Joint Mobilization and Manipulation: Palpation, Assessment, and Reliability

In this course, we cover a topic that has only recently become controversial. Palpation and palpation assessment (passive accessory motion exam) were considered standard components of a physical examination, and they were performed by a variety of healthcare providers. Recently, the reliability and efficacy of these techniques have been critiqued and contrarian therapists on social media claim they are no longer worthy of inclusion in practice. Although healthy skepticism is always encouraged, the research does not support dismissing these techniques. Deep palpation may require more skill and have lower reliability when performed by less experienced therapists, and the efficacy of a technique may be affected by a certain body part being harder to palpate because of its position deep to an internal organ. Further, additional palpation skills may be required to work around a structure carrying critical blood flow, light palpation may be needed when addressing effusion and an increase in joint fluids, and differentiation between tissues may require advanced anatomy knowledge. Despite these factors affecting the reliability and efficacy of palpation, it would be a logical fallacy to dismiss a technique for any presumed flaw. Reliability and efficacy are not binary measures, they are probabilistic measures. Less reliable or effective, does not imply "not reliable or effective".

This course is built from a comprehensive, systematic review of all relevant research, carefully explains the issues involved in interpreting the research, and attempts to develop the nuanced conclusions necessary to make evidence-based recommendations. A couple of examples from the research summary:

• Joint Motion Assessment by Palpation: When research investigates a well-differentiated definition of a positive finding, a practically relevant range of agreement, considers therapist confidence in findings (and perhaps therapist skill), good or better inter-therapist and intra-therapist reliability is achievable for joint motion assessment by palpation.
• Combined Assessments: Range of motion (ROM) assessments and special tests are generally more reliable than joint motion assessment by palpation; however, the addition of joint motion assessment by palpation to a combination of assessments (as is commonly observed in practice) likely increases the reliability of these assessments and the reliability of the evaluation overall.

We hope this course aids in providing clarity for a relatively complex topic and provides simple suggestions for practical application. Further, this course is pre-approved for credits toward the Integrated Manual Therapist (IMT) Certification, and pre-approved for continuing education credits for sports medicine professionals and health care providers (physical therapists, athletic trainers, massage therapists, chiropractors, occupational therapists, etc.).

Pre-approved credits for:

• Integrated Manual Therapist (IMT) Certification

Pre-approved for Continuing Education Credits for:

• Athletic Trainers
• Chiropractors
• Massage Therapists
• Occupational Therapists - Advanced
• Physical Therapists
• Physical Therapy Assistants
• Physiotherapists

This Course Includes:

• AI Tutor
• Study Guide
• Text and Illustrations
• Audio Voice-over
• Research Review
• Practice Exam
• Pre-approved Final Exam

Brookbush Institute's Position Statement (Sample from Course):

• Good to excellent inter-therapist and intra-therapist reliability may be achieved for the palpation of anatomical landmarks, joint stiffness assessment by palpation, and therapist force during mobilization/manipulation when parameters are well-defined, therapist confidence in findings is considered, and reliability is analyzed using a continuous interval measure and/or practically relevant range of agreement. The reliability, predictive value, and utility of these techniques are likely to improve when integrated into a standard patient evaluation that includes multiple assessments, and/or added to an integrated (multi-modal) intervention plan. Further, adding these techniques to practice reliably and significantly improves mean patient outcomes.
  • In short, when these techniques are judged based on how they are commonly used in practice, they demonstrate sufficient reliability to significantly improve patient outcomes.

Related Courses

• Joint Mobilization and Manipulation: Introduction
• Effects of Joint Mobilizations and Manipulations
• Joint Mobilizations and Manipulations: Risk of Adverse Events
• Joint Mobilizations and Manipulations: Evidenced-based Teaching and Learning

Palpation: Accuracy of Relative Locations

1. Chakraverty, R., Pynsent, P., & Isaacs, K. (2007). Which spinal levels are identified by palpation of the iliac crests and the posterior superior iliac spines?. Journal of anatomy, 210(2), 232-236.
2. Póvoa, L. C., Ferreira, A. P., Zanier, J. F., & Silva, J. G. (2018). Accuracy of Motion Palpation Flexion-Extension Test in Identifying the Seventh Cervical Spinal Process. Journal of chiropractic medicine, 17(1), 22-29.
3. Haneline, M. T., Cooperstein, R., Young, M. D., & Ross, J. (2008). Determining spinal level using the inferior angle of the scapula as a reference landmark: a retrospective analysis of 50 radiographs. The Journal of the Canadian Chiropractic Association, 52(1), 24.
4. Cooperstein, R., Haneline, M. T., & Young, M. D. (2009). The location of the inferior angle of the scapula in relation to the spinal level of prone patients. The Journal of the Canadian Chiropractic Association, 53(2), 121.
   • Palpation: Factors affecting accuracy (and 2)
5. Simmonds, M. J., & Kumar, S. (1993). Health care ergonomics Part II: Location of body structures by palpation-A reliability study. International Journal of Industrial Ergonomics, 11(2), 145-151.
6. Harlick, J. C., Milosavljevic, S., & Milburn, P. D. (2007). Palpation identification of spinous processes in the lumbar spine. Manual therapy, 12(1), 56-62.
7. Pagé, I., Descarreaux, M., & Sobczak, S. (2017). Development of a new palpation method using alternative landmarks for the determination of thoracic transverse processes: an in vitro study. Musculoskeletal Science and Practice, 27, 142-149.
   • Palpation: Measurement Issues
8. Billis, E. V., Foster, N. E., & Wright, C. C. (2003). Reproducibility and repeatability: errors of three groups of physiotherapists in locating spinal levels by palpation. Manual Therapy, 8(4), 223-232.
9. McKenzie, A. M., & Taylor, N. F. (1997). Can physiotherapists locate lumbar spinal levels by palpation?. Physiotherapy, 83(5), 235-239.
10. Pattyn, E., & Rajendran, D. (2014). Anatomical landmark position–can we trust what we see? Results from an online reliability and validity study of osteopaths. Manual therapy, 19(2), 158-164.
11. Robinson, R., Robinson, H. S., Bjørke, G., & Kvale, A. (2009). Reliability and validity of a palpation technique for identifying the spinous processes of C7 and L5. Manual therapy, 14(4), 409-414.
    • Assessment: Cervical and thoracic
12. Rossettini, G., Rondoni, A., Lovato, T., Strobe, M., Verzè, E., Vicentini, M., & Testa, M. (2017). Intra-and inter-rater reliability of 3D passive intervertebral motion in subjects with non-specific neck pain assessed by physical therapy students: A pilot study. Journal of back and musculoskeletal rehabilitation, 30(1), 85-99.
13. Smedmark, V., Wallin, M., & Arvidsson, I. (2000). Inter-examiner reliability in assessing passive intervertebral motion of the cervical spine. Manual Therapy, 5(2), 97-101.
14. Potter, L., McCarthy, C., & Oldham, J. (2006). Intraexaminer reliability of identifying a dysfunctional segment in the thoracic and lumbar spine. Journal of manipulative and physiological therapeutics, 29(3), 203-207.
15. Ghoukassian, M., Nicholls, B., & McLaughlin, P. (2001). Inter-examiner reliability of the Johnson and Friedman percussion scan of the thoracic spine. Journal of Osteopathic Medicine, 4(1), 15-20.
16. Cooperstein, R. (2012). Interexaminer reliability of the Johnston and Friedman percussion scan of the thoracic spine: secondary data analysis using modified methods. Journal of chiropractic medicine, 11(3), 154-159.
17. Christensen, H. W., Vach, W., Vach, K., Manniche, C., Haghfelt, T., Hartvigsen, L., & Høilund-Carlsen, P. F. (2002). Palpation of the upper thoracic spine: an observer reliability study. Journal of Manipulative and Physiological Therapeutics, 25(5), 285-292.
    • Assessment: Lumbar
18. Lynette Inscoe, E., Witt, P. L., Gross, M. T., & Mitchell, R. U. (1995). Reliability in Evaluating Passive Intervertebral Motion of the Lumber Spine. Journal of Manual & Manipulative Therapy, 3(4), 135-143.
19. Mootz, R. D., Keating Jr, J. C., Kontz, H. P., Milus, T. B., & Jacobs, G. E. (1989). Intra-and interobserver reliability of passive motion palpation of the lumbar spine. Journal of Manipulative and Physiological Therapeutics, 12(6), 440-445.
20. Gonnella, C., Paris, S. V., & Kutner, M. (1982). Reliability in evaluating passive intervertebral motion. Physical Therapy, 62(4), 436-444.
21. Owens Jr, E. F., DeVocht, J. W., Gudavalli, M. R., Wilder, D. G., & Meeker, W. C. (2007). Comparison of posteroanterior spinal stiffness measures to clinical and demographic findings at baseline in patients enrolled in a clinical study of spinal manipulation for low back pain. Journal of manipulative and physiological therapeutics, 30(7), 493-500.
    • Assessment: Extremity
22. van Duijn, A. J., & Jensen, R. H. (2001). Reliability of inferior glide mobility testing of the glenohumeral joint. Journal of Manual & Manipulative Therapy, 9(2), 109-114.
23. Lin, H. T., Hsu, A. T., An, K. N., Chien, J. R. C., Kuan, T. S., & Chang, G. L. (2008). Reliability of stiffness measured in glenohumeral joint and its application to assess the effect of end-range mobilization in subjects with adhesive capsulitis. Manual Therapy, 13(4), 307-316.
24. Hayes, K. W., & Petersen, C. M. (2001). Reliability of assessing end-feel and pain and resistance sequence in subjects with painful shoulders and knees. Journal of Orthopaedic & Sports Physical Therapy, 31(8), 432-445.
25. Staes, F. F., Banks, K. J., De Smet, L., Daniels, K. J., & Carels, P. (2009). Reliability of accessory motion testing at the carpal joints. Manual Therapy, 14(3), 292-298.
    • Assessment: Pain Versus Motion
26. Schneider, G. M., Jull, G., Thomas, K., Smith, A., Emery, C., Faris, P., … & Salo, P. (2013). Intrarater and interrater reliability of select clinical tests in patients referred for diagnostic facet joint blocks in the cervical spine. Archives of physical medicine and rehabilitation, 94(8), 1628-1634.
27. Cleland, J. A., Childs, J. D., Fritz, J. M., & Whitman, J. M. (2006). Interrater reliability of the history and physical examination in patients with mechanical neck pain. Archives of physical medicine and rehabilitation, 87(10), 1388-1395.
28. Hubka, M. J., & Phelan, S. P. (1994). Interexaminer reliability of palpation for cervical spine tenderness. Journal of manipulative and physiological therapeutics, 17(9), 591-595.
29. Fjellner, A., Bexander, C., Faleij, R., & Strender, L. E. (1999). Interexaminer reliability in physical examination of the cervical spine. Journal of manipulative and physiological therapeutics, 22(8), 511-516.
30. Maher, C., & Adams, R. (1994). Reliability of pain and stiffness assessments in clinical manual lumbar spine examination. Physical Therapy, 74(9), 801-809.
31. Binkley J, Stratford PW, Gill C. Interrater reliability of lumbar accessory motion mobility testing. Phys Ther. 1995;75(9):786–792; discussion 793–5
    • Assessment: Factors Affecting Palpation
32. Lakhani, E., Nook, B., Haas, M., & Docrat, A. (2009). Motion palpation used as a postmanipulation assessment tool for monitoring end-feel improvement: a randomized controlled trial of test responsiveness. Journal of manipulative and physiological therapeutics, 32(7), 549-555.
33. Haas, M., Panzer, D., Peterson, D., & Raphael, R. (1995). Short-term responsiveness of manual thoracic end-play assessment to spinal manipulation: a randomized controlled trial of construct validity. Journal of manipulative and physiological therapeutics, 18(9), 582-589.
34. Cook, C., Turney, L., Ramirez, L., Miles, A., Haas, S., & Karakostas, T. (2002). Predictive factors in poor inter-rater reliability among physical therapists. Journal of Manual & Manipulative Therapy, 10(4), 200-205.
35. Cook, C., Brismée, J. M., & Sizer, P. S. (2005). Factors associated with physiotherapists' confidence during assessment of clinical cervical and lumbar spine instability. Physiotherapy Research International, 10(2), 59-71.
36. Downey, B., Taylor, N., & Niere, K. (2003). Can manipulative physiotherapists agree on which lumbar level to treat based on palpation?. Physiotherapy, 89(2), 74-81.
37. Cook, C., & Showalter, C. (2004). A survey on the importance of lumbar coupling biomechanics in physiotherapy practice. Manual therapy, 9(3), 164-172.
38. Keating, L., Lubke, C., Powell, V., Young, T., Souvlis, T., & Jull, G. (2001). Mid-thoracic tenderness: a comparison of pressure pain threshold between spinal regions, in asymptomatic subjects. Manual therapy, 6(1), 34-39.
39. Chiradejnant, A., Maher, C. G., & Latimer, J. (2003). Objective manual assessment of lumbar posteroanterior stiffness is now possible. Journal of manipulative and physiological therapeutics, 26(1), 34-39.
40. Maher, C. G., & Adams, R. D. (1996). Stiffness judgments are affected by visual occlusion. Journal of Manipulative and Physiological Therapeutics, 19(4), 250-256.
41. Maher, C., & Adams, R. (1996). A comparison of pisiform and thumb grips in stiffness assessment. Physical therapy, 76(1), 41-48.
    • Assessment: Palpation Compared to other Assessments
42. Fraser, J. J., Koldenhoven, R. M., Saliba, S. A., & Hertel, J. (2017). Reliability of ankle-foot morphology, mobility, strength, and motor performance measures. International Journal of Sports Physical Therapy, 12(7), 1134.
43. Schneider, M., Erhard, R., Brach, J., Tellin, W., Imbarlina, F., & Delitto, A. (2008). Spinal palpation for lumbar segmental mobility and pain provocation: an interexaminer reliability study. Journal of manipulative and physiological therapeutics, 31(6), 465-473.
44. Maigne, J. Y., Chantelot, F., & Chatellier, G. (2009). Interexaminer agreement of clinical examination of the neck in manual medicine. Annals of physical and rehabilitation medicine, 52(1), 41-48.
45. Viikari-Juntura, E. (1987). Interexaminer reliability of observations in physical examinations of the neck. Physical Therapy, 67(10), 1526-1532.
46. Piva, S. R., Erhard, R. E., Childs, J. D., & Browder, D. A. (2006). Inter-tester reliability of passive intervertebral and active movements of the cervical spine. Manual therapy, 11(4), 321-330.
47. Aartun, E., Degerfalk, A., Kentsdotter, L., & Hestbaek, L. (2014). Screening of the spine in adolescents: inter-and intra-rater reliability and measurement error of commonly used clinical tests. BMC musculoskeletal disorders, 15(1), 37.
48. Pool, J. J., Hoving, J. L., De Vet, H. C., Van Mameren, H., & Bouter, L. M. (2004). The interexaminer reproducibility of physical examination of the cervical spine. Journal of Manipulative and Physiological Therapeutics, 27(2), 84-90.
49. Bertilson, B. C., Grunnesjö, M., & Strender, L. E. (2003). Reliability of clinical tests in the assessment of patients with neck/shoulder problems—impact of history. Spine, 28(19), 2222-2231.
50. Hanten, W. P., Olson, S. L., & Ludwig, G. M. (2002). Reliability of manual mobility testing of the upper cervical spine in subjects with cervicogenic headache. Journal of Manual & Manipulative Therapy, 10(2), 76-82.
51. Jull, G., Zito, G., Trott, P., Potter, H., Shirley, D., & Richardson, C. (1997). Inter-examiner reliability to detect painful upper cervical joint dysfunction. Australian Journal of Physiotherapy, 43(2), 125-129.
    • Measurement Issues with Reliability of Assessing Joint Motion by Palpation (and 37)
52. Marcotte, J., Normand, M. C., & Black, P. (2005). Measurement of the pressure applied during motion palpation and reliability for cervical spine rotation. Journal of manipulative and physiological therapeutics, 28(8), 591-596.
53. Cooperstein, R., Haneline, M., & Young, M. (2010). Interexaminer reliability of thoracic motion palpation using confidence ratings and continuous analysis. Journal of chiropractic medicine, 9(3), 99-106.
54. Cooperstein, R., & Young, M. (2016). The reliability of lumbar motion palpation using continuous analysis and confidence ratings: choosing a relevant index of agreement. The Journal of the Canadian Chiropractic Association, 60(2), 146.
55. Humphreys, B. K., Delahaye, M., & Peterson, C. K. (2004). An investigation into the validity of cervical spine motion palpation using subjects with congenital block vertebrae as a'gold standard'. BMC Musculoskeletal Disorders, 5(1), 19.
56. Walker, B. F., Koppenhaver, S. L., Stomski, N. J., & Hebert, J. J. (2015). Interrater reliability of motion palpation in the thoracic spine. Evidence-Based Complementary and Alternative Medicine, 2015.
    • Reliability of Therapist Force during Joint Mobilization/Manipulation
57. Snodgrass, S. J., Rivett, D. A., & Robertson, V. J. (2007). Manual forces applied during cervical mobilization. Journal of manipulative and physiological therapeutics, 30(1), 17-25.
58. Snodgrass, S. J., Rivett, D. A., Robertson, V. J., & Stojanovski, E. (2009). Forces applied to the cervical spine during posteroanterior mobilization. Journal of Manipulative and Physiological Therapeutics, 32(1), 72-83.
59. An, H. J., Heo, S. Y., Choi, J. H., & Choi, W. S. (2017). Quantification of Mobilization Grade for Mean Peak Force During Central Posteroanterior Mobilization of C3-C5 in Asymptomatic College Students. Journal of International Academy of Physical Therapy Research, 8(4), 1285-1290.
    • Thoracic Spine
60. Forand, D., Drover, J., Suleman, Z., Symons, B., & Herzog, W. (2004). The forces applied by female and male chiropractors during thoracic spinal manipulation. Journal of manipulative and physiological therapeutics, 27(1), 49-56.
61. Pasquier, M., Barbier-Cazorla, F., Audo, Y., Descarreaux, M., & Lardon, A. (2019). Learning spinal manipulation: Gender and expertise differences in biomechanical parameters, accuracy, and variability. Journal of Chiropractic Education, 33(1), 1-7.
62. Cambridge, E. D., Triano, J. J., Ross, J. K., & Abbott, M. S. (2012). Comparison of force development strategies of spinal manipulation used for thoracic pain. Manual therapy, 17(3), 241-245.\
63. Gagnon, D. H., Longtin, C., Berbiche, D., & Gaudreault, N. (2016). Do experienced physiotherapists and final year physiotherapy trainees apply similar force during posterior-to-anterior lumbar mobilization techniques?. Manual therapy, 21, 287-291.
    • Lumbar Spine
64. Harms, M. C., & Bader, D. L. (1997). Variability of forces applied by experienced therapists during spinal mobilization. Clinical Biomechanics, 12(6), 393-399.
65. Choi, W. S., Heo, S. Y., Moon, O. K., Kim, B. K., & San Wang, J. (2017). Effects of Mobilization Grade on Maximum Pressure Force During Central Posteroanterior Movement of Lumbar Spine in Healthy Person. Journal of International Academy of Physical Therapy Research, 8(4), 1291-1295.
66. Chester, R., Swift, L., & Watson, M. J. (2003). An evaluation of therapist's ability to perform graded mobilization on a simulated spine. Physiotherapy Theory and Practice, 19(1), 23-34.
    • Knee
67. Silvernail, J. L., Gill, N. W., Teyhen, D. S., & Allison, S. C. (2011). Biomechanical measures of knee joint mobilization. Journal of Manual & Manipulative Therapy, 19(3), 162-171.
68. Tragord, B. S., Gill, N. W., Silvernail, J. L., Teyhen, D. S., & Allison, S. C. (2013). Joint mobilization forces and therapist reliability in subjects with knee osteoarthritis. Journal of Manual & Manipulative Therapy, 21(4), 196-206.
    • Ankle:
69. Venturini, C., Penedo, M. M., Peixoto, G. H., Chagas, M. H., Ferreira, M. L., & de Resende, M. A. (2007). Study of the force applied during anteroposterior articular mobilization of the talus and its effect on the dorsiflexion range of motion. Journal of manipulative and physiological therapeutics, 30(8), 593-597.
70. vS de Souza, M., Venturini, C., Teixeira, L. M., Chagas, M. H., & de Resende, M. A. (2008). Force-displacement relationship during anteroposterior mobilization of the ankle joint. Journal of manipulative and physiological therapeutics, 31(4), 285-292.
    • Experience
71. Snodgrass, S. J., Rivett, D. A., Robertson, V. J., & Stojanovski, E. (2010). Cervical spine mobilisation forces applied by physiotherapy students. Physiotherapy, 96(2), 120-129.
72. Snodgrass, S. J., Rivett, D. A., Robertson, V. J., & Stojanovski, E. (2010). A comparison of cervical spine mobilization forces applied by experienced and novice physiotherapists. journal of orthopaedic & sports physical therapy, 40(7), 392-401.
73. Derian, J. M., Smith, J. A., Wang, Y., Lam, W., & Kulig, K. (2020). Biomechanical characteristics of lumbar manipulation performed by expert, resident, and student physical therapists. Musculoskeletal Science and Practice, 102150.
74. Loranger, M., Treboz, J., Boucher, J. A., Nougarou, F., Dugas, C., & Descarreaux, M. (2016). Correlation of expertise with error detection skills of force application during spinal manipulation learning. Journal of Chiropractic Education, 30(1), 1-6.
    • Unexpected Influences (and 56, 57, 35, 36)
75. Maher, C. G., Latimer, J., & Holland, M. J. (1999). Plinth padding confounds measures of posteroanterior spinal stiffness. Manual therapy, 4(3), 145-150.
    • Improved Reliability with Instrumented Manakins and Force Gauges
76. Björnsdóttir, S. V., & Kumar, S. (2003). Posteroanterior motion test of a lumbar vertebra: accuracy of perception. Disability and rehabilitation, 25(4-5), 170-178.
77. Triano, J. J., Giuliano, D., Kanga, I., Starmer, D., Brazeau, J., Screaton, C. E., & Semple, C. (2015). Consistency and malleability of manipulation performance in experienced clinicians: a pre-post experimental design. Journal of manipulative and physiological therapeutics, 38(6), 407-415.
78. Kope, R., O’Brien, J., Sadi, J., Walton, D. M., & Ferreira, L. M. (2018). Quantifying performance metrics of cervical spine mobilization for improved education and clinical outcomes: Early experience with a novel wearable device. Journal of rehabilitation and assistive technologies engineering, 5, 2055668318765396.
    • Measurement Problems with the Reliability of Therapist Force
79. Owens Jr, E. F., Hosek, R. S., Sullivan, S. G., Russell, B. S., Mullin, L. E., & Dever, L. L. (2016). Establishing force and speed training targets for lumbar spine high-velocity, low-amplitude chiropractic adjustments. Journal of Chiropractic Education, 30(1), 7-13.
80. Petersen, E. J., Thurmond, S. M., Shaw, C. A., Miller, K. N., Lee, T. W., & Koborsi, J. A. (2020). Reliability and accuracy of an expert physical therapist as a reference standard for a manual therapy joint mobilization trial. Journal of Manual & Manipulative Therapy, 1-7.
81. Snodgrass, S. J., Rivett, D. A., Sterling, M., & Vicenzino, B. (2014). Dose optimization for spinal treatment effectiveness: a randomized controlled trial investigating the effects of high and low mobilization forces in patients with neck pain. journal of orthopaedic & sports physical therapy, 44(3), 141-152.
82. McLean, S., Naish, R., Reed, L., Urry, S., & Vicenzino, B. (2002). A pilot study of the manual force levels required to produce manipulation induced hypoalgesia. Clinical Biomechanics, 17(4), 304-308.
83. Chiradejnant, A., Latimer, J., & Maher, C. G. (2002). Forces applied during manual therapy to patients with low back pain. Journal of manipulative and physiological therapeutics, 25(6), 362-369.
84. Pasquier, M., Chéron, C., Barbier, G., Dugas, C., Lardon, A., & Descarreaux, M. (2020). Learning Spinal Manipulation: Objective and Subjective Assessment of Performance. Journal of Manipulative and Physiological Therapeutics, 43(3), 189-196.
85. Latimer, J., Lee, M., & Adams, R. D. (1998). The effects of high and low loading forces on measured values of lumbar stiffness. Journal of manipulative and physiological therapeutics, 21(3), 157-163.
86. Ward, J., Hebron, C., & Petty, N. J. (2017). The intra-rater reliability of a revised 3-point grading system for accessory joint mobilizations. Journal of Manual & Manipulative Therapy, 25(4), 201-207.
    • Study Problems
87. Smit, E., Conradie, M., Wessels, J., Witbooi, I., & Otto, R. (2003). Measurement of the magnitude of force applied by students when learning a mobilisation technique. South African Journal of Physiotherapy, 59(4), 3-8.
88. Conradie, M., Smit, E., Louw, M., Prinsloo, M., Loubser, L., & Wilsdorf, A. (2004). Do experienced physiotherapists apply equal magnitude of force during a grade I central pa on the cervical spine?. South African Journal of Physiotherapy, 60(4), 18-25.
    • Assessment, Force and Outcomes
89. Aquino, R. L., Caires, P. M., Furtado, F. C., Loureiro, A. V., Ferreira, P. H., & Ferreira, M. L. (2009). Applying joint mobilization at different cervical vertebral levels does not influence immediate pain reduction in patients with chronic neck pain: a randomized clinical trial. Journal of Manual & Manipulative Therapy, 17(2), 95-100.
90. Haas, M., Groupp, E., Panzer, D., Partna, L., Lumsden, S., & Aickin, M. (2003). Efficacy of cervical endplay assessment as an indicator for spinal manipulation. Spine, 28(11), 1091-1096
91. Karas, S., Olson Hunt, M. J., Temes, B., Thiel, M., Swoverland, T., & Windsor, B. (2018). The effect of direction specific thoracic spine manipulation on the cervical spine: a randomized controlled trial. Journal of Manual & Manipulative Therapy, 26(1), 3-10.
92. Kanlayanaphotporn, R., Chiradejnant, A., & Vachalathiti, R. (2009). The immediate effects of mobilization technique on pain and range of motion in patients presenting with unilateral neck pain: a randomized controlled trial. Archives of physical medicine and rehabilitation, 90(2), 187-192.
93. Donaldson, M., Petersen, S., Cook, C., & Learman, K. (2016). A prescriptively selected nonthrust manipulation versus a therapist-selected nonthrust manipulation for treatment of individuals with low back pain: a randomized clinical trial. journal of orthopaedic & sports physical therapy, 46(4), 243-250.
94. Fritz, J. M., Whitman, J. M., & Childs, J. D. (2005). Lumbar spine segmental mobility assessment: an examination of validity for determining intervention strategies in patients with low back pain. Archives of Physical Medicine and Rehabilitation, 86(9), 1745-1752.
95. Hidalgo García, C., Fanlo Mazas, P., Malo Urriés, M., Pérez Guillén, S., Tricás Moreno, J. M., Lucha López, O., … & Krauss, J. (2016). Short term efficacy of C0-C1 mobilization in the cervical neutral position in upper cervical hypomobility: a randomized controlled trial (No. ART-2016-100536).
96. Talbott and, N. R., & Witt, D. W. (2016). In vivo measurements of humeral movement during posterior glenohumeral mobilizations. Journal of Manual & Manipulative Therapy, 24(5), 269-276.
97. Ngan, J. M., Chow, D. H., & Holmes, A. D. (2005). The kinematics and intra-and inter-therapist consistencies of lower cervical rotational manipulation. Medical engineering & physics, 27(5), 395-401.
98. Gianola, S., Cattrysse, E., Provyn, S., & Van Roy, P. (2015). Reproducibility of the kinematics in rotational high-velocity, low-amplitude thrust of the upper cervical spine: a cadaveric study. Journal of manipulative and physiological therapeutics, 38(1), 51-58.