Introduction

Research Corner Summary

Efficacy

Comparing Interventions

Combining Techniques

Combination and Comparing Mobilization Techniques

Systemic Response to Shoulder Mobilizations

Research Corner: Sternoclavicular (SC) and Acromioclavicular (AC) Joint

Techniques

Joint Mobilization: Glenohumeral, Acromioclavicular and Sternoclavicular Joints

AOTA

TPTA

AUSPHYSIO

NYPT

PACE

Joint Mobilization: Shoulder Joint, Acromioclavicular Joint and Sternoclavicular Joint

<h3>Introduction</h3>
This course describes joint mobilizations for the shoulder joint, acromioclavicular (AC) joint, and sternoclavicular (SC) joint. 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.
This course includes mobilization techniques that intend to improve excessive stiffness of the shoulder joint, AC joint, and SC joint, reduce scapular <a id="dyskinesis" data-tip="1693" target="_blank" href="/glossary-term/dyskinesis" class="glossary">dyskinesis</a> (altered shoulder blade motion), improve shoulder range of motion (ROM), and reduce upper extremity dysfunction. For example, alterations in scapular motion have been correlated with shoulder impingement syndrome (SIS), mobilization of scapular joints has been correlated with improvement in shoulder ROM, and improvements in shoulder ROM have been correlated with a reduction in pain, improvements in function, and performance enhancement. 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/upper-body-dysfunction-ubd" title="Upper Body Dysfunction" target="_blank" rel="noopener">upper body dysfunction (UBD)</a> including sternocostal pain, upper thoracic pain, AC joint pain, frozen shoulder (post-acute phase), <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylitis (tennis elbow), and <a id="movement-impairment" data-tip="1578" target="_blank" href="/glossary-term/movement-impairment" class="glossary">postural dysfunctions</a> including rounded shoulder <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>. Several studies even demonstrate that adding these mobilizations to conventional medical and therapeutic interventions may have a significant positive influence on short-term and long-term outcomes.&#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/anterior-posterior-shoulder-glenohumeral-joint-manual-mobilization" target="_blank" rel="noopener">Shoulder Joint Mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/acromioclavicular-ac-joint-posterior-anterior-manual-mobilization" target="_blank" rel="noopener">Acromioclavicular (AC) Joint Mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/sternoclavicular-superior-inferior-manual-joint-mobilization" target="_blank" rel="noopener">Sternoclavicular (SC) Joint Mobilization</a></li>
</ul>
<h3>Sample Intervention (Shoulder Impingement Syndrome Pain)</h3>
<ul>
 <li>Manual Release
 <ul>
 <li><a href="https://brookbushinstitute.com/video/levator-scapulae-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Levator Scapulae</a></li>
 <li><a href="https://brookbushinstitute.com/video/upper-trapezius-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Upper Trapezius</a></li>
 <li><a href="https://brookbushinstitute.com/video/pectoralis-minor-static-manual-release" target="_blank" rel="noopener">Pectoralis Minor</a></li>
 <li><a href="https://brookbushinstitute.com/video/posterior-deltoid-manual-static-release" target="_blank" rel="noopener">Posterior Deltoid</a></li>
 </ul>
 </li>
 <li>Mobilization or Manipulation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/thoracic-spine-mobilization-posterior-anterior-transverse" target="_blank" rel="noopener">Thoracic mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/anterior-posterior-shoulder-glenohumeral-joint-manual-mobilization" target="_blank" rel="noopener">Shoulder Joint Mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/acromioclavicular-ac-joint-posterior-anterior-manual-mobilization" target="_blank" rel="noopener">Acromioclavicular (AC) Joint Mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/sternoclavicular-superior-inferior-manual-joint-mobilization" target="_blank" rel="noopener">Sternoclavicular (SC) Joint Mobilization</a></li>
 </ul>
 </li>
 <li>Manual Lengthening
 <ul>
 <li><a href="https://brookbushinstitute.com/video/pectoralis-minor-manual-stretch" target="_blank" rel="noopener">Manual Pectoralis Minor Stretch</a></li>
 <li><a href="https://brookbushinstitute.com/video/manual-latissimus-dorsi-and-shoulder-internal-rotator-stretch" target="_blank" rel="noopener">Manual Latissimus Dorsi Stretch</a></li>
 </ul>
 </li>
 <li>Activation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/shoulder-external-rotator-activation-progression" target="_blank" rel="noopener">External Rotator Activation</a></li>
 <li><a href="https://brookbushinstitute.com/video/serratus-anterior-isolated-activation-2" target="_blank" rel="noopener">Serratus </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Activation</li>
 </ul>
 </li>
 <li>Integration
 <ul>
 <li><a href="https://brookbushinstitute.com/video/standing-cobra" target="_blank" rel="noopener">Standing Cobra</a></li>
 </ul>
 </li>
 <li>Support
 <ul>
 <li><a href="https://brookbushinstitute.com/video/shoulder-external-rotator-activation-taping" target="_blank" rel="noopener">Shoulder External Rotator </a><a id="kinesiology" data-tip="1692" target="_blank" href="/glossary-term/kinesiology" class="glossary">Kinesiology</a> Taping</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: Shoulder Joint, Acromioclavicular Joint and Sternoclavicular Joint Mobilizations

<h2>For <a href="https://brookbushinstitute.com/article/upper-body-dysfunction-ubd" target="_blank" rel="noopener">Upper-Body Dysfunction</a>:</h2>
For an introduction to joint mobilizations and manipulations:
<ul>
 <li><a href="https://brookbushinstitute.com/courses/introduction-joint-mobilizations-joint-manipulations" title="Introduction to Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Introduction</a></li>
 <li><a href="https://brookbushinstitute.com/courses/mobilization-and-manipulation-reliability-of-palpation-and-assessment" title="Reliability of Joint Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Reliability</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" title="Effects of Mobilizations and Manipulations" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: Effects</a>&#xA0;</li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilization-and-manipulation-risk-of-adverse-events" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Risk of Adverse Effects</a></li>
 <li><a href="https://brookbushinstitute.com/courses/joint-mobilizations-and-manipulations-evidence-based-teaching-and-learning" title="Evidence-based Teaching and Learning" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: </a><a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">Evidence-based</a> Teaching and Learning</li>
</ul>
<h3>Techniques Covered in this Course:</h3>
<ul>
 <li><a href="https://brookbushinstitute.com/video/anterior-posterior-shoulder-glenohumeral-joint-manual-mobilization" target="_blank" rel="noopener">Shoulder Joint Mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/acromioclavicular-ac-joint-posterior-anterior-manual-mobilization" target="_blank" rel="noopener">Acromioclavicular (AC) Joint Mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/sternoclavicular-superior-inferior-manual-joint-mobilization" target="_blank" rel="noopener">Sternoclavicular (SC) 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-11-shoulders-elevate" target="_blank" rel="noopener">Shoulders Elevate</a></li>
 <li><a href="https://brookbushinstitute.com/video/overhead-squat-assessment-10-arms-fall" target="_blank" rel="noopener">Arms Fall</a></li>
 </ul>
 </li>
 <li><a href="https://brookbushinstitute.com/article/introduction-to-goniometry" target="_blank" rel="noopener">Goniometry</a>
 <ul>
 <li><a href="https://brookbushinstitute.com/video/shoulder-flexion-goniometry" target="_blank" rel="noopener">Shoulder Flexion</a> &lt; 180&#xB0;</li>
 <li><a href="https://brookbushinstitute.com/video/shoulder-external-rotation-goniometry" target="_blank" rel="noopener">Shoulder External Rotation</a> &lt;90 - 95&#xB0;</li>
 <li><a href="https://brookbushinstitute.com/video/shoulder-internal-rotation-goniometry" target="_blank" rel="noopener">Shoulder Internal Rotation</a> &lt;50 - 70&#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/external-rotator-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">External Rotator MMT</a>: Weak or With Compensation (shoulder abduction)</li>
 <li><a href="https://brookbushinstitute.com/video/serratus-anterior-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">Serratus </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> MMT: Weak or With Compensation (scapular protraction or elevation)</li>
 <li><a href="https://brookbushinstitute.com/video/lower-trapezius-manual-muscle-testing-mmt-for-an-active-population" target="_blank" rel="noopener">Lower Trapezius MMT</a>: Weak or With Compensation (scapular protraction or elevation)</li>
 </ul>
 </li>
</ul>
<h3>Sample Intervention (Shoulder Impingement Syndrome Pain)</h3>
<ul>
 <li>Manual Release
 <ul>
 <li><a href="https://brookbushinstitute.com/video/levator-scapulae-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Levator Scapulae</a></li>
 <li><a href="https://brookbushinstitute.com/video/upper-trapezius-static-manual-release-soft-tissue-mobilization" target="_blank" rel="noopener">Upper Trapezius</a></li>
 <li><a href="https://brookbushinstitute.com/video/pectoralis-minor-static-manual-release" target="_blank" rel="noopener">Pectoralis Minor</a></li>
 <li><a href="https://brookbushinstitute.com/video/posterior-deltoid-manual-static-release" target="_blank" rel="noopener">Posterior Deltoid</a></li>
 </ul>
 </li>
 <li>Mobilization or Manipulation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/thoracic-spine-mobilization-posterior-anterior-transverse" target="_blank" rel="noopener">Thoracic mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/anterior-posterior-shoulder-glenohumeral-joint-manual-mobilization" target="_blank" rel="noopener">Shoulder Joint Mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/acromioclavicular-ac-joint-posterior-anterior-manual-mobilization" target="_blank" rel="noopener">Acromioclavicular (AC) Joint Mobilization</a></li>
 <li><a href="https://brookbushinstitute.com/video/sternoclavicular-superior-inferior-manual-joint-mobilization" target="_blank" rel="noopener">Sternoclavicular (SC) Joint Mobilization</a></li>
 </ul>
 </li>
 <li>Manual Lengthening
 <ul>
 <li><a href="https://brookbushinstitute.com/video/pectoralis-minor-manual-stretch" target="_blank" rel="noopener">Manual Pectoralis Minor Stretch</a></li>
 <li><a href="https://brookbushinstitute.com/video/manual-latissimus-dorsi-and-shoulder-internal-rotator-stretch" target="_blank" rel="noopener">Manual Latissimus Dorsi Stretch</a></li>
 </ul>
 </li>
 <li>Activation
 <ul>
 <li><a href="https://brookbushinstitute.com/video/shoulder-external-rotator-activation-progression" target="_blank" rel="noopener">External Rotator Activation</a></li>
 <li><a href="https://brookbushinstitute.com/video/serratus-anterior-isolated-activation-2" target="_blank" rel="noopener">Serratus </a><a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">Anterior</a> Activation</li>
 </ul>
 </li>
 <li>Integration
 <ul>
 <li><a href="https://brookbushinstitute.com/video/standing-cobra" target="_blank" rel="noopener">Standing Cobra</a></li>
 </ul>
 </li>
 <li>Support
 <ul>
 <li><a href="https://brookbushinstitute.com/video/shoulder-external-rotator-activation-taping" target="_blank" rel="noopener">Shoulder External Rotator </a><a id="kinesiology" data-tip="1692" target="_blank" href="/glossary-term/kinesiology" class="glossary">Kinesiology</a> Taping</li>
 </ul>
 </li>
</ul>

<table>
 <tbody>
 <tr>
 <td>
 <h3>Summary</h3>
 <ul>
 <li>Shoulder Mobilization Efficacy: Shoulder mobilization alone has demonstrated efficacy for reducing pain and disability associated with shoulder impingement syndrome (SIS) and adhesive capsulitis (frozen shoulder).</li>
 <li>Comparing Mobilization to other Interventions: Shoulder mobilizations may have a larger effect on SIS and adhesive capsulitis patients&#x2019; outcomes than exercise, PNF exercise or neuromobilization.</li>
 <li>Comparing Combinations of Interventions: Comparing various combinations of conventional physical medicine interventions, suggests that combinations that include mobilizations are generally more beneficial.</li>
 <li>Combining Mobilization, Exercise, Stretching, and&#x2026; Research implies that mobilization and exercise are an especially effective combination for improving pain, function, ROM, and potentially subacromial space. The combination of mobilization and stretching has also demonstrated larger increases in <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> than either technique alone. When mobilization and exercise are combined with additional modalities, the results are similarly impressive. The only exception may be ultrasound, which demonstrated no additional benefit when added to a combination of interventions.</li>
 <li>Combining Mobilization, Manual Therapy, and <a id="kinesiology" data-tip="1692" target="_blank" href="/glossary-term/kinesiology" class="glossary">Kinesiology</a> Tape: The addition of manual therapy and/or <a id="kinesiology" data-tip="1692" target="_blank" href="/glossary-term/kinesiology" class="glossary">Kinesiology</a> tape to mobilization techniques has demonstrated additional benefit for individuals with shoulder dysfunction.</li>
 <li>Medical Intervention: Studies have demonstrated that the treatment of shoulder dysfunction with buprenorphine, capsular distension, and capsular distension with steroid injection may be enhanced by the addition of joint mobilizations.</li>
 <li>Combination of Mobilization Techniques: Studies imply that the combination of shoulder, scapular, and thoracic mobilizations, and potentially multiple mobilizations per joint, may be more beneficial than a single joint mobilization.</li>
 <li>Not for Everyone: Some studies suggest that confounding factors, and/or the severity of symptoms, may place certain adhesive capsulitis patients in a subset that is beyond the reach of conservative physical interventions.</li>
 <li>Beyond Mobilizations: It may be reasonable to conclude that joint mobilizations improve initial outcomes but should be replaced by self-administered techniques by the end of the first month, and/or that other techniques may provide similar benefits.</li>
 <li>Comparing Mobilization Techniques: Studies suggest that Maitland, Kaltenborn, McKenzie, and Mulligan (MWM) protocols have similar efficacy, and perhaps slightly better efficacy than MET. Further, studies likely imply that shoulder mobilizations are generally more effective when performed with <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> force, applied at end-range, and use grade III and/or IV amplitudes.</li>
 <li>Systemic Response: The systemic responses to shoulder mobilization appears to be similar to spinal mobilizations, with research demonstrating increased skin conductance and no change in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity in asymptomatic individuals.</li>
 <li>SC and AC Joint Mobilization: There is not enough research to refine the use of these joint mobilizations; however, clinical results are favorable.</li>
 </ul>
 </td>
 </tr>
 </tbody>
</table>

Research Corner: Glenohumeral Joint

Several studies have demonstrated the effectiveness of shoulder mobilization for the treatment of shoulder impingement syndrome (SIS) and adhesive capsulitis (also known as frozen shoulder or periarthritis). Interestingly, a large percentage of research on shoulder mobilization compares various mobilization techniques to one another. The video below, titled &quot;Shoulder Mobilization&quot;, is of a mid-range Maitland mobilization. Videos demonstrating end-range shoulder mobilizations and mobilizations with movement (MWM) will be added to this course in the future. Please do not allow the nuances of various techniques to confuse or confound the implications of the research review below, which is generally supportive of the use of mobilization for shoulder and shoulder girdle dysfunction.
<h3>Efficacy of Mobilization Alone</h3>
Shoulder mobilizations may be particularly effective for the treatment of shoulder impingement syndrome (SIS). Ajit et al. demonstrated that posterolateral mobilization with movement (MWM) improved pain, disability, and function, as well as subacromial space in patients diagnosed with shoulder impingement syndrome (SIS) (1). A <a id="randomized-control-trial" data-tip="1403" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">randomized controlled </a><a id="randomized-control-trial" data-tip="1407" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">trial</a> (RCT) by Guimar&#xE3;es et al. demonstrated MWM resulted in significant improvements in range of motion (ROM), pain, disability, and function when compared to sham for individuals with SIS (2). In another sham controlled RCT by Delgado et al., patients with shoulder impingement syndrome who received 4 sessions of MWM exhibited better outcomes for pain-free shoulder flexion ROM, total flexion ROM and external rotation ROM (3). A double-blind RCT by Teys et al. demonstrated that MWM resulted in immediate improvements in ROM and pain pressure threshold for individuals with pain-limited shoulder motion (4). An RCT by Makwana et al. demonstrated end-range mobilizations when compared to sham mobilizations, resulting in larger increases in ROM, but a similar reduction in pain for individuals with adhesive capsulitis (73). With somewhat contradictory results, an RCT by Lluch et al. demonstrated that <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> shoulder mobilizations reduced pain pressure <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>, but had no effect on ROM in athletes with chronic shoulder pain (5). This may be due in part to the use of mid-range mobilizations without subsequent lengthening techniques or exercise (discussed later). Interesting cadaveric studies by Hsu et al. have demonstrated that <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a>, <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a>, and <a id="caudal" data-tip="1557" target="_blank" href="/glossary-term/caudal" class="glossary">caudal</a> mobilizations resulted in an increase in abduction ROM, and end-range mobilizations were more effective than mid-range mobilization for increasing ROM and passive resistance to stretch (6 - 8). In summary, research has demonstrated that mobilizations for the shoulder are likely effective for reducing pain and disability associated with SIS, and further that end-range mobilizations and MWM may be more effective than mid-range mobilizations for improving ROM when mobilizations are performed alone.

There is a fairly large amount of research comparing shoulder mobilizations to other interventions for SIS and adhesive capsulitis. Interestingly, many of these studies demonstrate that mobilization alone is more effective than exercise alone. An RCT by Yeole et al. demonstrated that MWM improved pain and ROM more than supervised exercise following one week of treatment for patients with adhesive capsulitis (9). An RCT by Neelapala et al. demonstrated that MWM with <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> resulted in larger improvements in&#xA0;<a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">external rotator</a>&#xA0;strength and shoulder pain than active exercise for individuals with shoulder pain; however, some <a id="specificity" data-tip="1223" target="_blank" href="/glossary-term/specificity" class="glossary">specificity</a> was demonstrated as neither technique improved&#xA0;<a href="https://brookbushinstitute.com/article/subscapularis" target="_blank" rel="noopener">internal rotator</a>&#xA0;strength or scapular motion (10). Citaker et al. compared shoulder mobilization and proprioceptive neuromuscular facilitation (PNF) for the treatment of SIS, demonstrating that both were similarly effective; however, mobilization was less painful and better tolerated by the patient (11). In a pilot prospective, double-blind RCT including 18 women who underwent <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> breast cancer surgery and axillary lymph node dissection, de la Rosa Diaz et al. demonstrated a clear trend that shoulder mobilization improved ROM more than neural mobilization; a follow-up full-scale RCT was recommended (12). Although a single technique is not recommended as a complete intervention plan, these studies suggest that mobilizations may have a larger effect on outcomes for SIS and adhesive capsulitis than exercise, PNF, or neuromobilization.
Several studies have made rather strange comparisons of two distinct pairs of techniques, with one pair including mobilization. That is, four or more techniques were compared in two separate groups. This type of comparison makes it impossible to ascertain the effect or effectiveness of any one technique compared to another. However, one trend was clear in these studies; most demonstrate that the group including mobilization resulted in better outcomes. Djordjevic et al. demonstrated that the combination of MWM and kinesiotaping resulted in better outcomes in pain and ROM than supervised exercise for treating shoulder pain (13). In an RCT by Panchal et al., the combination of end-range mobilization and interferential current resulted in larger improvements in ROM than the combination of stretching and heat; however, both combinations were equally effective for reducing pain in individuals with adhesive capsulitis (14). An RCT by Doner et al. compared the combination of hot pack, TENS, and either mobilization or passive stretching exercise for adhesive capsulitis, demonstrating that the mobilization group exhibited larger improvements in pain, ROM, dysfunction, and patient satisfaction (15). Guler-Uyal et al. compared Cyriax/Maitland style soft-tissue and shoulder joint mobilization three times a week, to hot pack and short wave diathermy performed daily for the treatment of adhesive capsulitis, noting that 95% of patients in the mobilization group and only 65% of modalities group achieved 80% of normal shoulder ROM (74). And, Ansari et al. demonstrated that the combination of end-range mobilization and ultrasound was more effective for improving ROM and pain than capsular stretching and cryotherapy in individuals with adhesive capsulitis (16). Although these studies do not demonstrate a single combination of techniques that is most effective, they do imply that mobilizations should likely be included in an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> intervention for shoulder pain and dysfunction.
Only two studies could be found that contradicted the superiority of mobilizations implied by the previous studies. An RCT by Tanaka et al. demonstrated that home exercise may be more important than mobilization frequency in a hospital setting for the treatment of adhesive capsulitis (17). And, an interesting study by Diercks et al., demonstrated that 89% of patients participating in selective neglect reached normal or near normal function at 12 months, compared to just 64% in the intensive physical therapy group (including joint mobilization) for the treatment of adhesive capsulitis (18). Considering these two studies were performed on older patients in a hospital setting, it may be reasonable to conclude that confounding factors, and/or the severity of adhesive capsulitis symptoms, may place certain patients in a subset that is beyond the reach of conservative physical interventions.

<h4>Mobilization and Exercise</h4>
As mentioned in other courses, the comparison of one technique to another often results in contradictory findings that do not consider the original intent of the technique or the outcome measures that should be expected to change. Combining mobilization with other effective treatment options generally results in better outcomes than either technique alone. This may be especially true of the combination of mobilization and exercise. An RCT by Satpute et al. demonstrated that MWM and exercise resulted in larger improvements in ROM, pain, and dysfunction than exercise alone for acute shoulder pain and dysfunction (19). Kumar et al. demonstrated that the combination of shoulder mobilization and exercise resulted in larger improvement in pain, ROM, and function, when compared to exercise alone, for the treatment of adhesive capsulitis (75). An RCT by Nicholson et al. demonstrated that mobilization and active exercise increased ROM more than active exercise alone for individuals diagnosed with adhesive capsulitis; however, both groups exhibited similar reductions in pain (20). And, Choo Y., compared MWM and exercise to exercise alone for 4 weeks of treatment (3x/week) of SIS, demonstrating that the combination group exhibited larger changes in subacromial space, ROM, pain, and function (21). These studies demonstrate that mobilization and exercise are more effective than exercise alone for shoulder pain, SIS, and adhesive capsulitis.
<h4>Mobilization and stretching</h4>
The combination of mobilization and stretching has also demonstrated better results than either technique alone. An RCT by Celik et al. demonstrated that the addition of mobilization to stretching resulted in larger improvements in ROM and function for adhesive capsulitis patients when compared to a stretching program alone (22). An RCT by Manske et al. demonstrated that mobilization and cross-body stretching resulted in larger improvements in shoulder internal rotation ROM when compared to cross-body stretching alone (23). And, Tyler et al. demonstrated that the combination of shoulder mobilization and <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> capsule stretching resulted in a reduction in pain associated with SIS; however, this reduction in pain was correlated with horizontal adduction range of motion and not shoulder rotation ROM (24). Based on these studies <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> programs for the shoulder should include shoulder joint mobilization techniques.
<h4>Mobilization, exercise, stretching, and&#x2026;.</h4>
Additional studies combine shoulder mobilizations, stretching, and exercise with additional modalities; however, the superiority of mobilization and exercise continues to be demonstrated. Bang et al. demonstrated that manual therapy (including joint mobilization) combined with supervised exercise was <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to exercise alone for the treatment of patients with SIS, including larger improvements in pain, function, and strength (25). A prospective RCT by Senbursa et al. demonstrated that joint and soft tissue mobilization combined with supervised exercise resulted in larger improvements for SIS patients, including increasing strength, decreasing pain, and improving function earlier than with an exercise program (26). Patel et al. demonstrated that mobilization with movement combined with conventional treatment (stretching and strengthening), improved internal rotation ROM more than conventional treatment alone for individuals with adhesive capsulitis (27). An RCT by Sharad et al. compared the combination of end-range mobilizations, ultrasound, and exercise to ultrasound and exercise only, demonstrating that the mobilization group exhibited larger increases in ROM for individuals diagnosed with adhesive capsulitis (28). An RCT by Land et al. demonstrated that thoracic mobilization and a home exercise program, or passive manual therapy including massage, stretching and shoulder mobilization and a home-exercise program, resulted in significantly better outcomes for pain, disability, and ROM when compared to active exercise alone (29). Conroy et al. demonstrated that the addition of mobilization to a comprehensive treatment approach (including hot packs, active range of motion, physiologic stretching, <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strengthening, soft tissue mobilization, and patient education) resulted in better outcomes on more functional outcome measures (30). Finally, in a retrospective of 5 cases, Wong et al. demonstrated that an impairment-based, <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> approach with consideration of <a id="regional-interdependence" data-tip="1542" target="_blank" href="/glossary-term/regional-interdependence" class="glossary">regional interdependence</a> resulted in full recovery in ROM and pain from adhesive capsulitis, including follow-up several months post-intervention (31). Generally, the Brookbush Institute refrains from using case series research to <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> a position, but this study is included as it demonstrates a high level of efficacy, and more closely reflects the <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> approach recommended by many practitioners, including the Brookbush Institute. These studies demonstrate that even when exercise is combined with additional modalities, the addition of mobilization continues to provide additional benefits.
<h4>The addition of mobilization to exercise did not improve outcomes</h4>
A few studies have demonstrated that the addition of mobilizations does not enhance outcomes. An RCT by Yiasemides et al. with long-term follow-up demonstrated that the addition of mid-range passive mobilizations to exercise and advice did not improve pain, function, or pain-free range of motion in patients with shoulder pain (32). In a similar RCT by Chen et al. the addition of passive mid-range shoulder mobilization to advice and exercise showed some additional benefits in pain and active ROM during the first month, but statistically insignificant differences in the following months (33). These studies may suggest that shoulder mobilizations are effective in the first month of treatment but should be replaced by self-administered techniques for long-term programming. In a pilot RCT by Romero et al., the addition of MWM to a standardized physical therapy approach did not result in an additional benefit (34), which may suggest that other techniques in the physical therapy program were achieving the same effects. Last, Ali et al. demonstrated that there was no difference in groups of adhesive capsulitis patients receiving Maitland mobilizations (like those below) and exercise, when compared to exercise alone, following 5 consecutive weeks of treatment 3x/week (35). Based on these studies and the studies above, it may be reasonable to conclude that joint mobilizations improve initial outcomes but should be replaced by self-administered techniques by the end of the first month, that other techniques may provide similar benefits, and that some adhesive capsulitis patients do not benefit from joint mobilizations. Perspective must be maintained when considering this research, as four studies demonstrating contradictory findings in a group of more than 60 studies may be expected on the basis of statistical variability and p-values of &lt;.05.
<h4>Mobilization and manual therapy, kinesiotaping, and ultrasound</h4>
Research has also investigated the combination of shoulder mobilization with modalities commonly used in a rehabilitation setting. The addition of mobilization technique to manual therapy may provide additional benefits, similar to the intervention sequence recommended by the Brookbush Institute. Deshmukh et al. demonstrated that performing soft-tissue <a id="release" data-tip="1249" target="_blank" href="/glossary-term/release" class="glossary">release</a> and gentle <a id="distraction" data-tip="1589" target="_blank" href="/glossary-term/distraction" class="glossary">distraction</a> (stretching) prior to shoulder mobilization significantly improved pain, disability, and ROM in individuals with adhesive capsulitis (36). An RCT by Kuwiboonslip et al. demonstrated that both <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> energy technique (MET), as well as the combination of <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> energy technique and mobilization, were more effective than mobilization alone for treating adhesive capsulitis; resulting in larger improvement in pain, dysfunction, and active external rotation ROM (37). The combination of taping and mobilization may also provide additional benefits. Kanase et al. compared Maitland mobilizations (like those taught below) to Maitland mobilizations and kinesiotaping as part of a program that also included ultrasound, hotpack, and exercise for 4 weeks/3x week sessions for adhesive capsulitis. The combination of mobilization and taping resulted is statistically significant differences in pain and disability at the end of the treatment period (38). Park et al. demonstrated that SIS patients benefited more from the combination of mobilization and <a id="kinesiology" data-tip="1692" target="_blank" href="/glossary-term/kinesiology" class="glossary">kinesiology</a> tape than either technique alone, including improvements in pain, ROM, and&#xA0;<a href="https://brookbushinstitute.com/article/trapezius-muscle" target="_blank" rel="noopener">trapezius</a>&#xA0;tone (39). It may be recommended that an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> program include mobilization and end with kinesiotaping to enhance benefits. In a double-blind RCT by Ebadi et al., the addition of ultrasound to shoulder mobilization and exercise had no additional benefit for the treatment of adhesive capsulitis (40). In summary, it is likely that the combination of mobilization with manual therapy, and/or the addition of <a id="kinesiology" data-tip="1692" target="_blank" href="/glossary-term/kinesiology" class="glossary">kinesiology</a> tape may provide additional benefit; however, it is unlikely that the addition of ultrasound has any effect.
<h4>Medical intervention</h4>
Mobilizations have also demonstrated additional benefits for patients receiving conventional medical care. An RCT by Bergman et al. demonstrated that the addition of just 6 treatment sessions of mobilizations over a 12 week period to standard physician care for shoulder pain resulted in double the rate of full recovery (43% compared to 21%) at 12 weeks, 6 months and 1-year follow-ups (41). An RCT by Tao et al. demonstrated that the combination of buprenorphine and mobilization was significantly more effective than loxoprofen sodium and joint mobilization, or joint mobilization alone, for improving pain and ROM associated with adhesive capsulitis (42). Park et al. demonstrated that the combination of distention arthrography (injection of fluid) and mobilization was <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> to distention arthrography alone for improving passive ROM and pain in individuals with adhesive capsulitis (43). In another study by Park et al., the addition of shoulder mobilization to steroid injection with capsular distension resulted in larger improvements in pain, dysfunction, and active ROM for patients with adhesive capsulitis, when compared to either treatment alone, or the combination of injection and conventional physical therapy (44). And, an RCT by Buchbinder et al. demonstrated that the addition of joint mobilization and exercise to glenohumeral joint distension resulted in better ROM and patient-perceived recovery at 6 months (76). These studies demonstrate that treatment of shoulder dysfunction with buprenorphine, capsular distension, and capsular distension with steroid injection may be enhanced by the addition of joint mobilizations, and/or joint mobilization and exercise.

<h4>Combining Mobilization Techniques:</h4>
Studies have further demonstrated that the combination of mobilizations also enhances benefits. Sreenivasu et al. demonstrated that the combination of scapular and shoulder mobilization was more effective than shoulder mobilization alone, based on ROM, pain, and disability scores in individuals with adhesive capsulitis (45). An RCT by Yang et al. demonstrated that end-range shoulder mobilization and scapular mobilization resulted in larger improvements in disability, ROM, and kinematics at 4 and 8 weeks than conventional physiotherapy for a subgroup of adhesive capsulitis patients who fit a criterion from a prediction method (46). Rainbow et al. demonstrated that thoracic manipulation and exercise were slightly more effective than shoulder mobilization and exercise based on pain, disability, and ROM (47), which likely suggests that adding both techniques may be beneficial for adhesive capsulitis patients. And, Goyal et al. demonstrated that disability, pain, and ROM improved more for adhesive capsulitis patients when end-range shoulder mobilization was combined with shoulder mobilizations with movement when compared to either technique alone (48). In summary, these studies may imply that the combination of shoulder, scapular, and thoracic mobilizations, and potentially multiple mobilizations per joint, may be more beneficial than any single mobilization alone.
<h4>Comparing Mobilization Techniques:</h4>
Several studies have compared different variations of shoulder mobilization techniques for shoulder dysfunction. Do Moon et al. demonstrated that both Maitland and Kaltenborn protocols for <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> shoulder mobilization were equally effective for improving ROM and pain in a group of patients with adhesive capsulitis (49). An RCT by Naik et al. demonstrated that Maitland mobilizations and McKenzie technique were also equally effective for reducing pain and improving ROM for individuals diagnosed with adhesive capsulitis (50). Kumar et al. demonstrated that Maitland mobilizations were more effective for improving pain and function in individuals with adhesive capsulitis; however, <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> energy technique (MET) was also effective (51). Suri et al. compared the combination of heat pack, active exercise, and either Maitland mobilizations or MET, also demonstrating Maitland mobilization increased ROM more; however, MET resulted in larger decreases in pain (52). These studies may suggest that Maitland, Kaltenborn, and McKenzie protocols have near equal efficacy and slightly better efficacy than MET.
Several studies have also compared Maitland style mobilizations to mobilization with movement (MWM), also known as Mulligan mobilizations. Hussein et al. demonstrated that end-range mobilizations and MWM were equally effective for improving pain, ROM, and disability in individuals with adhesive capsulitis (53). An RCT by Sahay et al, demonstrated that both Maitland mobilizations (like those taught below) and MWM improved pain, disability, and ROM for patients with adhesive capsulitis; however, Mulligan mobilizations resulted in better outcomes for external rotation ROM (54). A double-blind, prospective RCT by Shrivastava et al. demonstrated that MWM and Maitland resulted in similar changes in ROM and pain, with only slight differences favoring Maitland mobilizations for pain, and MWM for shoulder extension ROM (55). Arshad et al. demonstrated that end-range mobilization techniques (like those taught below) and MWM resulted in similar outcomes in pain and ROM for patients with adhesive capsulitis (56). Last. in a multiple-treatment <a id="randomized-control-trial" data-tip="1407" target="_blank" href="/glossary-term/randomized-control-trial" class="glossary">trial</a>, Yang et al. compared MWM, end-range mobilizations, and mid-range mobilizations for 12 weeks, 3/week, for the treatment of adhesive capsulitis, demonstrating that end-range mobilizations and MWM resulted in larger improvements in ROM and function than mid-range mobilizations (57). These studies suggest that Maitland mobilizations and MWM have similar efficacy; however, it may be reasonable to conclude that MWM has a slight advantage for increasing ROM, and Maitland mobilizations are slightly more effective for pain.
Several studies have compared aspects of mobilizations that may aid in refining shoulder mobilization protocols. Johnson et al. compared <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> mobilizations to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> mobilizations, demonstrating that <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> mobilizations (like those taught below) resulted in larger increases in shoulder external rotation ROM in adhesive capsulitis patients (58). The study above by Yang et al., as well as others by lluch et al and Hsu et al. (5-8, 57), demonstrated that end-range mobilizations were more effective than mid-range mobilizations. These studies are further supported by Vermeulen et al., demonstrating that larger amplitude mobilizations at end-range were more effective than lower amplitude mobilizations in pain-free range for adhesive capsulitis patients, including larger changes in ROM, pain, and disability (59). Talbot et al. determined that the motions during Grade I, II, III (3.2, 7.02, 9.82 mm respectively) mobilizations were not significantly different following several repetitions; however, the resting position and amount of <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> humeral <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> following the mobilizations was significantly different with larger grades resulting in more motion (60). A cadaveric study by Muraki et al. demonstrated that joint mobilizations at 5 N of load resulted in temporary elongation of the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> capsule; however, mobilization at 20 and 40 N loads resulted in sustained elongation of the capsule for up to 1 hour. Further, this study demonstrated that loads up to the linear region of the load-displacement curve could be performed without serious damage to the <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> capsule (61). Last, Hsu et al. demonstrated that although inter-tester and inter-session <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> were variable for forces applied during shoulder mobilizations, the range of forces fell safely between effective and dangerous loads (62). These studies likely imply that shoulder mobilizations are generally more effective when performed with <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> force, applied at end-range, using grade III and IV amplitudes.
A few novel techniques have also been investigated. Agarwal et al. compared reverse <a id="distraction" data-tip="1589" target="_blank" href="/glossary-term/distraction" class="glossary">distraction</a> (<a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">medial</a> mobilization of the scapula while holding the arm) with <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> mobilizations, demonstrating that the reverse <a id="distraction" data-tip="1589" target="_blank" href="/glossary-term/distraction" class="glossary">distraction</a> mobilization was more effective (63). This is the only mention of this technique that could be located; further study is recommended. Another novel mobilization, Gong&apos;s mobilization is a combination of manual <a id="compression" data-tip="1595" target="_blank" href="/glossary-term/compression" class="glossary">compression</a> of the scapula and manual <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> pressure of the humeral head, while the patient actively abducts the shoulder in a seated position. Gong et al. demonstrated this mobilization resulted in similar changes in ROM as <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> shoulder mobilizations (64). A follow-up study by Gong et al. demonstrated that this mobilization may be more effective for improving shoulder internal rotation ROM when compared to <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> shoulder mobilizations (65); however, there should be some consideration of the potential for author bias. In an additional follow-up study by Gong et al., Gong&apos;s mobilization was found to be more effective when performed with the patient in side-lying (66). Although the search for more effective practices should always be encouraged, further research is needed regarding these techniques.

Combining and Comparing Mobilization Techniques

Several studies have demonstrated systemic changes following shoulder mobilizations. Yu et al. demonstrated that end-range shoulder mobilizations improved shoulder internal rotation ROM, and resulted in a significant increase in skin temperature of the skin over the shoulder, in individuals with assessed ROM restriction (67). Further, an RCT by Simon et al. demonstrated <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> shoulder mobilizations resulted in a significant increase in skin conductance when compared to control or placebo conditions (68). These studies likely imply that shoulder mobilization results in similar sympathoexcitatory effects as&#xA0;<a href="https://brookbushinstitute.com/article/manipulations-cervical-spine/" target="_blank" rel="noopener">spinal mobilization/manipulations</a>. Ribeiro et al. using asymptomatic individuals demonstrated that the sustained force during MWM resulted in a decrease in shoulder <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity during the mobilization; however, the decrease in <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity only lasted while performing the mobilization (69). Ribeiro et al. also demonstrated that grade IV <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> shoulder mobilizations did not affect post-mobilization shoulder or scapular <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity in asymptomatic individuals (70). However, a pilot study by Swanson et al. demonstrated that the&#xA0;<a href="https://brookbushinstitute.com/article/supraspinatus" target="_blank" rel="noopener">supraspinatus</a>&#xA0;and&#xA0;<a href="https://brookbushinstitute.com/article/infraspinatus-and-teres-minor" target="_blank" rel="noopener">infraspinatus</a>&#xA0;were more active during a grade III <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> shoulder mobilization, approaching activity levels noted during arm elevation in asymptomatic individuals (71). Because these studies were performed on asymptomatic individuals, and studies on other joints demonstrate that mobilization has a propensity to normalize the altered <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity associated with dysfunction, it is unlikely that the results from these studies are indicative of the effects of shoulder mobilization would have on <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> activity of symptomatic individuals. Although there is a relatively small number of studies investigating systemic responses to shoulder mobilization, the few studies available are congruent with the systemic responses noted following spinal mobilization/manipulation.

Unfortunately, there is a lack of research on SC and AC joint mobilizations. The only studies that could be located were a case study, and a research study discussed earlier that included SC and AC joint mobilizations along with shoulder mobilizations. The case study by Mischke et al. discussed additional benefits achieved by adding SC joint mobilization on the 7th session, following a plateau in pain, function, and ROM for conservative treatment of an inoperable full-thickness&#xA0;<a href="https://brookbushinstitute.com/article/supraspinatus" target="_blank" rel="noopener">supraspinatus</a>&#xA0;tear. The patient did achieve respectable outcomes considering the severity of the injury and the patient&apos;s comorbidities (72). The RCT by Yiasemides et al. discussed earlier, demonstrated that the addition of shoulder girdle mobilizations to exercise and advice did not improve pain, function, or pain-free range of motion in patients with shoulder pain (32); however, this study only assessed outcomes at 3 months, missing any earlier benefits that may have been achieved by either group. Although these studies are insufficient to refine practice, clinical outcomes suggest that SC and AC joint mobilizations can be helpful for optimizing scapular motion and achieving the last few degrees of shoulder ROM.
Note: The lack of research on these fairly common techniques is puzzling. If you know of any original research on these techniques please let us know by leaving the citation in the comments box below.

Video Demonstration

Shoulder Mobilization

Acromioclavicular (AC) Joint Mobilization

Sternoclavicular (SC) 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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