopener noreferrer">Cleland J, Selleck B, Stowell T, Brown L, Alberini S, St. Cyr H, Caron T. Short-term Effects of Thoracic Manipulation on Lower Trapezius Muscle Strength. <em> Journal of Manual &amp; Manipulative Therapy</em>. 2004; 12(2): 82-90</a></li>
</ol>

An anatomical direction; further from the trunk or center of the body

Example, the foot is at the <em>distal</em> end of the leg.

An arthrokinematic motion - a <span class="_Tgc">force applied to a body part that may result in the separation of joint surfaces, a reduction in intra-articular pressure, and/or an increase in intra-articlar space.</span>

For example, to hang from one's hands (i.g. in preparation for a pull-up) results in a traction force on the glenohumeral joint (shoulder).

An anatomical term of location; back or upper surface

Example, shoe laces may compress tissues on the <em>dorsal</em> surface of the foot

The "drawing-in" maneuver is a common cue used during exercise and rehabilitation programs. A light contraction of the <a href="https://brentbrookbush.com/articles/muscular-anatomy/transverse-abdominis/" target="_blank" rel="noopener">transverse abominis</a> (and potentially the entire <a href="https://brentbrookbush.com/articles/corrective-exercise-articles/core-subsystems/intrinsic-stabilization-subsystem/" target="_blank" rel="noopener">intrinsic stabilization subsystem</a>) achieved by gently pulling the lower abdominal region away from one's waist band. This should have minimal effect on breathing, and should not be confused with a maximal contraction of the <a href="https://brentbrookbush.com/articles/muscular-anatomy/transverse-abdominis/" target="_blank" rel="noopener">transverse abdominis</a> resulting in a "vacuum pose".
<ul>
 	<li>Research often refers to this maneuver as the "abdominal drawing-in maneuver"; abbreviated ADIM.</li>
</ul>
Development and introduction of this cue into practice is based on the pivotal research and resulting text:
<ol>
 	<li>Carolyn Richardson, Paul Hodges, Julie Hides. Therapeutic Exercise for Lumbo Pelvic Stabilization – A Motor Control Approach for the Treatment and Prevention of Low Back Pain: 2nd Edition (c) Elsevier Limited, 2004</li>
</ol>

Faulty or abnormal movement; an<span class="_Tgc"> alteration of normal kinematics.</span>

For example, joint stiffness or a reduction in arthrokinematics motion that results in limited osteokinematic range of motion - inadequate inferior glide of the femoral head resulting in limited abduction of the hip.

The seeping into, or abnormal collection of fluid in a body cavity.

For example, knee effusion describes swelling within the knee joint.

Note: the word "effusion" is used differently in medicine than it is used in reference to the movement (seeping out) of liquids and gases, for example in chemistry.

&nbsp;

A trait of body tissues that allows a tissue to return to its resting length or state after deformation or stretch.
Example:  Muscle is elastic tissue; many muscles will return to their resting length after being stretched to 150% of that length without any appreciable change in tissue quality.

<strong>Elasticity</strong>: Elasticity refers to the ability of a cell to return to its resting length after being stretched/lengthened.
<ul>
 	<li>Note: this term is often confused with extensibility. Elasticity is not the ability to stretch; it is the ability to return to normal length after being stretched. Muscle tissue, connective tissue and even nerve tissue have varying levels of elasticity.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Epithelial cell - One of the four basic cell types, found lining the body's cavities, blood vessels, organs and constitutes most gland tissue.  These cells are specialized to aid with absorption, secretion, or act as a barrier from foreign objects.
<ol>
 	<li>Saladin, K. S., &amp; Miller, L. (1998). <i>Anatomy &amp; physiology</i>. New York (NY): WCB/McGraw-Hill.</li>
</ol>

<strong>Equilibrium</strong> - a state in which opposing forces or influences are balanced.
<ul>
 	<li>For example, to maintain a neutral trunk while pushing or pulling a weight in one hand, your core musculature must balance the force by creating an equal amount of force in the opposite direction.</li>
</ul>

The study of causation, or origination. The word is commonly used in the medical professions, where it may refer to the study of why things occur, or the reason behind why things act a certain way.

For example, the etiology of low back pain is a complex subject, with multiple contributing factors and various structures implicated.

<div class="gs_citr" tabindex="0"><strong>Evidence-based medicine (practice)</strong> is the integration of best research evidence with clinical expertise and patient(client) values (2)."</div>
<ul>
 	<li class="gs_citr" tabindex="0">...the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients (clients).  It involves the integration of at least (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve (1).</li>
</ul>
&nbsp;
<ol>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Sackett, D. L., Rosenberg, W. M., Gray, J. M., Haynes, R. B., &amp; Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn't. <i>Bmj</i>, <i>312</i>(7023), 71-72.</li>
 	<li class="gs_citr" tabindex="0">Sackett D et al. Evidence-Based Medicine: How to Practice and Teach EBM, 2nd edition. Churchill Livingstone, Edinburgh, 2000, p.1</li>
</ol>

<strong>Excitability:</strong> The ability of a cell to <span class="hvr">change</span> in <span class="hvr">membrane</span> <span class="hvr">conductance</span> as a <span class="hvr">response</span> to <span class="hvr">stimulation.
</span>
<ul>
 	<li><span class="hvr">For example, muscle cells are specialized to react to a change in membrane potential with contraction, where as nerve cells are specialized to propagate a change in membrane potential along there axons and communicate that message to other tissues via neurotransmitters.
</span></li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

<strong>Excitation threshold:</strong> The level that a depolarization must reach for an action potential to occur.
<ul>
 	<li>The excitation threshold is a contributing factor to the "all-or-none" response of muscle and nerves cells to a stimulus.</li>
</ul>

<strong>Exercise Progression</strong> - Modification of an exercise with the intent of promoting adaptation by increasing demand. This can be accomplished by increasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability.
<ul>
 	<li>Because load, reps, tempo and complexity are often explicitly noted, the term "exercise progression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise, or series of exercises that make it harder to maintain stability with good form.
<ul>
 	<li>Sample Exercise Progression: <a href="https://brentbrookbush.com/vimeo_videos/kneeling-chop-pattern/" target="_blank" rel="noopener">Kneeling Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/static-standing-chop-pattern/" target="_blank" rel="noopener">Standing Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/single-leg-chop-pattern/" target="_blank" rel="noopener">Single-leg Chop</a></li>
</ul>
</li>
</ul>

<strong>Exercise regression</strong> - The opposite of progression; that is, modification of an exercise with the intent of reducing demand. This can be accomplished by decreasing reps, load, tempo, range of motion, complexity, and/or challenge to an individual's stability. Generally, regressions are used to modify an exercise to the client's current level of ability, with the intent of improving form, motor learning and retention.
<ul>
 	<li>Because load, reps, tempo and complexity are often explicitly noted, the term "exercise regression" is most often used throughout Brookbush Institute (BI) content to refer to an exercise or series of exercises that make it easier to maintain stability with good form.
<ul>
 	<li>Sample Exercise Regression: <a href="https://brentbrookbush.com/vimeo_videos/single-leg-chop-pattern/" target="_blank" rel="noopener">Single-leg Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/static-standing-chop-pattern/" target="_blank" rel="noopener">Standing Chop</a> to <a href="https://brentbrookbush.com/vimeo_videos/kneeling-chop-pattern/" target="_blank" rel="noopener">Kneeling Chop</a></li>
</ul>
</li>
</ul>

<strong>Experimental Research</strong> - Studies in which the researchers introduce the variable to be studied, with the intent of observing the outcome. This is different than observational research which observes the effect of a variable already present. Many texts also assert that experimental research should include randomization and ideally a control group, as is seen in Randomized Control Trials. Studies in which the variable is introduced by the researchers, but participants are not randomized may be considered Quasi-experimental research.
<ul>
 	<li>In this study by Esformes, the experimental variable was squat depth and the outcome measures observed were various performance measures related to power (1).</li>
</ul>
<ol>
 	<li><a href="https://brookbushinstitute.com/article/back-squat-depth-lower-body-post-activation-potentiation/" target="_blank" rel="noopener">Esformes, J., &amp; Bampouras, T. (2013). Effect of back squat depth on lower-body postactivation potentiation. <em>Journal of Strength and Conditioning Research, 27</em>(11), 2997-3000.</a></li>
</ol>
&nbsp;

<strong>Extensibility</strong>: The ability of a cell to be stretched or lengthened without damage (1).
<ul>
 	<li>For example, most cells would rupture with even a modest stretch, but muscles can stretch up to 3 times their contracted length.</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

<strong>False Negative </strong>- the proportion of negatives in a group that were assessed incorrectly (assessed as negative when the patient was actually positive)
<ul>
 	<li>Test Results: Although most tests/assessments result in either a positive or negative, the accuracy of a test is dependent on the number  of positives and negatives that are correct. Therefore, when the accuracy of a test is determined, their are 4 possible results, because a positive or negative result could be right (true) or wrong (false).</li>
</ul>

<strong>False Positive </strong>- the proportion of positives in a group that were assessed incorrectly (assessed as positive when the patient was actually negative)
<ul>
 	<li>Test Results: Although most tests/assessments result in either a positive or negative, the accuracy of a test is dependent on the number  of positives and negatives that are correct. Therefore, when the accuracy of a test is determined, their are 4 possible results, because a positive or negative result could be right (true) or wrong (false).</li>
</ul>

The function of fascia is to transmit force, provide support, and protect tissues. Fascia can effect motion by:
Transmitting force from one or more muscles (example: the thoracolumbar fascia)
Restricting motion in cases of adaptive shortening and/or adhesion to proximal structures (example: iliotibial band in cases of lower-leg dysfunction)
Elastic recoil after stretching can contribute to force production (example: plyometric exercise)

Note: There is evidence that fascia may house more receptors related to human movement than other tissues. In this way fascia may act as a motherboard for the nervous system

The fascial system does not contract or develop trigger points, and its capacity to adapt to stretching and or strengthening exercise is limited, especially when compared to the adaptive capacity of muscle tissue.

<strong>Fibromyalgia</strong> - A loosely defined diagnosis that is associated with a combination of widespread pain <i>in combination with</i> 2) tenderness at 11 or more of the 18 specific tender point sites. Consideration may also be given to the presence of psychosocial stressors and inflammatory disease in the patients history. Newer research suggests that fibromyalgia may be at least in part due to central sensitization of myofascial pain, often associated with trigger points (1 - 4).
<ol>
 	<li>Wolfe, F. (2018). Fibromyalgia Syndrome and Fibromyalgia Syndrome Criteria: Problems in Definition and Validity. <i>Fibromyalgia Syndrome and Widespread Pain: From Construction to Relevant Recognition</i>.</li>
 	<li>Wolfe, F., Smythe, H. A., Yunus, M. B., Bennett, R. M., Bombardier, C., Goldenberg, D. L., ... &amp; Fam, A. G. (1990). The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. <i>Arthritis &amp; Rheumatism: Official Journal of the American College of Rheumatology</i>, <i>33</i>(2), 160-172.</li>
 	<li>Alonso-Blanco, C., Fernandez-de-las-Penas, C., Morales-Cabezas, M., Zarco-Moreno, P., Ge, H. Y., &amp; Florez-García, M. (2011). Multiple active myofascial trigger points reproduce the overall spontaneous pain pattern in women with fibromyalgia and are related to widespread mechanical hypersensitivity. <i>The Clinical journal of pain</i>, <i>27</i>(5), 405-413.</li>
 	<li>Staud, R., Nagel, S., Robinson, M. E., &amp; Price, D. D. (2009). Enhanced central pain processing of fibromyalgia patients is maintained by muscle afferent input: a randomized, double-blind, placebo-controlled study. <i>PAIN®</i>, <i>145</i>(1-2), 96-104.</li>
</ol>
&nbsp;

Muscles that act to reduce or prevent movement at proximal joints to improve force transmission.
Example: The muscles of the core are important fixators; reducing motion of the spine/trunk to enhance force transmission between the extremities and environment.

An increase in joint stability via compressive forces resulting from muscular contraction and increased tension in fascial structures (1,2).
<ul>
 	<li>This term is most often used in reference to core intrinsic stabilizers, the thoracolumbar fascia and the sacroiliac joint; however, force closure and form closure have been mentioned in the literature referring to other joints.</li>
 	<li>Related term: Form closure</li>
</ul>
<ol>
 	<li>Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability &amp; Lumbopelvic Pain: <a class="glossaryLink " title="Glossary: Integration" href="https://brentbrookbush.com/glossary/integration/" target="_blank" rel="noopener noreferrer" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Integration&lt;/div&gt;&lt;div class=glossaryItemBody&gt;Making a whole of parts.&lt;br /&gt;&lt;br /&gt;Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.&lt;/div&gt;">Integration</a> of Research and Therapy. (c) 2007 Elsevier Limited</li>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Vleeming, A., Pool-Goudzwaard, A. L., Stoeckart, R., van Wingerden, J. P., &amp; Snijders, C. J. (1995). The Posterior Layer of the Thoracolumbar Fascia| Its Function in Load Transfer From Spine to Legs. <i>Spine</i>, <i>20</i>(7), 753-758.</li>
</ol>

The relative contribution of joint shape and structure to the stability of a joint (1,2).
<ul>
 	<li>This term is most often used in reference to the "rough" articulating surfaces of the sacroiliac joint and the wedge shape of the sacrum; however, force closure and form closure have been mentioned in the literature referring to other joints.</li>
 	<li>Related term: Force closure</li>
</ul>
<ol>
 	<li>Andry Vleeming, Vert Mooney, Rob Stoeckart. Movement, Stability &amp; Lumbopelvic Pain: <a class="glossaryLink " title="Glossary: Integration" href="https://brentbrookbush.com/glossary/integration/" target="_blank" rel="noopener noreferrer" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Integration&lt;/div&gt;&lt;div class=glossaryItemBody&gt;Making a whole of parts.&lt;br /&gt;&lt;br /&gt;Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.&lt;/div&gt;">Integration</a> of Research and Therapy. (c) 2007 Elsevier Limited</li>
 	<li id="gs_cit1" class="gs_citr" tabindex="0">Vleeming, A., Pool-Goudzwaard, A. L., Stoeckart, R., van Wingerden, J. P., &amp; Snijders, C. J. (1995). The Posterior Layer of the Thoracolumbar Fascia| Its Function in Load Transfer From Spine to Legs. <i>Spine</i>, <i>20</i>(7), 753-758.</li>
</ol>

An arthrokinematic motion - linear motion across a joint surface parallel to the plane of the adjacent joint surface, just as your posterior moves relative to a "slide" in a park.

For example, the glide of facet joint in the spine during spinal flexion and extension, or the posterior glide of the humeral head that must accompany anterior roll to maintain congruence with glenoid fossa during shoulder horizontal adduction.

A plane joint (also called an arthrodial joint, gliding joint or plane articulation) is a synovial joint which allows only gliding movement in the plane of the articular surfaces. The opposed surfaces of the bones are flat or almost flat, with movement generally limited by tight capsules and ligaments. Plane joints are numerous, are most often small, and allow very little motion.  Examples include the carpal joints of the wrist, the tarsal joints of the ankle, and the facet joints of the spine.

"...refers to the measurement of angles, in particular the measurement of angles created at human joints by the bones of the body (1).

&nbsp;
<ol>
 	<li>Cynthia C. Norkin, D. Joyce White. Measurement of Joint Motion: A Guide to Goniometry 3rd Edition. Copyright (C) 2003 by F.A. Davis Company</li>
</ol>

Ground reaction force (GRF) - The force exerted by the ground on the body in contact with it.

For example, when a runner's foot strikes the ground with a force equal to the mass of the individual times their acceleration due to gravity, momentum and muscular exertion, the ground exerts an equal and opposite force on the runner's foot.
<ul>
 	<li>GRF is often measured in research studies using force plates as a means of quantitatively measuring the force generated by an individual.</li>
</ul>

<strong>H-Band</strong> - Refers to the central zone of a sarcomere that looks lighter under a microscope.  This area of the sarcomere is a lighter portion of the A-band where there is no overlap between the thinner filaments (actin), and the thicker filaments (myosin).
<ul>
 	<li>Example, when a muscle contracts, actin and myosin cross-bridging occurs in the region of the A-band until the H-band is reached where no overlap occurs.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

A hinge joint (also called a ginglymus) is a synovial joint in which the articular surfaces fit one another in a way that only permits motion in one plane. Examples include the elbow, the knee (unless considered a condyloid joint) and the interphalangeal joints.

Holism (holistic) (<em>biological holism</em>) - (from Greek <i>holos</i> "all, whole, entire") is the idea that systems and their properties should be viewed as wholes, not just as a collection of parts.
<ul>
 	<li>Summarized by Aristotle in his "Metaphysics": "The whole is more than the sum of its parts". However, the term "holism" was introduced into language by the South African statesman Jan Smuts as recently as 1926. (Smuts J. C. 1987 [1926]. <em class="EmphasisTypeItalic ">Holism and evolution</em>. Cape Town: N &amp; S Press.)</li>
</ul>
Example: The Brookbush Institute promotes a holistic approach to human movement science, in which the muscular, fascial, articular and neural systems are not viewed as separable and all proximal segments are considered.

<strong>Hormone: </strong>Chemical messengers produced by the endocrine system, transported via tissue fluids such as blood, to stimulate cells to "act."
<ul>
 	<li>Example: Growth hormone is secreted by the pituitary gland in the brain; stimulating growth, cell reproduction and cell regeneration in certain types of cells</li>
</ul>
The English physician E. H. Starling discovered in collaboration with the physiologist W. M. Bayliss secretin, the first hormone, in 1902. (1).
<ol>
 	<li>Henriksen, J. H., &amp; de Muckadell, O. S. (2000). Secretin, its discovery, and the introduction of the hormone concept. <i>Scandinavian journal of clinical and laboratory investigation</i>, <i>60</i>(6), 463-472.</li>
</ol>

A range of motion achieved by the patient/client that is more than normal.
<ul>
 	<li>Note: Both hyper-mobility and hypo-mobility may adversely affect motion and may lead to deleterious effects on joints and soft tissue over time. There is no evidence to suggest that more or less flexibility than normal is beneficial.</li>
</ul>
Example: If an individual can place their forehead on their knees they are likely hypermobile at one, if not several joints

Example 2: 110° of shoulder external rotation would be considered hyper-mobile.

<strong>Hyperplasia</strong> is an increase in organic tissue size due to an adaptive increase in the number of cells per organ.
<ul>
 	<li>Although muscle hyperplasia has been noted in some animals, human muscle tissue does not seem to have this adaptive ability.</li>
</ul>

A condition of excessive tone of the skeletal muscles; increased resistance of muscle to passive stretching.  May be related to increased neural drive, synergistic dominance, trigger points, reflexive over-activity, and/or muscle length.
Example:  Individuals who exhibit ankle eversion and abduction during an overhead squat assessment likely have hypertonic fibularis (peroneal) muscles.

<strong>Muscular hypertrophy</strong> is an increase in muscle mass/size due to increase in the volume and cross-sectional area (CSA) of individual muscle cells. The increase in cross-sectional area can be attributed to an an increase in contractile proteins and structural elements (myofibrillar hypertophy), as well as an increase in glycogen storage and elements related to metabolism (sarcoplasmic hypertophy). Hypertrophy is an adaptation of both cardiac and skeletal muscle fibers in response to progressive increases in workload.
<ul>
 	<li>Note: Hypertrophy is not hyperplasia. Hyperplasia is an increase in muscle size due to an adaptive increase in the number of muscle fibers/cells per muscle. This type of adaptation does not occur in human muscle tissue.</li>
</ul>

A range of motion achieved by a patient/client that is less than normal.
<ul>
 	<li>Note: Both hyper-mobility and hypo-mobility may adversely affect motion and may lead to deleterious effects on joints and soft tissue over time. There is no evidence to suggest that more or less flexibility than normal is beneficial.</li>
</ul>
Example: If the end range of shoulder external rotation is reached and measured as 75° during goniometric assessment, the client/patient is exhibiting hypomobility of the glenohumeral joint (shoulder).

Hypothesis - a proposed explanation for a phenomenon; "scientific hypotheses" are generally constructed in a way that is testable or falsifiable.
<ul>
 	<li>Example: The hypothesis, "excessive knee valgus may be correlated with future knee pain and injury," has been the subject of several studies published over the last decade.</li>
</ul>

Diminished tone of skeletal muscles; diminished resistance of muscles to passive stretching.   May be related to inhibition, reciprocal inhibition, arthrokinematics inhibition and/or  increased resting length of muscle.
Example:  If your knees cave (hip adduction) during a squat or leg-press it is likely that your gluteus medius is hypotonic.

<strong>I-Band</strong> - Refers to the part of the muscle cell that looks lighter under a microscope.  This area of the cell is lighter due to parallel arrangement of thinner filaments (actin), and no overlap with the thicker filaments (myosin).
<ul>
 	<li>As a muscle contracts, the I-bands will decrease in width and move closer to one another.</li>
</ul>
<ol>
 	<li>Saladin, K. (2014). Anatomy &amp; physiology: The unity of form and function. McGraw-Hill Higher Education, New York. ISBN: 9780073403717</li>
</ol>

Independent variable - in research, this is the variable or phenomenon being manipulated in the study.
<ul>
 	<li>Example, in the study by Ghanbari et al. (1), the independent variable is "knee joint mobilization", the dependent variable is "quadriceps muscle strength."</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/effect-knee-joint-mobilization-quadriceps-muscle-strength/" target="_blank" rel="noopener noreferrer">Ghanbari A. and Kamalgharibi S. (2013). Effect of knee joint mobilization on quadriceps muscle strength. <em>International Journal of Health and Rehabilitation Sciences</em>. 2(4): 186-191</a></li>
</ol>

An anatomical direction; toward the bottom (below)

Example, the mouth is <em>inferior</em> to the eyes

A reduction in neural drive, muscular activity, and or force output due to altered neuromuscular reflex.  Alterations in neuromuscular reflex may occur due to increases in muscle length (hypothesis: increased excitation threshold), altered reciprocal inhibition in response to increased antagonist tone, and or alterations in joint motion (arthrokinematics inhibition).

Making a whole of parts.

Example, The Brookbush Institute uses an integrative approach to explaining and addressing human movement.

<strong>Intermuscular Coordination</strong> - Optimal timing and motor unit recruitment of agonists, antagonists, synergists, neutralizers, stabilizers and fixators.

<strong>Example: Role of Muscles during Hip Extension</strong>
<ul>
 	<li><strong><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Prime Mover" href="https://brentbrookbush.com/glossary/prime-mover/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Prime Mover&lt;/div&gt;The muscle most responsible for a joint action under load -&lt;br /&gt;&lt;br /&gt;That is, the muscle that can produce the most force for a given joint action. Often this term is used synonymously with the term agonist. The prime mover as defined above, may or may not be the most active muscle for a joint action during activities of daily living.&lt;br /&gt;&lt;br /&gt;Example: the gluteus maximus is the most powerful hip extensor and therefore the prime mover; however, the hamstrings are likely the most active hip extensors during low level activities like walking or standing.">Prime Mover</a>:</strong>  <a href="https://player.vimeo.com/external/82855344.hd.mp4?s=54c3e7d98fb9d4e0af8d282c85ba9b3e">Gluteus maximus</a></li>
 	<li><strong><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Synergists" href="https://brentbrookbush.com/glossary/synergists/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Synergists&lt;/div&gt;Muscles that assist the prime mover in performing a joint action.&lt;br /&gt;&lt;br /&gt;That is, all muscles that can perform a joint action that are not the prime mover, are termed synergists.&lt;br /&gt;Example: The rectus abdominis is the prime mover of spinal flexion. All other muscles that can perform spinal flexion are synergists including – external obliques, internal obliques and psoas.">Synergists</a>:</strong> <a href="https://brentbrookbush.com/articles/muscular-anatomy/biceps-femoris/">Biceps femoris (long head)</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/semitendinosus-and-semimembranosus/">semitendinosus, semimembranosus</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/adductors/">posterior head of adductor magnus</a></li>
 	<li><strong><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Antagonist" href="https://brentbrookbush.com/glossary/antagonists/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Antagonist&lt;/div&gt;Muscles that oppose the prime mover and synergists for a given joint action.&lt;br /&gt;&lt;br /&gt;That is, all the muscles that can perform the opposing joint action.&lt;br /&gt;&lt;br /&gt;Example: The triceps and anconeus are antagonists during elbow flexion.">Antagonists</a>:</strong> <a href="https://brentbrookbush.com/articles/muscular-anatomy/psoas/">Psoas</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/iliacus/">iliacus</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/tensor-fascia-latae-tfl/">tensor fascia latae</a> (TFL),<a href="https://brentbrookbush.com/articles/muscular-anatomy/rectus-femoris/"> rectus femoris</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/adductors/">anterior adductors (especially pectineus)</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/sartorius/">sartorius</a></li>
 	<li><strong><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Neutralizer" href="https://brentbrookbush.com/glossary/neutralizers/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Neutralizer&lt;/div&gt;Muscles that oppose unwanted joint motions created by the prime mover and/or synergists, and/or muscles that prevent unwanted ancillary motion.&lt;br /&gt;Example: The teres minor and infraspinatus neutralize the internal rotation force created by the pectoralis major during horizontal adduction of the shoulder.">Neutralizers</a>:</strong> <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-minimus/">Gluteus minimus</a> and <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-medius/">anterior fibers of gluteus medius</a> neutralize external rotation force of <a href="https://brentbrookbush.com/articles/muscular-anatomy/gluteus-maximus/">gluteus maximus</a></li>
 	<li><strong><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Stabilizer" href="https://brentbrookbush.com/glossary/stabilizers/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Stabilizer&lt;/div&gt;Muscles whose primary role is to improve arthrokinematics by maintaining optimal alignment of joint surfaces.&lt;br /&gt;&lt;br /&gt;Most often these muscles are the most intrinsic muscles of a joint, have a larger percentage of Type I muscle fibers and are rich in proprioceptors.&lt;br /&gt;Example: The muscles of the rotator cuff act as stabilizers for most shoulder motions.">Stabilizers</a>:</strong> <a href="https://brentbrookbush.com/articles/muscular-anatomy/deep-rotators-of-the-hip/">Deep rotators of hip</a></li>
 	<li><strong><a class="glossaryLink " style="box-sizing: border-box; font-family: roboto; color: #000000 !important; font-size: 15px; outline: none; background: transparent; border-bottom: 1px dotted #000000 !important; text-decoration: none;" title="Glossary: Fixator" href="https://brentbrookbush.com/glossary/fixators/" target="_blank" rel="noopener" data-cmtooltip="&lt;div class=glossaryItemTitle&gt;Fixator&lt;/div&gt;Muscles that act to reduce or prevent movement at proximal joints to improve force transmission.&lt;br /&gt;Example: The muscles of the core are important fixators; reducing motion of the spine/trunk to enhance force transmission between the extremities and environment.">Fixators</a>: </strong><a href="https://brentbrookbush.com/articles/core-subsystems/intrinsic-stabilization-subsystem/">Intrinsic stabilization subsystem</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/rectus-abdominis/">rectus abdominis</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/internal-obliques/">internal</a> and <a href="https://brentbrookbush.com/articles/muscular-anatomy/external-obliques/">external obliques</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/quadratus-lumborum/">quadratus lumborum</a>, <a href="https://brentbrookbush.com/articles/muscular-anatomy/erector-spinae/">erector spinae</a></li>
</ul>
&nbsp;

Example from: <a href="https://brentbrookbush.com/articles/anatomy-articles/introduction-to-functional-anatomy/kinesiology-of-the-hip/" target="_blank" rel="noopener">Introduction to Functional Anatomy: Kinesiology of the Hip</a>

Intramuscular coordination refers to the coordinated recruitment of motor units within a single muscle. This concept is used to explain increases in maximal strength and power; however, the coordinated and sequential recruitment of motor units is also essential to strength endurance and smooth coordinated motion.  Related terminology may include; motor unit recruitment, preferential recruitment, rate coding, sequence, etc..

Example: It is hypothesized that the "shaking" noted during a novice exercisers attempt at an activity like the <a href="https://brentbrookbush.com/vimeo_videos/ball-crunch-and-progressions/" target="_blank">stability ball crunch</a> may be due to relatively poor intramuscular coordination. Rather than smooth, sequential firing of rectus abdominis motor units, groups of motor units turn on and off in an uncoordinated manner.

Pertaining to the same side

Example, the quadratus lumborum performs ipsilateral flexion; lateral flexion toward the same side as the muscle.

An <strong>isoform</strong>, or variant, is a member of a set of similar proteins, that originate from the same gene, or gene family.<sup id="cite_ref-2" class="reference"></sup>
<ul>
 	<li>Example, the variations in myosin heavy chain proteins (MHC I, MHC IIA, MHC IIB/X) that contribute to the characteristic differences between muscle fiber types.</li>
</ul>

“The Prime Assumption”
Everything crossing a joint will influence joint motion during every joint action.

A concept that has expanded over the past several decades to describe the integration of 4 body systems (muscle, joints, fascia and nerves), as well as, the coordinated function of various body segments (e.g. hip, knee and ankle) to produce motion. Kinetic referring to motion, and chain being an analogy for the interdependent link between systems.

Example, the posterior <em>kinetic chain</em>, refers to the integrated function of nerves, muscles, fascia and joints on the posterior side of the body.

The concept of the kinetic chain was originally adapted from the work of a mechanical engineer named Franz Reuleaux (Kinematics of Machinery (1875)) by Dr. Arthur Steindler in 1955 (Steindler A: Kinesiology of the Human Body. Springfield, IL, Charles C. Thomas Co.. 1955).

<strong>Latent Trigger Point</strong> - A myofascial trigger point that is not painful at rest, only painful when palpated, and may or may not exhibit a characteristic referral pain pattern when palpated.  Latent trigger points do result in an acute point of sensitivity, in a taut band of muscle, and may restrict range of motion (1).

Note: Based on the clinical experience, the Brookbush Institute suggests that latent trigger points (sometimes refereed to as Tender Points) are more common than active trigger points. Further, they are likely addressed more often than trigger points; being the intended target of many soft-tissue mobility techniques.
<ol>
 	<li>David G. Simons, Janet Travell, Lois S. Simons, <em>Travell &amp; Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition</em>,© 1999 Williams and Wilkens</li>
</ol>

An anatomical direction; further from the midline

Example, the anterior deltoid is <em>lateral</em> to the pectoralis major

<strong>Length/Tension Relationship</strong> - The amount of force generated by a muscle is dependent on sarcomere length.
<ul>
 	<li>The ability of sarcomere to maximally produce force occurs when sarcomere length results in optimal overlap between actin and myosin. Stretching a sarcomere decreases overlap between actin and myosin filaments and reduces force production (1-3). When length is less than optimal, actin from opposite ends overlap and interfere with cross-bridging, and myosin filament are compressed as they contact the the Z-disk also reducing force (4)</li>
</ul>
<ol>
 	<li>Gordon, A. M., Huxley, A. F., &amp; Julian, F. J. (1966). The variation in isometric tension with sarcomere length in vertebrate muscle fibres. <i>The Journal of physiology</i>, <i>184</i>(1), 170-192.</li>
 	<li>Edman, K. A. P. (1966). The relation between sarcomere length and active tension in isolated semitendinosus fibres of the frog. <i>The Journal of Physiology</i>, <i>183</i>(2), 407-417.</li>
 	<li>Lieber, R. L., Loren, G. J., &amp; Friden, J. (1994). In vivo measurement of human wrist extensor muscle sarcomere length changes. <i>Journal of neurophysiology</i>, <i>71</i>(3), 874-881.</li>
 	<li>Lieber, R. L. (2002). <i>Skeletal muscle structure, function, and plasticity</i>. Lippincott Williams &amp; Wilkins.</li>
</ol>
&nbsp;

<span class="_Tgc"><strong>Levels of Evidence</strong> - Relative to evidence-based practice, levels of evidence are an attempt to describe the strength of the results measured in a clinical trial or research study.  Note: levels of evidence do not supersede the critical evaluation of an experienced professional, and should be viewed as guidelines - a meta-analysis may be poorly constructed (Level IA), and a comparative study (Level III) may employ new technologies and a strong methodology.
</span>

The Levels of Evidence used by the Brookbush Institute, as described by Shekelle et al.(1):
<ul>
 	<li class="p1">IA - Evidence from meta-analysis of randomized controlled trials</li>
 	<li class="p1">IB - Evidence from at least one randomized controlled trial</li>
 	<li class="p1">IIA - Evidence from at least one controlled study without randomization</li>
 	<li class="p1">IIB - Evidence from at least one other type of quasi-experimental study</li>
 	<li class="p1">III - Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies</li>
 	<li class="p1">IV - Evidence from expert committee reports or opinions or clinical experience of respected authorities, or both</li>
</ul>
<ol>
 	<li>Shekelle, P. G., Woolf, S. H., Eccles, M., &amp; Grimshaw, J. (1999). Developing clinical guidelines. <i>Western Journal of Medicine</i>, <i>170</i>(6), 348.</li>
</ol>

<strong>Likelihood Ratios</strong> - Likilihood ratios are used for assessing the value of performing a diagnostic test. They use sensitivity and specificity to determine whether a test result usefully changes the practitioner's chance (probability) of reaching the correct assessment. Calculation of likelihood ratios is based on Baye's theorem.
<ul>
 	<li><strong>Positive Likelihood Ratio (LR+)</strong> - The ratio of a positive test result in people with the pathology to a positive test result in people without the pathology.</li>
 	<li><strong>Negative Likelihood Ratio (LR-)</strong> - The ratio of a negative test result in people with the pathology to a negative test result in people without the pathology.</li>
</ul>

Longitudinal Study - a research design that involves observing the same variables, several times over a period of time.
<ul>
 	<li>Example, the study by Hewett et al. (1) is a type of longitudinal study called a "cohort study." This study investigated whether excessive knee valgus during landing was a predictor of knee injury risk in adolescent females over the course of a season.</li>
</ul>
<ol>
 	<li><a href="https://brentbrookbush.com/articles/research-corner/knee/research-review-increased-valgus-during-landing-predicts-acl-injury-in-adolescent-female-athletes/" target="_blank" rel="noopener noreferrer">Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., &amp; Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes A prospective study. The American journal of sports medicine, 33(4), 492-501</a></li>
</ol>

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