Introduction

Research Corner Summary

Cervical Mobilization and Cervical Spine Dysfunction

Cervical Spine Mobilization and Distal Joints

Cervical Spine Mobilization and Effects on Muscle Activity

Systemic Response to Cervical Mobilization

Comparing and Combining Cervical Mobilizations with Other Techniques

Research Corner: Thoracic Spine

Techniques and Ending Info

Joint Mobilization: Cervical and Thoracic Spine

AOTA

TPTA

AUSPHYSIO

NYPT

PACE

<h3>Introduction</h3>
This course describes joint mobilizations for the cervical spine and thoracic spine. Several terms and definitions have been used to describe the &quot;mobilizations&quot; (e.g. mobilisations) that are taught in this course. The Brookbush Institute uses a conventional definition of &quot;mobilization&quot; that includes low amplitude, low-velocity, oscillatory techniques intended to reduce the stiffness of joints exhibiting a decrease in passive accessory range of motion (a.k.a. <a id="arthrokinematics" data-tip="1701" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic motion</a> and specifically <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> or <a id="glide" data-tip="1815" target="_blank" href="/glossary-term/glide" class="glossary">slide</a>). Note, the term &quot;manipulation&quot; is reserved for high-velocity techniques taught in a separate set of courses. Further, the types of mobilizations taught in this course are <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> (PA) and include both <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> (UPA) mobilizations directing force over facet joints, and central <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> (CPA) mobilizations directing force over the spinous process. These mobilization techniques likely represent the most commonly recommended techniques due in part to their relatively high <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and efficacy.
This course includes mobilization techniques that intend to improve excessive stiffness of the cervical spine and thoracic spine, improve restrictions in spine range of motion (ROM), and reduce cervicothoracic and upper extremity dysfunction. For example, cervical dysfunction has been correlated with <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylitis, and mobilizations of the cervical spine have been correlated with a reduction in pain and improvements in function, such as increased grip strength. 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 cervicothoracic dysfunction, and <a href="https://brookbushinstitute.com/courses/upper-body-dysfunction-ubd" title="Upper Body Dysfunction" target="_blank" rel="noopener">upper body dysfunction (UBD)</a> including cervicogenic headache, shoulder impingement syndrome (SIS), <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylitis (tennis elbow), chronic thoracic pain, chronic neck pain, and acromioclavicular dysfunction, and <a id="movement-impairment" data-tip="1578" target="_blank" href="/glossary-term/movement-impairment" class="glossary">postural dysfunctions</a> including rounded shoulder <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, thoracic kyphosis, or an <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> pelvic tilt. Some evidence and clinical outcomes even suggest that addressing cervical dysfunction and forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> can improve long-term outcomes for low back pain patients.
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.) with the intent of developing 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, and outcome-driven approach.&#xA0;
<h3>Techniques Covered in this Course:</h3>
<ul>
 <li><a href="https://brookbushinstitute.com/video/cervical-spine-posterior-to-anterior-mobilization" target="_blank" rel="noopener">Cervical Mobilization (Manual)</a></li>
 <li><a href="https://brookbushinstitute.com/video/thoracic-spine-mobilization-posterior-anterior-transverse" target="_blank" rel="noopener">Thoracic Mobilization (Manual)</a></li>
</ul>
<h3>Sample Intervention (Cervicothoracic Junction Pain/Stiffness)</h3>
<ul>
 <li>Manual Release
 <ul>
 <li><a href="https://brookbushinstitute.com/video/levator-scapulae-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Levator Scapulae</a></li>
 <li><a href="https://brookbushinstitute.com/video/upper-trapezius-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Upper Trapezius</a></li>
 <li><a href="https://brookbushinstitute.com/video/rhomboid-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Rhomboids</a></li>
 <li><a href="https://brookbushinstitute.com/video/pectoralis-minor-static-manual-release" target="_blank" rel="noopener">Pectoralis Minor</a></li>
 </ul>
 </li>
 <li>Mobilization or Manipulation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/cervical-spine-posterior-to-anterior-mobilization" target="_blank" rel="noopener">Cervical Mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/thoracic-spine-mobilization-posterior-anterior-transverse" target="_blank" rel="noopener">Thoracic mobilization</a></li>
 </ul>
 </li>
 <li>Manual Lengthening
 <ul>
 <li><a href="https://brookbushinstitute.com/video/pectoralis-minor-manual-stretch" target="_blank" rel="noopener">Manual Pectoralis Minor Stretch</a></li>
 </ul>
 </li>
 <li>Activation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/deep-cervical-flexor-isolated-activation" target="_blank" rel="noopener">Deep Cervical Flexor Activation</a></li>
 <li><a href="https://brookbushinstitute.com/video/serratus-anterior-isolated-activation-2" target="_blank" rel="noopener">Serratus </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Activation</li>
 </ul>
 </li>
 <li>Integration
 <ul>
 <li><a href="https://brookbushinstitute.com/video/prone-cobra-on-foam-roll-activation-for-muscles-of-the-scapula-thorax-deep-cervical-flexors" target="_blank" rel="noopener">Cobra on Foam Roll</a></li>
 </ul>
 </li>
</ul>
<h3>Related Courses</h3>
Additional Joint Mobilization Courses
<ul>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-ankle-and-tibiofibular-joints" title="Ankle and Tibiofibular Joint Mobilization" target="_blank" rel="noopener">Joint Mobilizations: Ankle and Tibiofibular Joints</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-hip-and-knee" title="Knee and Hip Joint Mobilization" target="_blank" rel="noopener">Joint Mobilizations: Knee and Hip Joints</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-lumbar-spine-and-sacroiliac-joint" title="Lumbar Spine and Sacroiliac Joints" target="_blank" rel="noopener">Joint Mobilizations: Lumbar Spine and Sacroiliac Joints</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-cervical-and-thoracic-spine" title="Cervical and Thoracic Spine" target="_blank" rel="noopener">Joint Mobilizations: Cervical and Thoracic Spine</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-shoulder-joint-acromioclavicular-joint-and-sternoclavicular-joint" title="Joint Mobilization Shoulder SC and AC" target="_blank" rel="noopener">Joint Mobilizations: Shoulder, Sternoclavicular, and Acromioclavicular Joints</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-elbow-and-proximal-radioulnar-joint" title="Joint Mobilization Elbow and &lt;a id=" proximal" data-tip="1564" target="_blank" class="glossary">Proximal</a> Radioulnar Joint&quot; target=&quot;_blank&quot; rel=&quot;noopener&quot;&gt;Joint Mobilizations: Elbow and <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">Proximal</a> Radioulnar Joints</li>
</ul>
For an introduction to joint mobilizations and manipulations:
<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: Cervical Spine and Thoracic Spine Joint Mobilizations

<h2>For Cervicothoracic Dysfunction and <a href="https://brookbushinstitute.com/article/upper-body-dysfunction-ubd" target="_blank" rel="noopener">Upper-Body Dysfunction</a>:</h2>
For an introduction to joint mobilizations and manipulations:
<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>
<ul></ul>
<h3>Techniques Covered in this Course:</h3>
<ul>
 <li><a href="https://brookbushinstitute.com/video/cervical-spine-posterior-to-anterior-mobilization" target="_blank" rel="noopener">Cervical Mobilization (Manual)</a></li>
 <li><a href="https://brookbushinstitute.com/video/thoracic-spine-mobilization-posterior-anterior-transverse" target="_blank" rel="noopener">Thoracic Mobilization (Manual)</a></li>
</ul>
<h3>Signs of correlated dysfunction:</h3>
<ul>
 <li><a href="https://brookbushinstitute.com/article/introduction-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat Assessment:</a>
 <ul>
 <li>Forward Head</li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-11-shoulders-elevate" target="_blank" rel="noopener">Shoulders Elevate</a></li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-10-arms-fall" target="_blank" rel="noopener">Arms Fall</a></li>
 </ul>
 </li>
 <li><a href="https://brookbushinstitute.com/article/introduction-to-goniometry" target="_blank" rel="noopener">Goniometry</a>
 <ul>
 <li><a href="https://brookbushinstitute.com/video/cervical-lateral-flexion-goniometry" target="_blank" rel="noopener">Cervical </a><a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">Lateral</a> Flexion &lt; 35 - 45&#xB0;
 <ul>
 <li>Note: Gross movement exams may be beneficial for identifying asymmetry, significant restriction, and pain with movement; however, cervical rotation, flexion, and extension are not <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> <a id="goniometry" data-tip="1524" target="_blank" href="/glossary-term/goniometry" class="glossary">goniometric</a> <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a>.</li>
 </ul>
 </li>
 <li><a href="https://brookbushinstitute.com/video/shoulder-flexion-goniometry" target="_blank" rel="noopener">Shoulder Flexion</a> &lt; 180&#xB0;</li>
 <li><a href="https://brookbushinstitute.com/video/shoulder-external-rotation-goniometry" target="_blank" rel="noopener">Shoulder External Rotation</a> &lt;90 - 95&#xB0;
 <ul>
 <li>Although shoulder flexion and external rotation are not a measure of cervical/thoracic spine motion, <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> thoracic <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> is needed to achieve <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> <a href="https://brookbushinstitute.com/article/sternoclavicular-acromioclavicular-scapulothoracic-joints" target="_blank" rel="noopener">scapular</a> motion, which is necessary to achieve <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> - assuming the patient/client does not exhibit signs of shoulder <a id="hypermobility" data-tip="1678" target="_blank" href="/glossary-term/hypermobility" class="glossary">hyper-mobility</a>. Although measuring <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> ROM is not a direct measure of thoracic <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a>, <a id="goniometry" data-tip="1523" target="_blank" href="/glossary-term/goniometry" class="glossary">Goniometry</a> of the cervical spine, thoracic spine and scapula are not <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a>.</li>
 </ul>
 </li>
 </ul>
 </li>
 <li><a href="https://brookbushinstitute.com/article/introduction-manual-muscle-testing-active-population" target="_blank" rel="noopener">Manual </a><a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> Testing MMT:
 <ul>
 <li><a href="https://brookbushinstitute.com/video/deep-cervical-flexor-endurance-test" target="_blank" rel="noopener">Deep Cervical Flexor Endurance Test</a>: Weak or With Compensation (cervical protraction)</li>
 <li><a href="https://brookbushinstitute.com/video/serratus-anterior-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">Serratus </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> MMT: Weak or With Compensation (scapular protraction or elevation)</li>
 <li><a href="https://brookbushinstitute.com/video/lower-trapezius-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">Lower Trapezius MMT</a>: Weak or With Compensation (scapular protraction or elevation)</li>
 </ul>
 </li>
</ul>
<h3>Sample Intervention (Cervicothoracic Junction Pain)</h3>
<ul>
 <li>Manual Release
 <ul>
 <li><a href="https://brookbushinstitute.com/video/levator-scapulae-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Levator Scapulae</a></li>
 <li><a href="https://brookbushinstitute.com/video/upper-trapezius-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Upper Trapezius</a></li>
 <li><a href="https://brookbushinstitute.com/video/rhomboid-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Rhomboids</a></li>
 <li><a href="https://brookbushinstitute.com/video/pectoralis-minor-static-manual-release" target="_blank" rel="noopener">Pectoralis Minor</a></li>
 </ul>
 </li>
 <li>Mobilization or Manipulation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/cervical-spine-posterior-to-anterior-mobilization" target="_blank" rel="noopener">Cervical Mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/thoracic-spine-mobilization-posterior-anterior-transverse" target="_blank" rel="noopener">Thoracic mobilization</a></li>
 </ul>
 </li>
 <li>Manual Lengthening
 <ul>
 <li><a href="https://brookbushinstitute.com/video/pectoralis-minor-manual-stretch" target="_blank" rel="noopener">Manual Pectoralis Minor Stretch</a></li>
 </ul>
 </li>
 <li>Activation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/deep-cervical-flexor-isolated-activation" target="_blank" rel="noopener">Deep Cervical Flexor Activation</a></li>
 <li><a href="https://brookbushinstitute.com/video/serratus-anterior-isolated-activation-2" target="_blank" rel="noopener">Serratus </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Activation</li>
 </ul>
 </li>
 <li>Integration
 <ul>
 <li><a href="https://brookbushinstitute.com/video/prone-cobra-on-foam-roll-activation-for-muscles-of-the-scapula-thorax-deep-cervical-flexors" target="_blank" rel="noopener">Cobra on Foam Roll</a></li>
 </ul>
 </li>
</ul>

<h3>Summary</h3>
<h3>Cervical Mobilizations</h3>
<ul>
 <li>Outcomes: Cervical mobilizations implemented to address <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> <a id="movement-impairment" data-tip="1576" target="_blank" href="/glossary-term/movement-impairment" class="glossary">movement impairments</a>, may improve functional outcomes, range of motion, joint position sense, general cervical pain, mechanical pain, radiculopathy/cervicobrachial pain.</li>
 <li>Posture: The addition of both cervical and thoracic mobilization to exercise and conventional therapy improves outcomes associated with forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> resulting in larger improvements in craniovertebral angle, cervical lordosis angle, range of motion, <a href="https://brookbushinstitute.com/article/deep-cervical-flexor-activation" target="_blank" rel="noopener">DCF</a>, and <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">trapezius</a> activity, functional disability index scores, and potentially respiratory function.</li>
 <li>Headache: Cervical mobilization may decrease headache frequency, duration, and/or intensity, but are more likely to improve symptoms when headaches are correlated with cervical <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> and cervical spine stiffness.</li>
 <li>Upper Extremity and Jaw: The addition of cervical mobilization to a shoulder, elbow, forearm, or jaw rehabilitation programs may improve pain, swelling, recovery time, disability, and strength.</li>
</ul>
<h3>Thoracic Mobilizations</h3>
<ul>
 <li>Outcomes: Thoracic mobilizations have demonstrated efficacy for improving outcomes associated with cervical, thoracic, low back, and shoulder pain.</li>
 <li>Respiration: Thoracic mobilizations have demonstrated efficacy for improving respiratory function associated with cervical, thoracic or lumbar dysfunction; however, thoracic mobilizations are not effective for respiratory dysfunction not associated with these impairments.</li>
</ul>
<h3>Cervical and Thoracic Mobilizations:</h3>
<ul>
 <li>Systemic Effects: Cervical and thoracic mobilizations result in neuromuscular and sympathoexcitatory responses including increased skin conductance, respiratory rate, heart rate, systolic blood pressure, analgesia, increased levels of cortisol, increased <a href="https://brookbushinstitute.com/article/longus-colli-longus-capitis-rectus-capitis-anterior-rectus-capitis-lateralis-deep-neck-flexors" target="_blank" rel="noopener">DCF</a> activity, lower <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius</a> and <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> activity, in conjunction with mechanical effects such as increased range of motion, decreased stiffness and optimization of joint alignment. No correlation was found between the level of patient stress, pain perception, and sympathoexcitatory response resulting from mobilizations; however, catastrophizing by the patient resulted in a decrease in the efficacy of high-velocity manipulations.</li>
 <li>Comparison: Comparing cervical and thoracic mobilizations to exercise, stretching, neurodynamics, taping and ischemic <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> does not imply that any single technique or modality is <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> for addressing dysfunction; however, studies near ubiquitously demonstrate that the combination of mobilization with other techniques is <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to these techniques technique alone.</li>
 <li>Refining Technique: The comparison of various cervical and thoracic mobilization techniques implies they should be oscillatory, Maitland mobilizations, in conjunction with exercise, performed faster, up to 2 oscillations/second, in 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> direction (or <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> in special cases of cervical dysfunction)</li>
</ul>

Research Corner: Cervical Spine

Mobilizations of the cervical and thoracic spine have been correlated with improvements in cervicogenic headache, neck, shoulder, thoracic spine, elbow, and jaw dysfunction.
The use of cervical mobilizations for addressing cervical dysfunction is well supported by research. Choi et al. demonstrated that cervical mobilizations like those demonstrated in this course (Maitland Mobilizations) improved pain and disability index scores in a group of individuals with cervical pain (1). Shah et al. demonstrated the effectiveness of cervical mobilizations for the treatment of cervical radiculopathy, noting that the addition of <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> may provide additional benefit (2). A <a id="randomized-control-trial" data-tip="1403" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">randomized controlled </a><a id="randomized-control-trial" data-tip="1407" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">trial</a> (RCT) by Rodriguez et al. demonstrated cervical mobilizations in conjunction with neural mobilizations improved brachiocervical pain, cervical range of motion, and upper limb function (3). In a double-blinded <a id="randomized-control-trial" data-tip="1403" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">randomized controlled </a><a id="randomized-control-trial" data-tip="1407" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">trial</a> (RCT) by Hayat et al., both Maitland and Mulligan mobilization techniques decreased pain and improved disability index scores for a group of patients with cervical radiculopathy (4). A randomized control <a id="randomized-control-trial" data-tip="1407" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">trial</a> by Ranganath et al. demonstrated that the addition of cervical mobilizations resulted in better improvements in range of motion, in addition to the improvements in pain and function demonstrated by both groups also performing neuromobilization and conventional therapy (5). Oh et al. demonstrated that self-administered mobilization using a Kaltenborn wedge on the upper cervical spine decreased pain and increased extension range of motion (6). Said et al. compared self-administered mobilizations with the Kaltenborn wedge and sustained natural apophyseal <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> (SNAG) mobilizations, demonstrating both were similarly effective for improving joint position sense, pain and disability in those with chronic mechanical neck pain (7). Only one study could be located that reported no additional positive change with the addition of cervical mobilization to therapeutic intervention; a study by Sonmezer et al., demonstrated adding cervical mobilization did not improve cervical pain, range of motion, pain pressure threshold of <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a>, or disability outcomes when added to a program of hot pack, massage and home exercise (8). This may be due to a lack of <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> or matched outcome measures. In a more recent double-blind, placebo-controlled RCT by Lascurain-Aguirrebe&#xF1;a et al., cervical mobilizations improved global perception of pain, reduced the pain associated with painful ranges of motion, and improved ranges of motion that were restricted. The mobilizations had no effect on motions that were not painful or restricted (9). This high-quality study suggests that mobilizations are effective for reducing impairment and pain; however, the results are <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> to restricted and painful motions. Considering these studies in aggregate, cervical mobilizations (including self-administered) are likely effective when implemented to address <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> <a id="movement-impairment" data-tip="1576" target="_blank" href="/glossary-term/movement-impairment" class="glossary">movement impairments</a> and/or added to conventional therapeutic interventions. Potential benefits include improvement in functional outcome scores, range of motion, joint position sense, general cervical pain, mechanical pain, radiculopathy/cervicobrachial pain.
<h3>Posture</h3>
Research has also demonstrated that cervical (and thoracic) mobilizations have a positive effect on <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> and function. A study by Gong et al. demonstrated cervical mobilizations were effective for improving cervical extension range of motion, cervical lordosis angle, and decreasing forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> in a group of 40 university students (10). A study by Kim et al. demonstrated that 4 weeks of SNAG mobilizations for the cervical spine improved craniovertebral angle and respiratory function in a group of individuals exhibiting forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> (11). In an additional study by Lee et al. cervical mobilization and strengthening resulted in better outcomes than passive stretching and <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a>, including improved craniovertebral angle, cervical lordosis angle, and decreased <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius</a> activity (12). In an interesting RCT by Cho et al., larger improvements in standing cervical vertebral angle, cervical extension ROM, cervical pain, and disability scores in individuals with forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> were noted after 4 - 6 weeks of upper thoracic mobilization and <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> exercise than a similar length program of upper cervical mobilization and <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> exercise (13). A study that may aid in coming to a practical conclusion regarding the findings of the Cho et al. study; Lee et al. demonstrated that the combination of cervical and thoracic mobilizations were more effective than cervical mobilizations alone for improving cervical alignment (14). In an interesting study that may highlight the importance of mobilization for improving <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment, an RCT by Cho et al. demonstrated that upper cervical and upper thoracic spine mobilizations improved forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> more than <a href="https://brookbushinstitute.com/article/deep-cervical-flexor-activation" target="_blank" rel="noopener">deep cervical flexor (DCF) exercise</a>, including larger improvements in <a href="https://brookbushinstitute.com/article/longus-colli-longus-capitis-rectus-capitis-anterior-rectus-capitis-lateralis-deep-neck-flexors" target="_blank" rel="noopener">DCF</a> activity/endurance (15). These studies demonstrate that the addition of both cervical and thoracic mobilization to a program with the intent of addressing forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> results in larger improvements in craniovertebral angle, cervical lordosis angle, range of motion, <a href="https://brookbushinstitute.com/article/deep-cervical-flexor-activation" target="_blank" rel="noopener">DCF</a>, and <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">trapezius</a> activity, functional disability index scores, and potentially respiratory function.
<h3>Cervicogenic headache</h3>
Although most studies have demonstrated that mobilization and exercise have a positive effect on headaches, some consideration must be given to the origin of the headache and our limited ability to differentiate headache types. Not all headaches are cervicogenic, but many headaches are &quot;mixed&quot; with cervicogenic symptoms contributing to the patient&apos;s experience. It is common for cervical interventions to reduce headache variables like frequency, duration, and intensity without complete resolution or patients symptoms. A study by Schoensee et al. demonstrated that cervical mobilization decreased headache frequency, duration, and intensity from the baseline to the end of the treatment period (9&#x2013;12 treatment sessions/3 - 4 weeks)(16). A study by Pilling et al. demonstrated that upper cervical mobilizations had a positive impact on migraines (17); a finding that is likely explained by &quot;mixed&quot; symptoms, or cervicogenic symptoms being a &quot;trigger&quot; for the onset of migraines. Hall et al. and Mohamed et al. have demonstrated SNAG self-administered joint mobilizations may increase cervical rotation ROM and decrease headache frequency, duration, and intensity (18, 19). These studies on self-administered techniques are important for demonstrating the efficacy of self-management. La Touche et al. demonstrated that upper cervical mobilizations decreased craniofascial pain, and resulted in a sympathoexcitatory response including a significant increase in skin conductance, breathing rate, and heart rate (20) (The sympathoexcitatory response to mobilizations will be covered in more detail under &quot;Systemic Response to Cervical Mobilization&quot;). Borusiak et al. demonstrated that mobilizations were not effective for reducing the frequency or intensity of headaches in adolescents (21). This may not be surprising, as adolescents likely exhibit less cervical impairment. A study by Fern&#xE1;ndez&#x2010;de&#x2010;las&#x2010;Pe&#xF1;as et al. is a great summary of the impact cervical mobilizations may have on headaches. The researchers developed a clinical prediction rule to aid in determining which headache sufferers may benefit from <a id="trigger-point" data-tip="1632" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger point</a> therapy and joint mobilizations, demonstrating that individuals most likely to benefit exhibited symptoms of headache in conjunction with the presence of sternocleidomastoid <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a>, suboccipital <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a>, and restriction in cervical rotation ROM (22). In summary, cervical mobilization may improve headache frequency, duration, and/or intensity, but are more likely to improve symptoms when headaches are correlated with cervical <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> <a id="trigger-point" data-tip="1634" target="_blank" href="/glossary-term/trigger-point" class="glossary">trigger points</a> and cervical spine stiffness.

<h3>Cervical Mobilizations and the Shoulder</h3>
Several studies have demonstrated that cervical mobilizations may influence shoulder pain, motion, and/or <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment. A study by Huang et al. demonstrated that cervical mobilizations improved non-specific shoulder and/or arm pain, including an increase in shoulder strength (23). In a similar study by Wang et al., mobilizations of C5/C6 facet joints resulted in an immediate increase in strength of the <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">shoulder external rotators</a> with carry-over of at least 20 minutes (24). Seo et al. also demonstrated that the addition of cervical mobilizations with arm motion resulted in an increase in shoulder abduction strength (25). A similar study by Chaudhery et al, demonstrated that the addition of spinal mobilization with arm movements (SMWAMs) was more effective than a supervised exercise program, for reducing pain and disability and increasing shoulder strength (26). Last, an RCT by McClatchie et al. demonstrated that mobilization of the asymptomatic cervical spine in shoulder pain patients reduced the range of the painful arc and pain intensity when compared to placebo (78). Although these studies do not aid in building a <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> that would explain the correlation between <a href="https://brookbushinstitute.com/article/cervical-spine/" target="_blank" rel="noopener">cervical</a> treatment and <a href="https://brookbushinstitute.com/article/shoulder-glenohumeral-joint" target="_blank" rel="noopener">shoulder</a> dysfunction, they provide strong evidence that the addition of cervical mobilization to a shoulder rehabilitation program may improve shoulder pain, disability, and strength.
<h3>Cervical Mobilization and the Elbow</h3>
Like &quot;Cervical Mobilizations and the Shoulder&quot;, several studies have demonstrated that cervical mobilizations improve therapeutic outcomes for individuals with elbow dysfunction. Muhsen et al. demonstrated that <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> mobilizations resulted in a significant increase in pain pressure threshold in patients with <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia (74). Cleland et al. demonstrated that the addition of cervicothoracic mobilization to conventional therapy resulted in significantly better outcomes for individuals recovering from <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia (27). In a study by Mohanty et al., the addition of cervical mobilizations to conventional therapy improved outcomes after plaster (cast) removal for <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> radius fracture, including reducing swelling and pain, improving range of motion and strength, and decreasing time to full function (28). In an RCT by Botelho et al., judo athletes receiving cervical mobilizations had larger improvements in grip strength during a three-week training period (29). Again, these studies do not aid in building a <a id="hypothesis" data-tip="1446" target="_blank" href="/glossary-term/hypothesis" class="glossary">hypothesis</a> that would explain the correlation, but they do imply some amount of &quot;regional interdependence&quot;. Further, the studies provide strong evidence that the addition of cervical mobilization had a significant impact on pain, function, strength, and recovery time for elbow and forearm related issues.
<h3>Cervical Mobilization and the Temporomandibular Joint (TMJ)</h3>
Research has also demonstrated that cervical mobilizations may improve symptoms associated with temporomandibular joint dysfunction (TMD). In the study mentioned earlier, La Touche et al. demonstrated that upper cervical mobilizations decreased craniofascial pain, including temporalis and masseter pain pressure threshold (20). Pedroni et al. demonstrated that patients with a combination of TMD and signs of cervical dysfunction reported an increase in ROM and decreased pain after a single bout of cervical mobilization (30). Calixtre et al. demonstrated that cervical mobilizations and exercise improved self-reported pain, pain-free maximal mouth opening, masseter and temporalis pain pressure threshold, and improved scores on the Mandibular Functional Impairment Questionnaire (31). Again, these studies do not infer a causal relationship between cervical dysfunction and dysfunction of the TMJ but may be evidence of <a id="regional-interdependence" data-tip="1542" target="_blank" href="/glossary-term/regional-interdependence" class="glossary">regional interdependence</a>. Further, these studies are evidence that cervical mobilizations should be <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> into a plan of care for TMD.

Several studies have demonstrated that mobilizations have an effect on <a id="proximal" data-tip="1564" target="_blank" href="/glossary-term/proximal" class="glossary">proximal</a> <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity and strength, including a few studies <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> to the cervical spine and joint mobilizations. As mentioned earlier, an RCT by Cho et al. demonstrated that upper cervical and upper thoracic spine mobilizations were more effective than <a href="https://brookbushinstitute.com/article/deep-cervical-flexor-activation" target="_blank" rel="noopener">deep cervical flexor (DCF) exercise</a> for improving <a href="https://brookbushinstitute.com/article/longus-colli-longus-capitis-rectus-capitis-anterior-rectus-capitis-lateralis-deep-neck-flexors" target="_blank" rel="noopener">DCF</a> activity, as well as other factors related to forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> (15). A study by Sterling et al., demonstrated that cervical mobilizations resulted in an immediate improvement in <a href="https://brookbushinstitute.com/video/deep-cervical-flexor-endurance-test" target="_blank" rel="noopener">DCF endurance test</a> times, including a decrease in superficial neck flexor activity (32). An additional study by Jesus-Moraleida used ultrasound to demonstrate that cervical mobilization appeared to modulate <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/neck-muscle" target="_blank" rel="noopener">neck muscle</a> function by increasing deep <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment and reducing superficial <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment (33). Another study mentioned earlier by Lee et al. demonstrated that cervical mobilization and strengthening resulted in better outcomes than passive stretching and <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> for individuals with forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, including a decrease in <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius muscle</a> activity (12). These four studies imply that cervical mobilizations result in an increase in <a href="https://brookbushinstitute.com/article/longus-colli-longus-capitis-rectus-capitis-anterior-rectus-capitis-lateralis-deep-neck-flexors" target="_blank" rel="noopener">DCF</a> activity, and a reduction in superficial neck <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> (SCM) and <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius muscle</a> activity. These are significant, clinically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> changes, that imply cervical mobilization should precede additional techniques for optimizing <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> recruitment and strength. Further, studies have demonstrated that cervical mobilization affects the activity of more <a id="distal" data-tip="1563" target="_blank" href="/glossary-term/distal" class="glossary">distal</a> musculature. Wang et al. demonstrated that mobilizations of C5/C6 joints increased the strength of <a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">shoulder external rotators</a> immediately after therapy with a carry-over of at least 20 minutes (24). And, two studies mentioned in &quot;Cervical Mobilizations and the Elbow&quot; demonstrated increased grip strength when cervical mobilizations were added to other therapeutic/strength exercises (28, 29). These studies provide strong evidence that cervical mobilizations should be <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> into any program with the intent of optimizing strength and/or recruitment of cervical, shoulder, or elbow muscles.

Recent studies have demonstrated that mobilizations result in systemic responses, and some of these responses may be related to the outcomes achieved in practice. In a study mentioned earlier under &quot;Cervicogenic Headache&quot;, La Touche et al. demonstrated that upper cervical mobilizations decreased craniofascial pain, and resulted in a &quot;sympathoexcitatory&quot; (increased activity of the sympathetic <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a>) response that included an increase in skin conductance, respiratory rate, and heart rate (20). In an RCT by Sterling et al. (mentioned earlier) investigating patients with mid to lower cervical spine pain, mobilizations were shown to have analgesic effects, sympathoexcitatory effects including increased skin conductance and decreased skin temperature, along with enhanced <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity during the&#xA0;<a href="https://brookbushinstitute.com/video/deep-cervical-flexor-endurance-test" target="_blank" rel="noopener">deep neck flexor </a><a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> endurance test&#xA0;(32). Additionally, an RCT by Valera-Calero, demonstrated that both cervical mobilization and manipulation resulted in similar increases in levels of cortisol (34). These neurophysiological effects are not limited to symptomatic individuals. In an RCT by Yung et al., cervical mobilizations in pain-free individuals resulted in a short-lived decrease in systolic blood pressure (35). RCTs by Vicenzino et al. and McGuiness et al. (same group of researchers), demonstrated cervical <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> and grade III <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> central mobilizations at C5/C6 resulted in increased systolic blood pressure, heart rate, and respiratory rate in pain-free individuals (36, 37). An RCT by Yung et al. demonstrated that mechanical neck pain patients experienced a transient reduction in blood pressure and pain following <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> and <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> cervical mobilization (75). More research is needed to investigate why blood pressure may increase or decrease the following mobilization depending on the technique or patient population. Moulson et al. demonstrated that the application of cervical SNAGs to the C5/6 intervertebral joint (with cervical right rotation) on asymptomatic individuals resulted in increased skin temperature and skin conductance (38). An interesting study by Chiu et al. demonstrated that sympathetic efferent activity was correlated with the speed of mobilization, with faster mobilization resulting in larger effects on skin conductance and temperature (39). This may imply that the frequency of oscillation could play a large role in outcomes, with high-velocity manipulations resulting in the largest changes; more research is needed to determine whether these neurophysiological effects are causally related to the benefits of mobilizations. Two studies have investigated whether the sympathoexcitatory effects are related to stress. Vicenzino et al. demonstrated that no correlation was found between the level of patient stress, pain perception, and sympathoexcitatory response resulting from cervical mobilization in asymptomatic individuals (40). However, an RCT by Alonso-Perez demonstrated catastrophizing by the patient resulted in high-velocity manipulations being less effective (41). These studies demonstrate cervical mobilizations result in neurophysiological responses including increased skin conductance, respiratory rate, heart rate, systolic blood pressure, analgesia, increased levels of cortisol, increased&#xA0;<a href="https://brookbushinstitute.com/article/longus-colli-longus-capitis-rectus-capitis-anterior-rectus-capitis-lateralis-deep-neck-flexors" target="_blank" rel="noopener">DCF</a>&#xA0;activity, and lower&#xA0;<a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius</a>&#xA0;activity, in conjunction with mechanical effects such as increased range of motion, decreased stiffness and optimization of cervical alignment.

<h3>Cervical Mobilization versus Other Techniques</h3>
Some studies have compared the efficacy of cervical mobilizations to the efficacy of other modalities and interventions. In a study by Ganesh et al., Maitland cervical mobilizations (like those demonstrated in the videos below), Mulligan cervical mobilizations, and supervised exercise were compared, demonstrating that all interventions were equally effective for mechanical neck pain at 12 weeks. Unfortunately, this study did not detail the exercises included in the supervised exercise program, and intermittent measures were not recorded to determine if differences were noted early on (42). As mentioned above, the RCT by Cho et al. demonstrated that upper cervical and upper thoracic spine mobilizations were more effective than&#xA0;<a href="https://brookbushinstitute.com/article/deep-cervical-flexor-activation" target="_blank" rel="noopener">deep cervical flexor (DCF) exercise</a>&#xA0;for individuals with forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, including a larger reduction in pain, craniovertebral angle, more&#xA0;<a href="https://brookbushinstitute.com/article/longus-colli-longus-capitis-rectus-capitis-anterior-rectus-capitis-lateralis-deep-neck-flexors" target="_blank" rel="noopener">DCF</a>&#xA0;activity, and better functional outcome scores (15). Conversely, a study by Vinodkumar et al. demonstrated that cervical stabilization exercise was more effective than cervical mobilization for treating cervicogenic headaches (43). Kim et al. demonstrated that cervical mobilization and stretching were equally effective for improving range of motion and reducing pain for patients with neck pain (44). Riaz et al. demonstrated that stretching and Kaltenborn cervical mobilization equally improved range of motion and pain in individuals with non-specific neck pain (45). In an RCT by Ganesh et al, both cervical mobilization and ischemic <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> were equally effective for improving the pain pressure threshold of <a id="latent-trigger-point" data-tip="1133" target="_blank" href="/glossary-term/latent-trigger-point" class="glossary">latent trigger points</a> in the&#xA0;<a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius</a>&#xA0;in asymptomatic individuals (46). These rather inconclusive findings may suggest that cervical mobilizations, exercise, and stretching are likely to result in similar positive outcomes when performed individually; however, cervical mobilizations do result in better outcomes than some techniques. Khan et al. demonstrated that individuals with cervicobrachial pain syndrome benefited more from cervical mobilizations than neurodynamic techniques (47). An RCT by Copurgensli et al. demonstrated that mobilizations and <a id="kinesiology" data-tip="1692" target="_blank" href="/glossary-term/kinesiology" class="glossary">kinesiology</a> tape resulted in larger increases in rotation and extension ROM than conventional therapy for individuals with cervical spondylosis. Further, <a id="kinesiology" data-tip="1692" target="_blank" href="/glossary-term/kinesiology" class="glossary">kinesiology</a> tape had a larger impact on <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> flexion ROM, and mobilizations had a larger impact on&#xA0;<a href="https://brookbushinstitute.com/article/longus-colli-longus-capitis-rectus-capitis-anterior-rectus-capitis-lateralis-deep-neck-flexors" target="_blank" rel="noopener">DCF</a>&#xA0;endurance (48). Comparing cervical mobilizations to exercise, stretching, neurodynamics, taping, and ischemic <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> does not imply that any single technique or modality is <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> for addressing cervical dysfunction.
<h3>Cervical Mobilization with Other Techniques</h3>
Although research does not consistently demonstrate that cervical mobilizations are <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to other techniques when techniques are performed alone, research near ubiquitously demonstrates that the addition of cervical mobilizations to other techniques is <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a>. Several studies demonstrating this trend were mentioned earlier. A <a id="randomized-control-trial" data-tip="1403" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">randomized controlled </a><a id="randomized-control-trial" data-tip="1407" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">trial</a> (RCT) by Rodriguez et al. demonstrated cervical mobilizations in conjunction with neural mobilizations improved brachiocervical pain, cervical range of motion, and upper limb function (3). A randomized control <a id="randomized-control-trial" data-tip="1407" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">trial</a> by Ranganath et al. demonstrated that the addition of cervical mobilizations to neuromobilization and conventional therapy resulted in better improvements in range of motion, pain, and dysfunction (5). In addition to these studies, a double-blind RCT by Buyukturan demonstrated that the combination of mobilization and conventional therapy resulted in larger improvements than conventional therapy alone in a group of older individuals with chronic neck pain, including improved pain, ROM, functional level, kinesiophobia, depression, and quality of life (QoL) (49). Farooq et al. reported similar findings, demonstrating mobilization and conventional physical therapy resulted in larger decreases in pain and larger increases in ROM for a group with mechanical neck pain (50). In an RCT by Lee et al., cervical and thoracic spine mobilization with therapeutic exercise resulted in better outcomes than therapeutic exercise alone for patients with chronic neck pain, demonstrating greater improvements in pain, disability index, range of motion, and&#xA0;<a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">upper trapezius</a>&#xA0;activity (14). In studies by Ko et al. and Gong et al., the combination of mobilization and&#xA0;<a href="https://brookbushinstitute.com/article/deep-cervical-flexor-activation" target="_blank" rel="noopener">deep cervical flexor (DCF) exercise</a>&#xA0;resulted in more&#xA0;<a href="https://brookbushinstitute.com/article/longus-colli-longus-capitis-rectus-capitis-anterior-rectus-capitis-lateralis-deep-neck-flexors" target="_blank" rel="noopener">DCF</a>&#xA0;strength and endurance than&#xA0;<a href="https://brookbushinstitute.com/article/deep-cervical-flexor-activation" target="_blank" rel="noopener">deep cervical flexor (DCF) exercise</a>&#xA0;alone (51, 52). In a similar study, mentioned earlier in &quot;Cervical Mobilizations and the Shoulder&quot;, a study by Chaudhery et al, demonstrated that the addition of spinal mobilization with arm movements (SMWAMs) was more effective than a supervised exercise program, for reducing pain and disability and increasing shoulder strength (26). Last, a study by Aquaroli et al. demonstrated the effectiveness of an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> approach including mobilizations, manual soft tissue therapy, and exercise for the treatment of cervical radiculopathy (53). These studies, as well as studies investigating mobilization/manipulation for other joints, demonstrate that the combination of mobilization with other techniques is <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to techniques performed individually.
<h3>Comparing Cervical Mobilization Techniques</h3>
A few studies have attempted to compare cervical mobilization techniques with the intent of refining protocols. Hassan et al. demonstrated that both oscillatory and sustained stretch mobilization techniques improved pain, ROM, and disability associated with cervical radiculopathy; however, oscillatory mobilization resulted in larger improvements in ROM and Neck Disability Index (NDI) scores (54). In a double-blind <a id="randomized-control-trial" data-tip="1403" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">randomized controlled </a><a id="randomized-control-trial" data-tip="1407" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">trial</a> (RCT) mentioned earlier by Hayat et al., both Maitland and Mulligan mobilization techniques decreased pain and improved NDI associated with cervical radiculopathy, with Mulligan mobilizations slightly out-performing Maitland mobilizations (4). Interestingly, a study by Al Shehri et al. demonstrated that Maitland mobilization resulted in better outcomes than Mulligan mobilizations when done in conjunction with conventional therapy (55). Note, Maitland mobilizations are taught in the videos below, and the BI always recommends that <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> techniques are performed in conjunction with <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> techniques and exercise. It might be hypothesized that Mulligan mobilizations when used alone result in better outcomes due to the inclusion of movement through the newly achieved ROM as part of the technique, whereas, Maitland mobilizations may be more effective for reducing stiffness, but must be performed with exercise to use any new range achieved. A study by Egwu compared the relative efficacy of Posterior-Anterior <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">Unilateral</a> Pressure (PAUP), Anterior-Posterior <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">Unilateral</a> Pressure (APUP), Cervical Oscillatory Rotation (COR), and Transverse Oscillatory Pressure (TOP) techniques for the management of <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">Unilateral</a> cervical spondylosis, demonstrating that APUP and PAUP resulted in better outcomes and that APUP resulting in the best overall outcomes at 12 weeks (56). Note, spondylosis is a special case of neck pain, in which the rather uncomfortable APUP mobilization may be worth the discomfort. Last, a study mentioned earlier by Chiu et al. demonstrated that sympathetic efferent activity was correlated with the speed of mobilization, with faster mobilization resulting in larger effects on skin conductance and temperature (39). This may imply that mobilizations should be performed faster, up to 2 oscillations/second, as long as the technique is not compromised. In summary, <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> (or <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> in special cases), oscillatory, Maitland mobilizations, in conjunction with exercise may provide the largest benefit for individuals exhibiting signs of cervical dysfunction.

There are far fewer studies on thoracic mobilization than cervical mobilization, likely due to the preference of many professionals to manipulate (high-velocity thrust) the thoracic spine. Manipulation techniques for the thoracic spine will be covered in a separate course.
<h3>Thoracic mobilizations, posture, and cervical pain:</h3>
Similar to research on cervical mobilizations, thoracic spine mobilizations have demonstrated efficacy for various <a id="movement-impairment" data-tip="1579" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctions</a>, including cervical pain and cervicothoracic <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>. Kim et al. demonstrated that the addition of thoracic mobilization was more effective than adding stretching to a conventional therapy program at 4 and 8-week follow-ups, including larger reductions in cervical pain and larger increases in cervical ROM (57). Several studies discussed under &quot;Cervical Mobilization and Posture&quot; also demonstrated the efficacy of thoracic mobilizations. The RCT by Cho et al. demonstrated that upper thoracic mobilization and <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> exercise resulted in larger improvements than cervical mobilizations and <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a> exercise for forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> (13). Lee et al. demonstrated that the combination of cervical and thoracic mobilizations was more effective than cervical mobilizations alone for improving cervical alignment (14). And, an RCT by Cho et al. demonstrated that upper cervical and upper thoracic spine mobilizations improved forward head <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> more than <a href="https://brookbushinstitute.com/article/deep-cervical-flexor-activation" target="_blank" rel="noopener">deep cervical flexor (DCF) exercise</a> (59). Additionally, an RCT by Nakamaru et al. demonstrated that self-administered mobilization of the thoracic spine increases active cervical flexion and extension range of motion in individuals with mechanical neck pain (76). And, Hwangbo et al. demonstrated that self-administered thoracic mobilization and stretching were more effective than either technique alone for reducing cervical pain and improving respiratory function (FVC, FEV1, and PEF) (58). These studies suggest that adding thoracic mobilizations (both manual and self-administered) to conventional therapy improves outcomes for cervicothoracic <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a> and pain.
<h3>Thoracic mobilizations, thoracic and low back pain, and respiratory function.</h3>
Thoracic mobilization may have a positive effect on the thoracic spine and low back pain, as well as respiratory function for some individuals. A study by Jeong et al demonstrated that thoracic mobilizations performed once a week for 3 weeks resulted in improvements in thoracic kyphosis angle (<a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>), and also improved <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> during follow-up at 6 weeks (59). Kirshner et al. demonstrated significant improvements in thoracic spine segmental <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> and thoracic <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> during respiration after just two treatments of Kaltenborn mobilizations (60). Park et al. demonstrated that thoracic spine <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 decreased pain in low back patients, as well as improved respiratory function including FVC, FEV1, PEF, FEF25~75%, and chest wall expansion (61). An RCT by Babina et al. demonstrated similar findings combining thoracic mobilization and breathing exercises, resulting in improvements in low back pain, respiratory function, and disability (62). However, the ability to improve respiratory function appears to be limited to regaining lost respiratory function due to cervical, thoracic, and/or lumbar spine dysfunction. Jung et al. demonstrated that self-administered thoracic mobilization was effective for increasing chest expansion but not respiratory function in asymptomatic healthy adults (63). Further, Wang et al. reported rather unfortunate findings for COPD patients, demonstrating that although thoracic mobilization improved kyphosis angle and <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a>, there was little effect on respiratory function (64). It is interesting that many of the studies investigating the efficacy of thoracic mobilizations on cervical, thoracic, and low back pain are paired with respiratory function; however, it is important not to separate and generalize these findings. Thoracic mobilizations are effective for improving thoracic spine and low back pain, and respiratory function associated with cervical, thoracic or lumbar dysfunction; however, thoracic mobilizations are not effective for respiratory dysfunction not associated with these impairments.
<h3>Thoracic mobilizations in combination with other techniques</h3>
Similar to cervical mobilizations several studies have demonstrated that the addition of thoracic mobilizations improves outcomes. Mentioned several times in this course, Lee et al. demonstrated that the combination of cervical and thoracic mobilizations was more effective than cervical mobilizations alone for improving cervical alignment (14). In another study by Lee et al., adding cervical and thoracic mobilizations to 2 weeks of therapeutic intervention including hot packs, neck strengthening, <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">trapezius</a> stretching and thoracic extensions resulted in similar results with the additional benefit of improved cervical range of motion (65). Yang et al. demonstrated that low back pain patients benefited from the addition of thoracic mobilization to stabilization exercises, demonstrating significantly better strength and range of motion at 12 weeks (66). Further, Mohanty et al demonstrated that mobilization of the thoracic spine in addition to therapeutic exercise and stretching resulted in a significant reduction in lumbar spondylolisthesis &quot;slip&quot; (67). These studies demonstrate that the addition of thoracic mobilization to conventional therapy results in better outcomes than individual interventions.
<h3>Thoracic mobilizations, muscle activity, and systemic changes:</h3>
Several studies have demonstrated that thoracic mobilizations also have effects on the muscular and sympathetic nervous systems. In a preliminary RCT by Pecos-Mart&#xED;n et al., findings indicate that grade III, central <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, over the most symptomatic thoracic segment, reduced thoracic <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> activity during extension of the trunk in people with non-specific thoracic spine pain (68). Leibler et al. demonstrated that grade IV thoracic mobilization resulted in an immediate increase in <a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">lower trapezius</a> activity in asymptomatic individuals (77). An RCT mentioned above by Cho et al., demonstrated that cervical and thoracic mobilizations had a positive effect on <a href="https://brookbushinstitute.com/article/longus-colli-longus-capitis-rectus-capitis-anterior-rectus-capitis-lateralis-deep-neck-flexors" target="_blank" rel="noopener">DCF</a> activity (15). In an RCT by Jowsey et al., grade III, central, <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 to T4 resulted in skin conductance changes in the hand, suggesting &quot;sympathoexcitatory&quot; changes (69). Ghaffer et al. tracked additional sympathetic associated variables, demonstrating that thoracic mobilization resulted in a sudden elevation in heart rate, respiratory rate, and blood pressure without any major change in blood oxygen saturation (70). Conversely, two studies by Araujo et al demonstrated that pain pressure threshold and heart rate variability did not change following mobilization of thoracic spine regardless of mobilization speed (71, 72). The studies by Jowsey et al., Ghaffer et al., and Araujo et al. were performed on healthy asymptomatic individuals which may account for some of the variances in effect; however, the studies may also demonstrate that heart rate variability is simply not a <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> indicator of sympathoexcitatory effects. Further research is needed comparing the neuromuscular and sympathoexcitatory effects of cervical, thoracic, and/or lumbar mobilization techniques, and studies are needed correlating these effects with the positive outcomes. These studies are evidence that thoracic mobilization has neuromuscular and sympathoexcitatory effects in addition to the mechanical effects expected.
<h3>Comparing Thoracic Spine Techniques</h3>
Only one study was located comparing thoracic spine mobilizations. Shukla et al. compared <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> and transverse mobilizations, demonstrating that only small differences between the two techniques were apparent, and both techniques were effective for reducing pain and increasing range of motion for mechanical neck pain (73).

Video Demonstration

Cervical Mobilizations

<h3><iframe src="https://player.vimeo.com/video/250502409" frameborder="0" allowfullscreen="allowfullscreen"></iframe></h3>
<h4>Set-Up</h4>
<ol>
 <li>The patient should be <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a>, face-down in a &quot;cut-out&quot; or headrest, with a towel placed under the forehead to reduce the force on <a id="sensitivity" data-tip="1227" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitive</a> cheekbones.</li>
 <li>Arms should be in a supported and comfortable position to reduce the amount of <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity in scapulothoracic and cervicoscapular muscles.</li>
 <li>The table should be low enough so that leaning forward slightly allows the practitioner to get their chest over the cervical spine, with arms fully extended and thumbs in position over the affected segment.</li>
 <li>Ideally, the set-up would allow the practitioner to oscillate pressure by gently rocking the torso (not by using grip or triceps strength).
 <ul>
 <li>Note: It is worth spending some time reviewing the anatomy of the thoracic spine and practicing on a plastic <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> before practicing these techniques on a colleague.</li>
 <li>Note: Unlike the cervical spine, all segments of the thoracic spine can be addressed in a similar manner.</li>
 </ul>
 </li>
</ol>
<h4>Central Posterior to Anterior (PA) Mobilization</h4>
<ol>
 <li>Place the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> aspect of the hypothenar eminence on the spinous process of the intended segment.</li>
 <li>Place the other hand over the palpating hand by saddling the palpating hand between fingers 2 and 3 of the top hand.</li>
 <li>Check body mechanics to ensure the chest is over the target segment and the arms are straight.</li>
 <li>Apply force in <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> direction with a slight inclination toward the client&apos;s chest.</li>
</ol>
<h4>Unilateral PA</h4>
<ol>
 <li>Find the spinous process of the affected segment, or the segment exhibiting stiffness.</li>
 <li>Generally, the facet associated with the spinous process of the same vertebrae is two segments lower. Locate the facet of the intended segment by mobilizing the spinous process laterally, while palpating the facets on the affected side.</li>
 <li><a id="glide" data-tip="1815" target="_blank" href="/glossary-term/glide" class="glossary">Slide</a> your thumbs (thumb over thumb) into the laminar trough over the facet.</li>
 <li>Apply force in <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> direction with a slight inclination toward the client&apos;s chest.</li>
</ol>
<h4>Bilateral PA</h4>
<ol>
 <li>Find the spinous process of the affected segment, or the segment exhibiting stiffness.</li>
 <li>Locate the facet of the intended segment by mobilizing the spinous process laterally, while palpating the facets on the affected side. Generally, the facet of the vertebrae associated with the spinous process exhibiting stiffness is 2 segments (spinous processes) higher.</li>
 <li><a id="glide" data-tip="1815" target="_blank" href="/glossary-term/glide" class="glossary">Slide</a> your second and 3rd fingers over the intended facets on either side of the spinous processes.</li>
 <li>Use the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> aspect of the hypothenar eminence to apply pressure through the palpating fingers.</li>
 <li>Apply force in <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> direction with a slight inclination toward the client&apos;s chest.</li>
</ol>
<h4>Transverse</h4>
<ol>
 <li>Find the spinous process of the affected segment, or the segment exhibiting stiffness.</li>
 <li>Use a thumb over thumb palpation to gently pull some skin back over the spinous process you intend the mobilize. This will allow some slack in the tissue so that your mobilization is not impeded by stretched skin and irritation.</li>
 <li>Depress your thumbs into the tissue to gain purchase on the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> aspect of the intended spinous process (this is not easy and takes some practice).</li>
 <li>Apply force in a <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> direction.
 <ul>
 <li>Note: Pay careful attention to the direction of rotation you intend to improve. For example, if you are trying to improve right rotation, you would at least start by trying mobilizations standing on the patient&apos;s right side, pushing the spinous process from right to left.</li>
 </ul>
 </li>
</ol>
<h4>Mobilization:</h4>
<ol>
 <li>Once you have located the segment you wish to mobilize, start with small <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> oscillations to locate the facet, feel for articular motion, and identify any exquisite tenderness.</li>
 <li>When you are satisfied with your <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> motions, identify the amount of pressure required before you first feel resistance, just before articular motion, and then identify the amount of pressure applied before any additional pressure results in no further articular motion.
 <ul>
 <li>Note: The end of articular motion is the end of <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a>, not the end of cervical extension or rotation. Locate the point where the joint will not <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> any further, but there is little if any <a id="osteokinematic-motion" data-tip="1518" target="_blank" href="/glossary-term/osteokinematic-motion" class="glossary">osteokinematic motion</a>.</li>
 </ul>
 </li>
 <li>Identify the mid-point between the first resistance barrier and articular end-range; approximately 50% resistance.
 <ul>
 <li>Grade III - Larger oscillations between the first resistance barrier and approximately 50% resistance. Note, these oscillations are large compared to grade IV oscillations, but are still very small motions.</li>
 <li>Grade IV - Small oscillations at 50% resistance or more.</li>
 </ul>
 </li>
 <li>Oscillate at 1 - 2 pulses per second.</li>
 <li>Continue oscillating until you feel a change in tissue resistance/joint stiffness.</li>
</ol>

Thoracic Spine Mobilizations

Bibliography

© 2019 Brent Brookbush
Questions, comments and critiques welcomed and encouraged

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>

Accuracy - 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.

Adenosine triphosphatase (ATPase): 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>

Adenosine triphosphate (ATP): 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>

Algometry - 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>

All-or-none principle - 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.

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 anterior aspect of the head

Appendicular Skeleton - 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.

Arthrokinematic Motion - 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;

Assessment - 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>"Clear" the Patient/Client for Intervention - 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 Calf Squeeze (Thompson) Test 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>Highlight Contraindications - 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>Refine Exercise/Intervention Selection: 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 Refine Exercise/Intervention Selection, 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 Clearance to resume rehab activities.  Further, that same patient may return to the human movement professional with a list of Contraindicated Activities from the physician. - "When in doubt, refer out!"

Axial Skeleton - 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 axis "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>".

Balance - 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)

Base of support (BoS) - 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.

Case-control Study - 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. American journal of epidemiology, 134(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 caudally.

Center of mass (CoM) - an object's mean position of mass; that is, a point that is perfectly surrounded by an equal amount mass in all directions.

Center of gravity (CoG) - point where gravity 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 cephalad.

Cohort Study - 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>

Comparable Sign: 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.

Concave (Concavity) - 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>

Concordant Sign - The patient's specific pain, symptom or complaint. 
<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>

Conductivity: 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>

Contractility: The ability to shorten (1).
<ul>
 	<li>Contractility: 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.

Convex (Convexity) - 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>

Correlational Research - 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. J. Phys. Ther. Sci. 26: 961-964</a></li>
</ol>

Counter-nutation - 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;

Crossover (Study) Design - 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. Journal of Human Kinetics, 58, 197-206. </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) Journal of Medical Science 5(1). 52-54</a></li>
</ol>

Cytokine - 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.  Journal of Manual &amp; Manipulative Therapy. 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 distal end of the leg.

An arthrokinematic motion - a 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.

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 dorsal 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 alteration of normal kinematics.

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.

Elasticity: 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). Anatomy &amp; physiology. New York (NY): WCB/McGraw-Hill.</li>
</ol>

Equilibrium - 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">Evidence-based medicine (practice) 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. Bmj, 312(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>

Excitability: The ability of a cell to change in membrane conductance as a response to stimulation.

<ul>
 	<li>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.
</li>
</ul>
<ol>
 	<li>Saladin, K. (2012). Anatomy &amp; Physiology: The unity of form and function. (6th ed.). New York: McGraw-Hill.</li>
</ol>

Excitation threshold: 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>

Exercise Progression - 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>

Exercise regression - 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>

Experimental Research - 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. Journal of Strength and Conditioning Research, 27(11), 2997-3000.</a></li>
</ol>
&nbsp;

Extensibility: 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>

False Negative - 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>

False Positive - 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.

Fibromyalgia - A loosely defined diagnosis that is associated with a combination of widespread pain in combination with 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. Fibromyalgia Syndrome and Widespread Pain: From Construction to Relevant Recognition.</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. Arthritis &amp; Rheumatism: Official Journal of the American College of Rheumatology, 33(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. The Clinical journal of pain, 27(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. PAIN®, 145(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. Spine, 20(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. Spine, 20(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>

H-Band - 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) (biological holism) - (from Greek holos "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]. Holism and evolution. 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.

Hormone: 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. Scandinavian journal of clinical and laboratory investigation, 60(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.

Hyperplasia 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.

Muscular hypertrophy 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.

I-Band - 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. International Journal of Health and Rehabilitation Sciences. 2(4): 186-191</a></li>
</ol>

An anatomical direction; toward the bottom (below)

Example, the mouth is inferior 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.

Intermuscular Coordination - Optimal timing and motor unit recruitment of agonists, antagonists, synergists, neutralizers, stabilizers and fixators.

Example: Role of Muscles during Hip Extension
<ul>
 	<li><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>:  <a href="https://player.vimeo.com/external/82855344.hd.mp4?s=54c3e7d98fb9d4e0af8d282c85ba9b3e">Gluteus maximus</a></li>
 	<li><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>: <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><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>: <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><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>: <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><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>: <a href="https://brentbrookbush.com/articles/muscular-anatomy/deep-rotators-of-the-hip/">Deep rotators of hip</a></li>
 	<li><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>: <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 isoform, or variant, is a member of a set of similar proteins, that originate from the same gene, or gene family.
<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 kinetic chain, 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).

Latent Trigger Point - 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, Travell &amp; Simmons’ Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body: Second Edition,© 1999 Williams and Wilkens</li>
</ol>

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

Length/Tension Relationship - 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. The Journal of physiology, 184(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. The Journal of Physiology, 183(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. Journal of neurophysiology, 71(3), 874-881.</li>
 	<li>Lieber, R. L. (2002). Skeletal muscle structure, function, and plasticity. Lippincott Williams &amp; Wilkins.</li>
</ol>
&nbsp;

Levels of Evidence - 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.


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. Western Journal of Medicine, 170(6), 348.</li>
</ol>

Likelihood Ratios - 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>Positive Likelihood Ratio (LR+) - The ratio of a positive test result in people with the pathology to a positive test result in people without the pathology.</li>
 	<li>Negative Likelihood Ratio (LR-) - 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>

Any Questions, Concerns or Recommendations?

Please contact us through the
Support Page

Legal

Social

Joint Mobilization: Cervical and Thoracic Spine

Any Questions, Concerns or Recommendations? Please contact us through the Support Page

Legal

Social

Any Questions, Concerns or Recommendations?

Please contact us through the
Support Page