Introduction

Muscle Energy Technique (MET)

Techniques

Research Corner Summary

Lumbar Spine Mobilization Efficacy

Comparing Interventions

Combining Interventions

Systemic Effects and Muscle Activity

Sacroiliac Joint Mobilization Efficacy

Joint Mobilization: Lumbar Spine and Sacroiliac Joint

AOTA

TPTA

AUSPHYSIO

NYPT

PACE

<h3>Introduction</h3>
This course describes joint mobilizations for the lumbar spine and sacroiliac joints (SIJ). 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 lumbar spine and SI joint, improve restrictions in spine range of motion (ROM), and reduce pelvic asymmetry. For example, research has demonstrated that the SIJ may be the origin of approximately 15% of low back pain cases, asymmetrical stiffness the most common sacroiliac joint dysfunction, and mobilization of the stiff side an effective method for improving pain, function, and symmetry. 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 <a href="https://brookbushinstitute.com/courses/lower-leg-dysfunction" title="Lower Extremity Dysfunction" target="_blank" rel="noopener">lower extremity </a><a id="movement-impairment" data-tip="1579" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctions</a> (LED) and <a href="https://brookbushinstitute.com/courses/lumbo-pelvic-hip-complex-dysfunction-lphcd" title="Lumbo Pelvic Hip Complex Dysfunction" target="_blank" rel="noopener">lumbopelvic hip complex </a><a id="movement-impairment" data-tip="1579" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctions</a> (LPHCD) including chronic low back pain, acute low back pain, hamstring tendinopathy, groin pain, hip impingement syndrome, patellofemoral pain syndrome (PFPS), and <a id="movement-impairment" data-tip="1578" target="_blank" href="/glossary-term/movement-impairment" class="glossary">postural dysfunctions</a> including knee valgus, knee varus, excessive forward lean, <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> pelvic tilt, and/or asymmetrical weight shift. Some research and clinical outcomes even suggest that addressing <a href="https://brookbushinstitute.com/courses/lumbo-pelvic-hip-complex-dysfunction-lphcd" title="Lumbo Pelvic Hip Complex Dysfunction" target="_blank" rel="noopener">lumbo pelvic hip complex </a><a id="movement-impairment" data-tip="1579" target="_blank" href="/glossary-term/movement-impairment" class="glossary">dysfunctions</a> (LPHCD) may reduce the risk of future lower extremity injury.&#xA0;
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/lumbar-spine-anterior-to-posterior-mobilization" target="_blank" rel="noopener">Lumbar Mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/sacroiliac-joint-mobilization-posterior-anterior" target="_blank" rel="noopener">Sacroiliac Joint Mobilization</a></li>
</ul>
<h3>Sample Intervention (Example, <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-9-anterior-pelvic-tilt-excessive-lordosis" target="_blank" rel="noopener">Anterior Pelvic Tilt</a>)</h3>
<ul>
 <li>Manual Release
 <ul>
 <li><a href="https://brookbushinstitute.com/video/tfl-manual-release" target="_blank" rel="noopener">Tensor Fascia Latae (TFL) and Gluteus Minimus Static Manual Release</a></li>
 <li><a href="https://brookbushinstitute.com/video/rectus-femoris-release" target="_blank" rel="noopener">Rectus Femoris Static Manual Release</a></li>
 <li><a href="https://brookbushinstitute.com/video/psoas-illiacus-static-manual-release" target="_blank" rel="noopener">Psoas and Iliacus Static Manual Release</a></li>
 <li><a href="https://brookbushinstitute.com/video/erector-spinae-multifidus-static-manual-release" target="_blank" rel="noopener">Erector Spinae and Multifidus Static Manual Release</a></li>
 </ul>
 </li>
 <li>Mobilization or Manipulation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/lumbar-spine-anterior-to-posterior-mobilization" target="_blank" rel="noopener">Lumbar Mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/sacroiliac-joint-mobilization-posterior-anterior" target="_blank" rel="noopener">Sacroiliac Joint Mobilization</a></li>
 </ul>
 </li>
 <li>Manual Lengthening
 <ul>
 <li><a href="https://brookbushinstitute.com/video/manual-hip-flexor-stretch-thomas-test-position" target="_blank" rel="noopener">Thomas </a><a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a> Hip Flexor Stretch</li>
 </ul>
 </li>
 <li>Activation
 <ul>
 <li><a href="https://brookbushinstitute.com/article/gluteus-maximus-activation" target="_blank" rel="noopener">Gluteus Maximus Activation</a></li>
 <li><a href="https://brookbushinstitute.com/article/gluteus-medius-activation-progression" target="_blank" rel="noopener">Gluteus Medius Activation</a></li>
 <li><a href="https://brookbushinstitute.com/video/quadruped-crawl" target="_blank" rel="noopener">Transverse Abdominis Activation</a></li>
 </ul>
 </li>
 <li>Integration
 <ul>
 <li><a href="https://brookbushinstitute.com/video/static-lunge-to-row-posterior-oblique-subsystem-integration-progressions" target="_blank" rel="noopener">Static Lunge to </a><a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">Unilateral</a> Row</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: Lumbar Spine and Sacroiliac (SIJ) Joint Mobilization

<h2>For <a href="https://brookbushinstitute.com/article/lumbo-pelvic-hip-complex-dysfunction-lphcd" target="_blank" rel="noopener">Lumbo Pelvic Hip Complex Dysfunction</a> and <a href="https://brookbushinstitute.com/article/lower-leg-dysfunction" target="_blank" rel="noopener">Lower Extremity Dysfunction</a>:</h2>
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>
<h3>Techniques Covered in this Course:</h3>
<ul>
 <li><a href="https://brookbushinstitute.com/video/lumbar-spine-anterior-to-posterior-mobilization" target="_blank" rel="noopener">Lumbar Mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/sacroiliac-joint-mobilization-posterior-anterior" target="_blank" rel="noopener">Sacroiliac Joint Mobilization</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><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-9-anterior-pelvic-tilt-excessive-lordosis" target="_blank" rel="noopener">Anterior Pelvic Tilt</a></li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-17-sign-clusters-posterior-pelvic-tilt-butt-wink-and-inadequate-forward-lean-breakdown" target="_blank" rel="noopener">Inadequate Forward Lean</a></li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-15-sign-clusters-asymmetrical-weight-shift" target="_blank" rel="noopener">Asymmetrical Weight Shift</a></li>
 <li><a href="https://brookbushinstitute.com/video/knees-bow-in-breakdown" target="_blank" rel="noopener">Knees Bow In</a></li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-7-knees-bow-out" target="_blank" rel="noopener">Knees Bow Out</a></li>
 </ul>
 </li>
 <li><a href="https://brookbushinstitute.com/article/special-tests-sacroiliac-joint" target="_blank" rel="noopener">Sacroiliac Joint: Special Test</a>
 <ul>
 <li><a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-stork-gillet-test" target="_blank" rel="noopener">Gillet Test</a></li>
 </ul>
 </li>
 <li><a href="https://brookbushinstitute.com/article/introduction-to-goniometry" target="_blank" rel="noopener">Goniometry</a>
 <ul>
 <li><a href="https://brookbushinstitute.com/video/goniometry-hip-internal-rotation-in-prone" target="_blank" rel="noopener">Hip Internal Rotation </a><a id="goniometry" data-tip="1523" target="_blank" href="/glossary-term/goniometry" class="glossary">Goniometry</a> in <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">Prone</a> &lt;40 - 50&#xB0;</li>
 <li><a href="https://brookbushinstitute.com/video/goniometry-hip-internal-rotation-at-90-degree-of-hip-flexion-9090-hip-ir" target="_blank" rel="noopener">Hip Internal Rotation </a><a id="goniometry" data-tip="1523" target="_blank" href="/glossary-term/goniometry" class="glossary">Goniometry</a> in <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">Supine</a> &lt;35 - 45&#xB0;</li>
 <li><a href="https://brookbushinstitute.com/video/goniometry-hip-external-rotation-in-prone" target="_blank" rel="noopener">Hip External Rotation </a><a id="goniometry" data-tip="1523" target="_blank" href="/glossary-term/goniometry" class="glossary">Goniometry</a> in <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">Prone</a> &lt;40 - 50&#xB0;</li>
 <li><a href="https://brookbushinstitute.com/video/goniometry-hip-external-rotation-at-90-degrees-of-hip-flexion-9090-hip-er" target="_blank" rel="noopener">Hip External Rotation </a><a id="goniometry" data-tip="1523" target="_blank" href="/glossary-term/goniometry" class="glossary">Goniometry</a> in <a id="supine" data-tip="1562" target="_blank" href="/glossary-term/supine" class="glossary">Supine</a> &lt;35 - 45&#xB0;</li>
 <li><a href="https://brookbushinstitute.com/video/hip-extension-goniometry" target="_blank" rel="noopener">Hip Extension Goniometry</a> &lt;0 - 10&#xB0;</li>
 </ul>
 </li>
 <li><a href="https://brookbushinstitute.com/article/introduction-manual-muscle-testing-active-population" target="_blank" rel="noopener">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/gluteus-maximus-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">Gluteus Maximus Manual </a><a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> Testing (MMT) - Weak or With Compensation (Lumbar extension and/or knee flexion)</li>
 <li><a href="https://brookbushinstitute.com/video/gluteus-medius-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">Gluteus Medius Manual </a><a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">Muscle</a> Testing (MMT) - Weak or With Compensation (Lumbar <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> flexion and/or hip flexion)</li>
 </ul>
 </li>
</ul>
<table>
 <tbody>
 <tr>
 <td>
 <h4>Brookbush/Grieve Sacroiliac Joint (SIJ) Movement Cluster:</h4>
 <h4>Assess:</h4>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/sign-clusters-compensation-patterns-overhead-squat-assessment" target="_blank" rel="noopener">Overhead Squat </a><a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> (OHSA): Stiff SIJ on the side opposite of the <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-15-sign-clusters-asymmetrical-weight-shift" target="_blank" rel="noopener">asymmetrical shift with &quot;heel rise&quot;</a>
 <ul>
 <li>&quot;Top tier exam&quot; used to identify asymmetry and imply further SIJ assessment</li>
 </ul>
 </li>
 <li>Asymmetrical Pelvic Tilt: <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">Posterior</a> tilted innominate correlated with stiffer side</li>
 <li><a href="https://brookbushinstitute.com/video/sacroiliac-joint-special-test-stork-gillet-test" target="_blank" rel="noopener">Gillet Test</a>: Less motion on the stiffer side</li>
 <li><a href="https://brookbushinstitute.com/article/lower-body-goniometry" target="_blank" rel="noopener">Hip Rotation Range of Motion</a>: Less motion on the stiffer side</li>
 </ul>
 <h4>Treat:</h4>
 <ul>
 <li><a href="https://brookbushinstitute.com/article/joint-manipulation-lumbar-spine-sacroiliac-joint-and-pubic-symphysis" target="_blank" rel="noopener">Mobilize/Manipulate</a>: Stiff SIJ</li>
 <li><a href="https://brookbushinstitute.com/article/gluteus-maximus-activation" target="_blank" rel="noopener">Glute Activation</a>: <a id="mobility" data-tip="1457" target="_blank" href="/glossary-term/mobility" class="glossary">Mobile</a> Side</li>
 </ul>
 </td>
 </tr>
 </tbody>
</table>
<h3>Sample Intervention (Example, <a href="https://brookbushinstitute.com/video/overhead-squat-assessment-9-anterior-pelvic-tilt-excessive-lordosis" target="_blank" rel="noopener">Anterior Pelvic Tilt</a>)</h3>
<ul>
 <li>Manual Release
 <ul>
 <li><a href="https://brookbushinstitute.com/video/tfl-manual-release" target="_blank" rel="noopener">Tensor Fascia Latae (TFL) and Gluteus Minimus Static Manual Release</a></li>
 <li><a href="https://brookbushinstitute.com/video/rectus-femoris-release" target="_blank" rel="noopener">Rectus Femoris Static Manual Release</a></li>
 <li><a href="https://brookbushinstitute.com/video/psoas-illiacus-static-manual-release" target="_blank" rel="noopener">Psoas and Iliacus Static Manual Release</a></li>
 <li><a href="https://brookbushinstitute.com/video/erector-spinae-multifidus-static-manual-release" target="_blank" rel="noopener">Erector Spinae and Multifidus Static Manual Release</a></li>
 </ul>
 </li>
 <li>Mobilization or Manipulation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/lumbar-spine-anterior-to-posterior-mobilization" target="_blank" rel="noopener">Lumbar Mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/sacroiliac-joint-mobilization-posterior-anterior" target="_blank" rel="noopener">Sacroiliac Joint Mobilization</a></li>
 </ul>
 </li>
 <li>Manual Lengthening
 <ul>
 <li><a href="https://brookbushinstitute.com/video/manual-hip-flexor-stretch-thomas-test-position" target="_blank" rel="noopener">Thomas </a><a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a> Hip Flexor Stretch</li>
 </ul>
 </li>
 <li>Activation
 <ul>
 <li><a href="https://brookbushinstitute.com/article/gluteus-maximus-activation" target="_blank" rel="noopener">Gluteus Maximus Activation</a></li>
 <li><a href="https://brookbushinstitute.com/article/gluteus-medius-activation-progression" target="_blank" rel="noopener">Gluteus Medius Activation</a></li>
 <li><a href="https://brookbushinstitute.com/video/quadruped-crawl" target="_blank" rel="noopener">Transverse Abdominis Activation</a></li>
 </ul>
 </li>
 <li>Integration
 <ul>
 <li><a href="https://brookbushinstitute.com/video/static-lunge-to-row-posterior-oblique-subsystem-integration-progressions" target="_blank" rel="noopener">Static Lunge to </a><a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">Unilateral</a> Row</li>
 </ul>
 </li>
</ul>

Research, with near ubiquity, demonstrates favorable outcomes using lumbar and sacroiliac joint (SIJ) mobilizations. However, similar to the body of research on <a href="https://brookbushinstitute.com/article/joint-mobilization-shoulder-joint-acromioclavicular-joint-and-sternoclavicular-joint" target="_blank" rel="noopener">shoulder mobilizations</a>, a large percentage of lumbar and SIJ mobilization studies compare techniques. The videos below depict techniques conventionally referred to as <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) oscillatory mobilizations, or &quot;Maitland Mobilizations&quot;. Studies discussed in this course compare this technique to other techniques; however, for the most part, all techniques demonstrate efficacy and the differences between techniques are small. Please do not allow the nuances of various techniques to confuse or confound the implied efficacy of lumbar and SIJ mobilizations.
<table>
 <tbody>
 <tr>
 <td>
 <h3>Summary:</h3>
 <h3>Lumbar Mobilization:</h3>
 <ul>
 <li>Pain and Disability: Research demonstrates, nearly unanimously, that lumbar mobilization has a positive effect on pain and disability.</li>
 <li>Range of Motion (ROM): Lumbar mobilizations likely increase pain-free ROM in symptomatic individuals, and increase passive ROM when a restriction has been assessed.</li>
 <li>Stiffness: Studies suggest that lumbar mobilizations are effective for decreasing segmental stiffness when a restriction is present; however, practitioners should be careful not to assume that the painful segment is the segment that is <a id="hypomobility" data-tip="1675" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypo-mobile</a>.</li>
 <li>Straight Leg Raise <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">Test</a> (SLR) ROM: Lumbar mobilizations improve SLR ROM, including improving outcomes when added to other effective interventions.</li>
 <li>Comparing Interventions: Lumbar mobilizations are more effective than exercise in the first 2 months of treatment and are similarly as effective as dry needling, neural mobilizations, and Thai massage.</li>
 <li>Comparing Mobilizations: There is some evidence to suggest that individual mobilization techniques may have unique strengths; however, all mobilization techniques demonstrate similar efficacy. The efficacy of self-administered McKenzie press-ups demonstrated in research is impressive for a self-administered technique, and should motivate professionals to learn these techniques for possible addition to home exercise programs.</li>
 <li>Combining Interventions: These studies demonstrate that the addition of lumbar mobilization techniques to conventional medical intervention, conventional physical therapy, exercise, and/or neural mobilizations results in better outcomes, both short-term and long-term.</li>
 <li>Systemic <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">Nervous System</a> Response: Lumbar mobilizations result in altered pain <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>, a reduction in substance P, a reduction in H-reflex <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>, altered joint position sense, and an increase in skin conductance (sympatho-excitatory effects).</li>
 <li>Changes in Disk Hydration: Studies demonstrate a correlation between individuals who have an immediate reduction in pain, and individuals who exhibit changes in the diffusion of water of the lumbar disk immediately following lumbar mobilization.</li>
 <li>Motion during Mobilization: Lumbar mobilization results in translation and extension of the segment being mobilized, and movement of adjacent segments resulting in an increase in the lumbar lordosis, i.e. extension of upper segments and flexion of lower segments.</li>
 <li>Refining Practice: Studies demonstrate that <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> activity may increase segmental stiffness, implying the patient should be relaxed and comfortable during PA mobilizations. Further, the least stiffness is exhibited when PA mobilizations are performed with a slight <a id="cephalad" data-tip="1559" target="_blank" href="/glossary-term/cephalad" class="glossary">cranial</a> inclination bias.</li>
 </ul>
 <h3>Sacroiliac Joint Mobilization:</h3>
 <ul>
 <li>Efficacy: Research demonstrates that SIJ mobilizations are more effective than exercise, <a id="kinesiology" data-tip="1692" target="_blank" href="/glossary-term/kinesiology" class="glossary">kinesiology</a> tape, or TENS alone and that the combination of SIJ mobilizations with other effective techniques results in additional benefits.</li>
 <li>Comparing Mobilizations: Considering that all studies demonstrate that all mobilization techniques may be effective, and comparisons do not clearly imply a single best technique, it is likely reasonable to conclude that mobilization of the SIJ is effective and that PA mobilizations, MET, MWM, and self-administered techniques have similar efficacy.</li>
 <li>Systemic Effects: SIJ mobilization may result in analgesia, alter <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity and <a id="extensibility-2" data-tip="1308" target="_blank" href="/glossary-term/extensibility-2" class="glossary">extensibility</a>, and increase <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a>, which are all traits that imply <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a> adaptation beyond changes that can be attributed to altered biomechanics.</li>
 <li>Muscle Energy Technique (MET): Met has demonstrated efficacy for SIJ dysfunction and potentially knee pain, especially when added to conventional therapies (e.g. exercise), and maybe more effective than TENS or hot pack.</li>
 </ul>
 </td>
 </tr>
 </tbody>
</table>

Research Corner: Lumbar Spine

The following survey studies imply that lumbar and SIJ mobilizations are commonly performed in practice, especially for cases of low back pain. In a survey study by Tomkins et al., physical therapists were asked about the most frequently advocated treatment options for lumbar spinal stenosis. Seventy-six physical therapists were interviewed, 87% advocated for flexibility techniques, 86% advocated for stabilization techniques, 83% advocated for strengthening exercises, 76% advocated for heat/ice, 63% advocated for acupuncture, and 62% advocated for joint mobilizations (1). This study implies most physical therapists are using mobilizations, and further that most are using an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> approach; however, based on the effect sizes demonstrated in the research below, joint mobilizations and needling should likely be advocated for most, not least. An interesting study by Konstantinou et al. collected surveys from 51.4% of physiotherapists in the national health services in the UK, demonstrating that more than half of the respondents used mobilizations with movement (MWM) on at least a weekly basis, with 61.9% using MWMs primarily for mechanical low back pain, and the most commonly reported changes were improvements in ROM and pain (2). Although these studies represent a small cross-section of the professionals using lumbar and sacroiliac joint (SIJ) mobilizations internationally, the use of these techniques is undoubtedly common and most often being used for low back pain with the expectation of increasing ROM and decreasing pain.
<h3>Efficacy</h3>
A significant amount of research has investigated the efficacy of lumbar mobilizations. An RCT by Fan et al. compared either sham treatment or gentle lumbar mobilizations directed at a segment associated with an MRI confirmed herniated nucleus pulposus (HNP), in conjunction with conservative medical treatment (anti-inflammatories, advise). The study demonstrated that the mobilization group had better scores on validated outcome measures for disability and radiating symptoms during a follow-up 20 days after therapy; however, neither group significantly changed MRI findings (3). The improvement in pain and disability reported in this study are similarly demonstrated in most of the studies discussed in this review.
<h4>Range of Motion (ROM)</h4>
Research findings regarding the impact of lumbar mobilization on lumbar range of motion (ROM) suggest a more nuanced relationship. Goodsell et al. demonstrated that lumbar mobilizations had a significant effect on pain during the worst movement, but overall ROM did not change for patients with non-specific low back pain. Note, this study used a self-controlled cross-over design which may have influenced results (4). An RCT by Hidalgo et al. demonstrated that mobilizations with movement (MWM) resulted in reduced pain, reduced pain with motion, and increased ROM; however, the patient&apos;s fear of movement and movement speed was not significantly different than placebo-controls (5). These studies may suggest that some of the increases in measured ROM following mobilizations on symptomatic individuals are due to a decrease in pain during motion. Studies on asymptomatic individuals are equally mixed. Stamos-Papastamos et al. demonstrated no significant correlation between lumbar mobilization and an increase in flexion and extension ROM in asymptomatic individuals; however, individual differences were noted (6). Moutzouri et al. used 3-D motion capture technology to demonstrate that lumbar SNAG mobilizations did not significantly affect ROM in asymptomatic individuals (7). McCollam et al. demonstrated that PA mobilizations had a significant effect on lumbar extension ROM in asymptomatic active duty military personal (8). And, an RCT by Gibson et al. demonstrated that flexion mobilizations resulted in a significant increase in lumbar flexion ROM for individuals with assessed lumbar flexion restriction (9). The note regarding &quot;assessed lumbar flexion restriction&quot; may be a significant clue for developing an accurate conclusion. Considering these studies in aggregate, it may be reasonable to conclude that lumbar mobilizations may increase pain-free ROM in symptomatic individuals, and increase direction-specific ROM when a restriction has been assessed.
<h4>Stiffness</h4>
Additional studies have investigated the effect of lumbar mobilizations on lumbar stiffness. Allison et al. demonstrated that 2 minutes of lumbar mobilizations at multiple levels, had no effect on PA stiffness in asymptomatic individuals (10). Whereas, Shum et al. demonstrated that treating low back patients with grade III PA mobilizations resulted in an immediate improvement in pain, and reduced bending stiffness to levels comparable to asymptomatic controls (11). These studies may imply that symptomatic and asymptomatic individuals respond differently to mobilizations. Kulig et al. used MRI to identify the end-range of PA mobilizations, demonstrating that individuals with non-specific low back pain had a tendency to demonstrate single-level lumbar <a id="hypermobility" data-tip="1677" target="_blank" href="/glossary-term/hypermobility" class="glossary">hypermobility</a> when compared to age-controlled asymptomatic participants (12). Beneck et al. demonstrated that there was no definitive correlation between stiffness and painful segments (13). These two studies may imply that both <a id="hypermobility" data-tip="1677" target="_blank" href="/glossary-term/hypermobility" class="glossary">hypermobility</a> and <a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a> may contribute to low back pain, and further, that a painful segment is not a <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> indicator of which segment should be mobilized. Sato et al. used pre-and post-mobilization radiographs to demonstrate that PA mobilizations decreased stiffness (increased motion) at the segment mobilized, and not adjacent segments (14), which suggests a level of <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a> for mobilization techniques. Like the studies on <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a>, these studies may suggest that lumbar mobilizations are effective for decreasing segmental stiffness when a restriction is present; however, practitioners should be careful not to assume that the painful segment is the segment that is <a id="hypomobility" data-tip="1676" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobile</a>.
<h4>Straight Leg Raise Test (SLR)</h4>
Additional studies have demonstrated that lumbar mobilizations have a positive effect on straight leg raise (SLR) ROM. An RCT by Szlezak et al. compared a static <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> chain <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> stretch, <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> (PA) mobilization, or control (no intervention); demonstrating that mobilization resulted in the largest changes in SLR ROM immediately following treatment in asymptomatic individuals (15). Ganesh et al. duplicated the study by <a href="https://www.sciencedirect.com/science/article/abs/pii/S1360859214000618#bib44" target="_blank" rel="noopener">Szlezak et al. (2011)</a> (15), demonstrating that SLR ROM improved in asymptomatic individuals following lumbar PA mobilizations, and improvements were retained during a 24-hour follow-up (16). A series of studies by Chesterton et al. demonstrated that <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 mobilizations of the L4/L5 segment improved SLR ROM and decreased <a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a> and <a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a> activity, and further that <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> PA mobilizations resulted in larger outcomes than central PA mobilizations (17 - 19). These studies demonstrate that mobilizations alone may have a significant effect on SLR ROM.
Additional studies have demonstrated that adding lumbar mobilizations to other interventions improved SLR ROM outcomes. An RCT by Das et al. demonstrated adding lumbar mobilization with leg movement to neural mobilization and conventional therapy (back extension exercises and hot pack) resulted in larger improvements in pain, disability, and SLR ROM at 2, 4, and 6-week follow-ups (20). A double-blind RCT by Satpute et al. demonstrated that adding spinal mobilization with leg movement to electrotherapy and exercise, resulted in larger improvements in pain, disability, SLR ROM, and patient satisfaction following 6 sessions (over 2 weeks), and during a 6-month follow-up (21). Note, the studies by Das et al., Satpute et al. (17, 18) demonstrate impressive long-term results. Ma et al. demonstrated that the combination of motorized decompression, mobilization, and stabilization exercise improved pain, disability, and SLR ROM in individuals with HNP (22). An RCT by Thakur et al. investigated treatment for lumbar radiculopathy comparing the addition of Mulligan mobilizations with leg movement or Shacklock neural tissue mobilization to hot packs, core stabilization, and ergonomic advice, demonstrating that both groups exhibited improvements in pain intensity, SLR ROM, lumbar ROM, and back-specific disability; however, that MWM with leg movement resulted in <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> outcomes (23). Adel, S.M. demonstrated that the addition of SLR neural mobilization to lumbar mobilization and exercise improved pain, disability scores, and SLR ROM; however, the addition of neural mobilization did not improve H-reflex latency (24). Although many of these studies will be discussed further in later sections, the addition of mobilizations to an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> approach consistently produces additional benefits for SLR ROM both short-term and long-term. Nagulkar et al. demonstrated that low back patients with radiculopathy responded better to the combination of lumbar <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> and neural mobilization when compared to lumbar <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> followed by neural mobilization (25). This study suggests that more research is needed combining interventions, as this may result in better outcomes and more efficient sessions. Although studies investigating lumbar mobilizations have reported mixed outcomes for lumbar ROM and stiffness, the research consistently demonstrates that lumbar mobilizations result in improvements in SLR ROM, including when mobilizations are added to other effective interventions.

Several studies have compared the efficacy of lumbar mobilizations to the efficacy of other techniques. Schneider et al. demonstrated that for the treatment of spinal stenosis, manual therapy and <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> exercise were more effective than medical care and group exercise for the first two months of treatment; note, outcomes were similar at 6 months (26). An RCT by Krekoukias et al. demonstrated that for the treatment of low back pain with disk degeneration, 5 sessions of mobilizations resulted in larger improvements in pain and disability than conventional physiotherapy (CP) (stretching exercises, transcutaneous electrical <a id="nerve-cell" data-tip="1361" target="_blank" href="/glossary-term/nerve-cell" class="glossary">nerve</a> stimulation, and massage), and both groups were more effective than sham treatment (27). Sharma et al. demonstrated that the combination of Maitland mobilizations and lumbar stabilization exercises was more effective than conventional physical therapy (<a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a>, strengthening, stretching exercises) for improving pain and dysfunction associated with lumbar spondylosis; however, both treatments resulted in similar changes in ROM (28). Note, these studies suggest that mobilizations, for at least the first 2 months of treatment, are more effective than exercise, and further that the addition of <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> exercise is more beneficial than general exercise. Studies have also compared mobilizations, to dry needling, massage, and neural mobilization. An RCT by Griswold et al. demonstrated that dry needling and mobilization resulted in similar changes in disability and pain following 6 sessions in 3 weeks for individuals with non-specific low back pain (29). MacKawan et al. demonstrated that both joint mobilization and traditional Thai massage can reduce pain and levels of substance P; however, patients reported slightly less pain following Thai massage (30). Nagulkar et al. demonstrated that low back patients with radiculopathy responded better to the combination of lumbar <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> and neural mobilization when compared to lumbar <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> followed by neural mobilization (25). And, An RCT by Ahmed et al, demonstrated that neural mobilizations were more effective than Mulligan mobilizations with limb movement for reducing pain and H-reflex latency in individuals with lumbar disk herniation (31). In summary, studies suggest that lumbar mobilizations are more effective than exercise in the first 2 months of treatment, and similarly as effective as dry needling, neural mobilizations, and Thai massage More research may be recommended; however, it may be more clinically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> to compare the combination of treatments.
<h4>Comparing Mobilizations</h4>
Studies have compared various mobilization techniques. An RCT by Schenk et al. investigated the treatment of low back pain patients diagnosed with &quot;posterior derangement&quot; by comparing 3-sessions of lumbar mobilizations to McKenzie self-administered press-ups, demonstrating that both techniques were effective but press-ups resulted in larger improvements in pain and disability (32). An RCT by Waqqar et al. demonstrated that McKenzie press-ups improved pain and disability slightly more than Mulligan SNAG mobilizations following 4-weeks of treatment (33). Powers et al. compared McKenzie press-ups and PA mobilizations, noting that both techniques were similarly effective for increasing extension ROM and decreasing pain (34). These studies highlight the impressive efficacy of self-administered McKenzie press-ups, suggesting they are at least as effective as several manual mobilization techniques. Additional studies have compared Maitland mobilizations (like those taught below) to other mobilization techniques. A pilot RCT by Javaherian et al. demonstrated that when compared to sham, Maitland PA mobilizations improved extension, while Mulligan SNAG mobilizations improved flexion (35). Kim et al. compared conventional PA mobilization in <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a>, to mobilization in a sling (device not pictured in study), demonstrating that both techniques improved <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> <a id="tone" data-tip="1639" target="_blank" href="/glossary-term/tone" class="glossary">tone</a> and extensibility; however, the sling group may have exhibited larger reductions in right/left asymmetry (36). A study by Chesterton et al. compared central PA mobilizations, <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> PA mobilizations, and controls, demonstrating that central PA and <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> PA mobilizations increased lumbar and hamstring ROM and reduced local <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity; however, <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> PA mobilizations trended toward larger changes when compared to central PA mobilizations (19). These studies may suggest that each technique has unique benefits; however, all techniques demonstrated efficacy. Last, an RCT by Thakur et al. compared MWM with leg movement to Shacklock neural tissue mobilizations for lumbar radiculopathy, demonstrating that MWM with leg movement resulted in <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> outcomes for pain intensity, lumbar ROM, and back-specific disability (23). In summary, there is some evidence to suggest that individual mobilization techniques may have unique strengths; however, all mobilization techniques demonstrated similar efficacy. The efficacy of self-administered McKenzie press-ups is impressive and should motivate professionals to learn these techniques for possible addition to home exercise programs.

Similar to research investigating the efficacy of other manual techniques, the addition of lumbar mobilizations to an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> approach most often results in additional benefits. An RCT by Hussien et al. demonstrated that the addition of Mulligan SNAG lumbar mobilizations to a conventional physical therapy program that included strengthening and stretching, improved disability, pain, and joint repositioning error scores (37). A double-blind RCT by Satpute et al. demonstrated that adding spinal mobilization with leg movement to electrotherapy and exercise, resulted in larger improvements in pain, disability, SLR ROM, and patient satisfaction following 6 sessions over 2 weeks, and during 6-month follow-up (21). Haggannavar et al. demonstrated that the addition of Mulligan lumbar SNAG mobilization to conventional therapy improved pain, ROM, and scores on the back performance scale (38). Choi et al. demonstrated that the addition of flexion-distraction mobilization to conventional therapy resulted in larger decreases in pain and dysfunction than conventional therapy alone (39). Niemist&#xF6; et al. demonstrated that for the treatment of chronic low back pain, mobilization and stabilization exercise resulted in larger improvement in pain and disability than physician advice and an education booklet at 5- and 12- month follow-ups (40). Another RCT by Nemisto et al. demonstrated that the combination of mobilization, exercise, and physician consultation/education resulted in a major recovery of 60% of patients compared to just 51% of patients in the physician consultation/education alone group at 1-year follow-up. Despite psychosocial issues being a strongly correlated factor with failure to recover, the study demonstrates that the addition of mobilization resulted in significantly better outcomes (41). These studies demonstrate that the addition of lumbar mobilization techniques to conventional therapy, exercise, and/or medical advice significantly improves outcomes both short-term and long-term.
Studies have also investigated the efficacy of combining various mobilization techniques. Lee et al. demonstrated that the combination of joint mobilization and decompression therapy resulted in larger improvement in pain and ROM than heat, electrotherapy, and decompression for patients with low back pain and HNP (42). Ma et al. demonstrated that the combination of motorized decompression, mobilization, and stabilization exercise improved pain, disability, and SLR ROM in individuals with HNP (43). Additional studies have investigated the combination of lumbar mobilization and neural mobilization. Murphy et al. demonstrated that the combination of <a id="distraction" data-tip="1589" target="_blank" href="/glossary-term/distraction" class="glossary">distraction</a> mobilization and neural mobilization resulted in significant changes in pain and disability in approximately 70% of patients with lumbar spinal stenosis during long-term follow-up (mean 16.5 months), resulting in only 2 of 57 patients progressing to surgical intervention (44). An RCT by Nagrale et al. investigated the treatment of non-radicular low back pain, comparing mobilization and exercise to slump neural mobilization and exercise, demonstrating that both combinations were effective with slightly larger improvements noted in the slump neural mobilization group (45). This study likely implies that a combination of mobilization, neural mobilization, and exercise should be considered for the treatment of non-radicular low back pain. Adel demonstrated that the addition of SLR neural mobilization to lumbar mobilization and exercise improved pain and disability scores; however, the addition of neural mobilization did not improve H-reflex latency (24). As demonstrated above, the combination of exercise and mobilization is effective; however, these studies suggest that combining mobilizations, in particular, neural mobilization may provide additional benefit.
Additional studies have investigated the combinations of lumbar mobilizations with other interventions. An RCT by Machado et al. demonstrated that McKenzie press-up self-administered care, when added to physician care including advice, reassurance, and time-contingent acetaminophen, did not result in significant short-term or long-term benefit; however, individuals using McKenzie press-up self-administered care sought less additional medical services (46). Shuiping et al. demonstrated that treatment of HNB with a combination of &#x3B2;-aescinate intravenous drip and lumbar mobilization resulted in a 67% curative rate, compared to just 23% curative rate from <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a> alone (47). And an RCT by Lizis et al. compared manual therapy including lumbar mobilization with either kinesiotaping or cryotherapy for the treatment of lumbar discopathy, demonstrating that cryotherapy resulted in better pain and quality of life scores (48). These studies may suggest that lumbar mobilization may be more effective than <a id="distraction" data-tip="1813" target="_blank" href="/glossary-term/distraction" class="glossary">traction</a>, cryotherapy more effective than kinesiotaping, and McKenzie press-ups only effective as an adjunct modality when combined with conventional physician treatment.

<h3>Systemic Effects</h3>
Studies have also demonstrated systemic effects resulting from mobilizations, similar to those noted for&#xA0;<a href="https://brookbushinstitute.com/article/joint-manipulation-lumbar-spine-sacroiliac-joint-and-pubic-symphysis" target="_blank" rel="noopener">lumbar manipulations</a>. Karvat et al. demonstrated that lumbar PA mobilization to L2/L3 on asymptomatic individuals resulted in a reduction in pain <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> to cold, but no change in pain pressure threshold (49). And, Terrett et al. demonstrated that lumbar mobilization increased cutaneous pain tolerance by about 40% in asymptomatic individuals (50). As mentioned above, MacKawan et al. demonstrated that both joint mobilization and traditional Thai massage can reduce pain and levels of substance P (30). These studies imply reflexive changes to pain <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> that occur in symptomatic and asymptomatic individuals, including alterations in neurotransmitters. Additional studies have demonstrated altered stretch reflex, joint position sense, and sympatho-excitatory change. Bulbulian et al. demonstrated that H-reflex (stretch reflex) <a id="excitability" data-tip="1310" target="_blank" href="/glossary-term/excitability" class="glossary">excitability</a> was diminished by flexion mobilizations, but not rotation or <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> flexion mobilizations (51). Gong et al. demonstrated that lumbar mobilizations and massage improved joint position sense, and massage alone did not in asymptomatic adults (52). An RCT by Tsirakis et al. demonstrated that the effects of spinal mobilization with leg movement resulted in sympatho-excitatory changes (skin conductance) on the treated side lower extremity when compared to sham and control interventions (53). And, An RCT by Moutzouri et al. demonstrated that central PA mobilizations and SNAG mobilizations applied to the L4 spinous process of asymptomatic individuals had a significant effect on lower extremity skin conductance (sympatho-excitatory effects) when compared to sham (54). In summary, mobilizations result in <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a> changes including altered pain <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>, reduced levels of substance P, a reduction in H-reflex <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>, altered joint position sense, and an increase in skin conductance (sympatho-excitatory effects).
<h3>Muscle Activity</h3>
Additional studies have demonstrated the effect of lumbar mobilization on <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity. (used above) Abe et al. demonstrated that Maitland mobilizations (like those taught below) improved <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strength and endurance of the&#xA0;<a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a>&#xA0;immediately following mobilization and during a 7-day follow-up, but had no effect on pain or <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> in young women with low back pain (55). An RCT Kamel et al. demonstrated that lumbar mobilizations, 3 sessions/week for 4 weeks, had a significant effect on pain intensity, function, and&#xA0;<a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a>&#xA0;EMG activity when compared to sham and control groups in postpartum females with low back pain (56). Hanrahan et al. demonstrated that lumbar mobilizations decreased overall pain, and pain during extension, as well as improved force production from the&#xA0;<a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a>&#xA0;(57). An RCT by Mehyar demonstrated that&#xA0;<a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a>&#xA0;activity decreased, but&#xA0;<a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a>&#xA0;activity did not, during arm elevation immediately following grade IV lumbar mobilization performed on asymptomatic individuals (58). Two of the three studies by Chesterton et al. mentioned above included EMG activity. The first demonstrated that <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 of the L4/L5 segment reduced <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity and increased <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> of the&#xA0;<a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a>&#xA0;and&#xA0;<a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a>&#xA0;(18). And, the following year the same group compared 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 (CPA), <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> to <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> mobilizations (UPA), and controls, demonstrating that CPA and UPA mobilizations increased lumbar and hamstring ROM and reduced local <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity (<a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a>&#xA0;and&#xA0;<a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a>) - UPA mobilizations trended toward larger changes when compared to CPA (19). These studies are strong evidence that mobilizations have an immediate effect on&#xA0;<a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">lumbar erector</a>&#xA0;and additionally&#xA0;<a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">biceps femoris</a>&#xA0;activity.
Additional muscles have also been tested. A pilot RCT by Chi-Ngai et al. demonstrated that PA mobilizations of the L2/L3 segment resulted in an increase in&#xA0;<a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">hip flexor</a>&#xA0;strength in individuals with pack pain (59). An RCT by Yuen et al. demonstrated that grade III lumbar mobilizations improved hip flexor <a id="torque" data-tip="1294" target="_blank" href="/glossary-term/torque" class="glossary">torque</a> and single-leg triple hop performance in women with a positive&#xA0;<a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">hip flexor</a>&#xA0;&quot;break&quot; <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> (60). These studies may suggest that lumbar pain/dysfunction may inhibit&#xA0;<a href="https://brookbushinstitute.com/article/psoas" target="_blank" rel="noopener">hip flexor</a>&#xA0;performance, and that lumbar mobilization is an effective treatment option. Kim et al. demonstrated that lumbar spine PA mobilizations resulted in an acute increase in isometric&#xA0;<a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">knee extension</a>&#xA0;torque in healthy, asymptomatic individuals; however, there was no effect on&#xA0;<a href="https://brookbushinstitute.com/video/back-squat" target="_blank" rel="noopener">squat</a>&#xA0;performance (61). In a pilot RCT by Heo et al., lumbar rotational mobilization and lumbar rotation exercise had similar small effects on single-leg standing balance; however, the follow-up RCT demonstrated a small but significant increase in <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> for the lumbar mobilization group (62). These additional studies imply that more research should be performed to investigate the effect lumbar mobilization has on lower extremity <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> EMG activity and <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>. At the very least, lumbar mobilizations may be effective for reducing hip flexor inhibition, and increasing isometric&#xA0;<a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">knee extension</a>&#xA0;torque.
<h3>Additional Notes:</h3>
Additional studies have investigated the mechanical and kinematic changes associated with lumbar mobilizations. An initial study by Beattie et al. used MRI to demonstrate that lumbar mobilization may be correlated with an increase in the diffusion of water of lumbar discs affected by degenerative disc disease (63). In a follow-up study, Beattie et al. demonstrated that an immediate reduction in low back pain intensity of 2 or more (out of 10) following PA mobilizations and <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> press-ups, was correlated with an increase in the diffusion of water in the nuclear region of the L5-S1 intervertebral disc. This study compared responders to non-immediate responders who did not exhibit a significant correlation (64). These studies may suggest that normalization of the diffusion of water in affected lumbar disks may be contributing factor to an immediate reduction in symptoms.
Kinematic studies have detailed the motion that occurs during PA mobilizations. A cadaver study by Lee et al. demonstrated that PA mobilization resulted in mostly translation and extension of the segment mobilized. Further, dissection (damage) of <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> tissues did not significantly alter motion during mobilization, until the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> longitudinal ligament was severed, which may imply mobilizations are safe for post-surgical treatment (65). Another MRI study by Kulig et al. demonstrated that PA mobilizations resulted in the extension of the target segment and significant motion of other segments (66). Powers et al. demonstrated that the application of a PA mobilization resulted in 1.2 - 3&#xB0; of segmental extension, with either an increase or decrease in the lumbar lordosis depending on the segment being mobilized (67). Another study Lee et al. used radiographs to demonstrate that PA pressure on L4, resulted in flexion of the L4 - S1 segments, an extension of L1 - L4 segments, and <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> translation of all segments (68). Lumbar mobilization results in translation and extension of the segment being mobilized, and movement of adjacent segments resulting in an increase in the lumbar lordosis, i.e. extension of upper segments and flexion of lower segments.
Kinematic studies may imply certain modifications that can be made to refine treatment. A study by Lee et al. demonstrated that contraction of the&#xA0;<a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">lumbar extensors</a>&#xA0;significantly increased stiffness of lumbar segments during PA mobilizations (69). Caling et al. compared the relative stiffness of the L3 segment during various inclinations of a PA central mobilization. The study demonstrated that a <a id="caudal" data-tip="1557" target="_blank" href="/glossary-term/caudal" class="glossary">caudal</a> inclination angle (14&#xB0;) resulted in the most stiffness, and a <a id="cephalad" data-tip="1559" target="_blank" href="/glossary-term/cephalad" class="glossary">cranial</a> inclination angle (11&#xB0;) resulted in the least stiffness (70). These studies may suggest that it is important to ensure the patient is relaxed and comfortable during PA mobilizations, and that PA mobilizations should likely be performed with a slight <a id="cephalad" data-tip="1559" target="_blank" href="/glossary-term/cephalad" class="glossary">cranial</a> inclination bias.

Research Corner: Sacroiliac Joint

The efficacy of sacroiliac (SIJ) mobilization is similar to the efficacy of lumbar mobilization. Unfortunately, there are far fewer studies investigating the effects of mobilizations when compared to the number of studies on lumbar mobilizations or <a href="https://brookbushinstitute.com/article/joint-manipulation-lumbar-spine-sacroiliac-joint-and-pubic-symphysis" target="_blank" rel="noopener">SIJ manipulations</a>. Guha, K. demonstrated that the combination of sacroiliac joint mobilization and <a href="https://brookbushinstitute.com/article/tva" target="_blank" rel="noopener">abdominal</a> and <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> strengthening exercise was significantly more effective for improving pain and function, when compared to <a href="https://brookbushinstitute.com/article/tva" target="_blank" rel="noopener">abdominal</a> and <a href="https://brookbushinstitute.com/article/multifidus" target="_blank" rel="noopener">multifidus</a> strengthening exercises alone, both immediately following treatment and during a 7-day follow (71). Son et al. demonstrated that the combination of SIJ mobilization with movement (MWM) and functional training improved pelvic asymmetry, as well as static <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> and control (72). Although fewer studies are available, current research suggests that the addition of SIJ mobilization results in <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> outcomes.

Research has compared SIJ mobilization to various interventions and combinations of interventions. An RCT by Visser et al. demonstrated that SIJ related leg pain was successfully treated with physiotherapy in 3 out of 15 patients (20 %), intra-articular injection in 9 of 18 patients (50 %), and manual therapy (mobilization and soft tissue) in 13 of the 18 patients (72 %), demonstrating manual therapy had a significantly better success rate than physiotherapy or injections (73). An RCT by Ulger et al. demonstrated that for the treatment of low back pain, SIJ mobilizations compared to stabilization exercise resulted in similar outcomes for quality of life scores; however, mobilizations resulted in larger improvements in pain and functional outcomes (74). Mathew et al. demonstrated that MET and joint mobilizations resulted in larger improvements in pain and quality of life scores than conventional physiotherapy (exercise); however, both groups exhibited significant positive changes (75). Sabour et al. demonstrated that the addition of SIJ MWM to <a id="posture" data-tip="1659" target="_blank" href="/glossary-term/posture" class="glossary">postural</a> exercise resulted in larger improvements in pain, disability, pain pressure threshold (algometry), and lumbar flexion ROM (76). Kristev et al. demonstrated that low back pain with signs of SIJ dysfunction treated with transverse lumbar massage and joint mobilization exhibited larger improvements in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strength and endurance than conventional massage and exercise (77). Note, some skepticism about the findings of this last study may be appropriate; the publication was very difficult to read, potentially due to a poor job translating the original publication. These studies demonstrate that SIJ mobilization alone is more effective than exercise and that the addition of SIJ mobilization to exercise is particularly effective for improving outcomes. Additional studies have compared SIJ mobilization to TENS and Kinesiotaping. A doctoral dissertation (RCT) by Fernandes demonstrated that Mulligan taping was more effective than Mulligan MWM (both groups also received ultrasound) for the treatment of SIJ pain and disability (78). An RCT by Vaidya et al. demonstrated that SIJ mobilization was more effective for reducing pain and improving function than TENS in women with pregnancy-related SIJ pain (79). And, Varghese et al. demonstrated MWM resulted in larger changes in pain, ROM, and quality of life scores than the combination of interferential electrical stimulation and conventional exercise for individuals with SIJ dysfunction (80). These studies demonstrate that SIJ mobilization is more effective than exercise or TENS alone and that the combination of SIJ mobilizations with other techniques is likely to result in better outcomes than either treatment alone. More research is needed comparing SIJ mobilizations and <a id="kinesiology" data-tip="1692" target="_blank" href="/glossary-term/kinesiology" class="glossary">kinesiology</a> taping.
<h4>Comparing SIJ Mobilizations</h4>
Several studies have compared SIJ mobilization techniques. Altaim et al. demonstrated that both Maitland mobilization (like those taught below) and Mulligan&apos;s MWM technique were equally effective for improving pain and function in individuals with 3 of 5 positive tests on the&#xA0;<a href="https://brookbushinstitute.com/video/sacroiliac-joint-testing-item-cluster-lasletts-cluster-ii" target="_blank" rel="noopener">Laslett SIJ Pain Provocation Cluster</a>&#xA0;(81). Sharma et al. demonstrated that mobilization and MET techniques result in similar improvements in pain and disability for patients with SIJ dysfunction (82). In another study by Vaidya et al., MWM was compared to MET technique (both groups receiving ultrasound) for treatment of SIJ dysfunction, demonstrating that both mobilization techniques were effective for improving pain and dysfunction; however, MET did result in slightly better outcomes (83). Kaur et al. compared Maitland and MWM mobilizations for the treatment of SIJ dysfunction, demonstrating that both techniques were equally effective for pain, but MWM was more effective for disability (84). Two additional studies also compared mobilization techniques; however, there were issues with the methodology of the study. An RCT by Nejati et al attempted to compare mobilization and exercise, but the groups included SIJ self-administered mobilization, manually assisted stretching that may affect the hip lumbar spine and SIJ, and dynamic lumbar and core exercise. The study demonstrated that all groups experienced similar improvements in pain and disability, which may imply that all 3 groups of interventions have an effect on SIJ motion (85). Sachdeva et al. demonstrated that the <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> energy technique was more effective than SIJ mobilization, but the methodology of this study is questionable. The mobilization technique used was an ilium rotation which has not been previously researched and it was compared to a series of 3 <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> energy techniques (86). This study needs to be redone using a mobilization technique that has demonstrated efficacy in research, and treatment protocols should include approximately equal amounts of intervention. Considering that all studies demonstrate that all techniques may be effective, and comparisons do not clearly imply a single best technique, it is likely reasonable to conclude that mobilization of the SIJ is effective and that PA mobilizations, MET, MWM, and self-administered techniques have similar efficacy.

Mobilization of the SIJ results in systemic responses that are similar to those noted during mobilization of the lumbar spine, and/or&#xA0;<a href="https://brookbushinstitute.com/article/joint-manipulation-lumbar-spine-sacroiliac-joint-and-pubic-symphysis" target="_blank" rel="noopener">manipulation of the lumbar spine or SIJ</a>. An RCT by Sipko et al. demonstrated that mobilization and self-mobilization of the SIJ resulted in analgesia, increasing pain pressure threshold over the iliolumbar ligament and&#xA0;<a href="https://brookbushinstitute.com/article/erector-spinae" target="_blank" rel="noopener">erector spinae</a>&#xA0;in asymptomatic individuals (87). Further, several studies have demonstrated changes in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity. An RCT by Gong et al. demonstrated that SIJ mobilization had a significant effect on leg length inequality testing and&#xA0;<a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a>&#xA0;strength when compared to a control group (88). Tamer et al. demonstrated that&#xA0;<a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a>&#xA0;muscle activity and strength, as well as&#xA0;<a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">hamstring</a>&#xA0;extensibility, improved following SIJ mobilization, and the results were maintained during a follow-up 4-days later (89). Cibulka et al. compared moist heat pack and gentle&#xA0;<a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">hamstring</a>&#xA0;stretching to SIJ mobilization for the treatment of&#xA0;<a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">hamstring</a>&#xA0;strain, demonstrating that&#xA0;<a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">hamstring</a>&#xA0;peak <a id="torque" data-tip="1294" target="_blank" href="/glossary-term/torque" class="glossary">torque</a> was significantly higher in the SIJ mobilization group, and&#xA0;<a href="https://brookbushinstitute.com/article/quadriceps-vastus-muscles" target="_blank" rel="noopener">quadriceps</a>&#xA0;peak <a id="torque" data-tip="1294" target="_blank" href="/glossary-term/torque" class="glossary">torque</a> and&#xA0;<a href="https://brookbushinstitute.com/article/biceps-femoris" target="_blank" rel="noopener">hamstring</a>&#xA0;extensibility were similar in both groups (90). Several studies have also demonstrated that SIJ mobilization may improve <a id="equilibrium" data-tip="1199" target="_blank" href="/glossary-term/equilibrium" class="glossary">equilibrium</a> or <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a>. Gong et al. demonstrated that SIJ mobilizations performed 3 times/week for 3 weeks significantly improved <a id="equilibrium" data-tip="1199" target="_blank" href="/glossary-term/equilibrium" class="glossary">equilibrium</a> (reduced sway) in healthy subjects (91). A follow-up RCT by Gong et al. demonstrated that SIJ mobilization or core stabilization exercise significantly improved <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> (reduced sway) when compared to a control group, following 3 weeks of treatment (92). As mentioned above, Son et al. demonstrated that the combination of sacroiliac mobilization with movement and functional training improved pelvic asymmetry, as well as static <a id="balance" data-tip="1190" target="_blank" href="/glossary-term/balance" class="glossary">balance</a> and control (72). These studies demonstrate that SIJ mobilization may result in analgesia, alter <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity and <a id="extensibility-2" data-tip="1308" target="_blank" href="/glossary-term/extensibility-2" class="glossary">extensibility</a>, and increase <a id="stability" data-tip="1191" target="_blank" href="/glossary-term/stability" class="glossary">stability</a>, which are all traits that imply <a id="nervous-system" data-tip="1690" target="_blank" href="/glossary-term/nervous-system" class="glossary">nervous system</a> adaptation beyond changes that can be attributed to altered biomechanics.

Systemic Effects

The use of <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> energy technique (MET) for SIJ mobilization has been investigated in a number of studies. Joshi et al. demonstrated treating SIJ dysfunction with MET mobilizations resulted in significant improvement of disability and pain scores following 3 sessions for 2 weeks; however, it was noted that the intervention was slightly more effective for younger participants (93). Antonelli et al. demonstrated that a self-administered SIJ MET resulted in significant improvements in knee pain and function (94). Sewani et al. demonstrated that hot pack and MET resulted in larger improvements in pain, function, and ROM than hot pack and core endurance exercise for individuals with SIJ dysfunction (95). Dhinkaran et al. demonstrated that MET and corrective exercise were more effective than TENS and corrective exercise for the treatment of SIJ dysfunction based on pain and disability scores (96). And, Mathew et al. demonstrated that MET and joint mobilizations resulted in larger improvements in pain and quality of life than conventional physiotherapy (exercise); however, both groups exhibited significant positive changes (75). These studies imply that MET is effective for SIJ dysfunction and potentially knee pain, especially when added to conventional therapies (e.g. exercise), and maybe more effective than TENS or hot pack.
MET has also been compared to other mobilizations; many of these studies were discussed above. Vaidya et al., compared MWM to MET technique, demonstrating MET resulted in slightly better outcomes than MWM (83). Sharma et al. compared SIJ mobilization and MET techniques, demonstrating similar improvements in pain and disability (82). Sachdeva et al. demonstrated that MET was more effective than SIJ mobilization, but the methodology of this study is questionable (86). The efficacy of MET matches or demonstrates slightly <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> outcomes to other effective SIJ mobilization techniques.

Video Demonstration

Lumbar Spine Mobilization

Sacroiliac Joint Mobilization

Bibliography

© 2020 Brent Brookbush
Questions, comments, and criticisms are 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>

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