Introduction

Measurement Issues with Reliability

Section Summary

Inter-therapist versus Intra-therapists Reliability of Assessment by Palpation

Additional Factors

Reliability of Joint Motion Assessment by Palpation Relative to Other Assessments

Measurement Issues with Studies Investigating the Reliability of Assessing Joint Motion by Palpation

Reliability of Joint Motion Assessment by Palpation Section Summary

Reliability of Therapist Force during Joint Mobilization/Manipulation

Inter-therapist and Intra-therapist Reliability

Factors Affecting Reliability of Therapists Force

Ignorance Fueled Controversy

Measurement Problems and the Reliability of Therapist Force

Reliability of Therapist Force Section Summary

Outcomes

Definitions and Word Choice

Course Summary

Accuracy of Relative Locations

Physical Factors Affecting Reliability

Inter-therapist Versus Intra-therapist Reliability

Questionable Research Methods

Joint Mobilization and Manipulation: Palpation, Assessment, and Reliability

PACE

AUSPHYSIO

TPTA

NYPT

AOTA

Joint Mobilization and Manipulation: Assessment and Reliability

<p>In this course, we cover a topic that has only recently become controversial. Palpation and palpation <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> (passive <a id="arthrokinematics" data-tip="1860" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">accessory motion</a> exam) were considered standard components of a physical examination, and they were performed by a variety of healthcare providers. Recently, the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> 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 <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> dismissing these techniques. Deep palpation may require more skill and have lower <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> 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 <a id="effusion" data-tip="1459" target="_blank" href="/glossary-term/effusion" class="glossary">effusion</a> and an increase in joint fluids, and differentiation between tissues may require advanced anatomy knowledge. Despite these factors affecting the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and efficacy of palpation, it would be a logical fallacy to dismiss a technique for any presumed flaw. <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and efficacy are not binary measures, they are probabilistic measures. Less <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> or effective, does not imply &quot;not <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> or effective&quot;.&#xA0;</p>
<p>This course is built from a comprehensive, systematic review of all <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> research, carefully explains the issues involved in interpreting the research, and attempts to develop the nuanced conclusions necessary to make <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a> recommendations. A couple of examples from the research summary:</p>
<ul>
  <li><strong>Joint Motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> by Palpation:</strong> When research investigates a well-differentiated definition of a positive finding, a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> range of agreement, considers therapist confidence in findings (and perhaps therapist skill), good or better inter-therapist and intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is achievable for joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> by palpation.</li>
  <li><strong>Combined Assessments:</strong> Range of motion (ROM) <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> and special tests are generally more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation; however, the addition of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation to a combination of <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> (as is commonly observed in practice) likely increases the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of these <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> and the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of the <a id="assessment" data-tip="1481" target="_blank" href="/glossary-term/assessment" class="glossary">evaluation</a> overall.</li>
</ul>
<p>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 <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">Integrated</a> 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.).</p>
<h3>Brookbush Institute&apos;s Position Statement <em>(Sample from Course)</em>:</h3>
<ul>
  <li>Good to excellent inter-therapist and intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> may be achieved for the palpation of anatomical landmarks, joint stiffness <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation, and therapist force during mobilization/manipulation when parameters are well-defined, therapist confidence in findings is considered, and <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is analyzed using a continuous interval measure and/or practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> range of agreement. The <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, <a id="predictive-values" data-tip="1738" target="_blank" href="/glossary-term/predictive-values" class="glossary">predictive value</a>, and utility of these techniques are likely to improve when <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> into a standard patient <a id="assessment" data-tip="1481" target="_blank" href="/glossary-term/assessment" class="glossary">evaluation</a> that includes multiple <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a>, and/or added to an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> (multi-modal) intervention plan. Further, adding these techniques to practice reliably and significantly improves mean patient outcomes.
    <ul>
      <li><strong>In short,</strong> when these techniques are judged based on how they are commonly used in practice, they demonstrate sufficient <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> to significantly improve patient outcomes.</li>
    </ul>
  </li>
</ul>
<h3><span>Related Courses</span></h3>
<ul>
  <li><a href="https://brookbushinstitute.com/courses/introduction-joint-mobilizations-joint-manipulations" target="_blank" rel="noopener">Joint Mobilization and Manipulation: Introduction</a></li>
  <li><span style="background-color: transparent; font-family: inherit; font-size: inherit; font-style: inherit; font-variant-ligatures: inherit; font-variant-caps: inherit; font-weight: inherit; letter-spacing: 0px;"></span><a href="https://brookbushinstitute.com/course/effect-joint-mobilizations-manipulations" style="letter-spacing: 0px;"><span style="background-color: transparent; font-family: inherit; font-size: inherit; font-style: inherit; font-variant-ligatures: inherit; font-variant-caps: inherit; font-weight: inherit; letter-spacing: 0px;">Effects of Joint Mobilizations and Manipulations</span></a></li>
  <li><span style="background-color: transparent; font-family: inherit; font-size: inherit; font-style: inherit; font-variant-ligatures: inherit; font-variant-caps: inherit; font-weight: inherit; letter-spacing: 0px;"></span><a href="https://brookbushinstitute.com/course/joint-mobilization-and-manipulation-risk-of-adverse-events" style="letter-spacing: 0px;">Joint Mobilizations and Manipulations: Risk of Adverse Events</a></li>
  <li><a href="https://brookbushinstitute.com/courses/joint-mobilizations-and-manipulations-evidence-based-teaching-and-learning" title="Joint Mobilization and Manipulation: Evidence-based Teaching and Learning" target="_blank" rel="noopener">Joint Mobilizations and Manipulations: Evidenced-based Teaching and Learning</a></li>
</ul>

Course Description: Palpation, Assessment, and Reliability

<h3>Position Statement:</h3>
<ul>
  <li>Good to excellent inter-therapist and intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> may be achieved for the palpation of anatomical landmarks, joint stiffness <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation, and therapist force during mobilization/manipulation when parameters are well-defined, therapist confidence in findings is considered, and <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is analyzed using a continuous interval measure and/or practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> range of agreement. The <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, <a id="predictive-values" data-tip="1738" target="_blank" href="/glossary-term/predictive-values" class="glossary">predictive value</a>, and utility of these techniques are likely to improve when <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> into a normal patient <a id="assessment" data-tip="1481" target="_blank" href="/glossary-term/assessment" class="glossary">evaluation</a> that includes multiple <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a>, and/or added to an <a id="integration" data-tip="1473" target="_blank" href="/glossary-term/integration" class="glossary">integrated</a> (multi-modal) intervention plan. Further, the addition of these techniques to practice reliably and significantly improves mean patient outcomes.
    <ul>
      <li><strong>In short,</strong> when these techniques are judged based on the way they are commonly used in practice, they demonstrate sufficient <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> to result in a significant improvement in patient outcomes.</li>
    </ul>
  </li>
</ul>
<h3><strong>Key Research Points</strong></h3>
<ul>
  <li><strong>Intra-therapist vs. Inter-therapist Reliability:</strong> Research suggests that intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is often good to excellent, and likely better than inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for these techniques.
    <ul>
      <li>This may imply that better inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is possible if additional research leads to a <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> set of protocols that are widely adopted by the movement professions.</li>
    </ul>
  </li>
  <li><strong>Palpation of Anatomical Landmarks:</strong> Imaging may not match the relative location of landmarks found by palpation, and the palpation of anatomical landmarks should be performed knowing that results are a narrow range of probable findings (findings are not discreet values).</li>
  <li><strong>Joint Motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> by Palpation:</strong> When research investigates a well-differentiated definition of a positive finding, a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> range of agreement, considers therapist confidence in findings (and perhaps therapist skill), good or better inter-therapist and intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is achievable for joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> by palpation.</li>
  <li><strong>Combined Assessments:</strong> Range of motion (ROM) <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> and special tests are generally more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation; however, the addition of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation to a combination of <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> (as is commonly observed in practice) likely increases the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of these <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> and the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of the <a id="assessment" data-tip="1481" target="_blank" href="/glossary-term/assessment" class="glossary">evaluation</a> overall.</li>
  <li><strong>Therapist force During Mobilization:</strong> Therapist force during mobilizations exhibits excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for peak force, mean peak force, amplitude, and oscillatory frequency. Inter-therapist force may exhibit relatively high amounts of variance; however, moderate <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> may be achieved when considering the mean force of grades I and II or grades III and IV together.
    <ul>
      <li>As might be expected in any professional setting, the most capable 1/3 of professionals exhibit good to excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and the bottom 1/3 exhibit greater variance.</li>
    </ul>
  </li>
  <li><strong>Outcomes:</strong> Mean peak force is likely more critical than mean minimal force during mobilizations and manipulation. Further, a relatively wide range of forces may be effective, with better outcomes correlated with more force or force above a certain low-end threshold.</li>
  <li><strong>What determines ideal therapist force:</strong> Patient characteristics, the rate of force development, and the duration of manipulation should be considered when developing an ideal range for therapist force, and pain intensity, nature of symptoms, and assumptions about factors contributing to comfort should be given less consideration or dismissed from consideration.</li>
</ul>
<h3>Brookbush Institute Evidence-based Recommendations</h3>
<ol>
  <li>Palpation and joint stiffness <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation should be performed knowing that <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> results reflect a narrow range of probable findings (findings are not discreet values).</li>
  <li>Joint stiffness <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation should be performed in conjunction with additional movement <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> (and special tests if necessary) with the intent of improving intervention selection.
    <ul>
      <li>It may be ideal to use joint stiffness <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation as an <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> to determine whether a mobilization or manipulation technique had an acute effect on joint stiffness.</li>
    </ul>
  </li>
  <li><a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">Reliability</a> may be improved for joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by incorporating the following into practice:
    <ul>
      <li>Well-differentiated definition of a positive finding (i.e. most stiff)</li>
      <li>Use of a consistent hand grip</li>
      <li>Visibility of the assessed segment
        <ul>
          <li>Although it is not common practice, research suggests a reference device for comparing normal and abnormal amounts of stiffness may improve the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">Reliability</a> of &quot;stiffness assessment&quot;.</li>
        </ul>
      </li>
    </ul>
  </li>
  <li>Mobilizations and manipulations should only be performed on joints exhibiting signs of <a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a>, and should not be used on <a id="hypermobility" data-tip="1679" target="_blank" href="/glossary-term/hypermobility" class="glossary">hypermobile</a> joints.</li>
  <li>Professionals should expect that the mean force of grades I and II, and the mean force of grades III and IV will be similar, and greater variance should be expected and potentially promoted during higher amplitude mobilizations (grades II and III).</li>
  <li>Peak force likely has a larger impact on outcomes. Professionals should prioritize determining the amount of peak force necessary to improve the <a id="arthrokinematics" data-tip="1863" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic</a> range of joints exhibiting stiffness, and attempt to maintain consistent peak force throughout the duration of the technique (until stiffness/symptoms change).</li>
  <li>Professionals performing high-velocity manipulations should practice with the intent to improve the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of forces imparted, increase the rate of force development, and decrease the duration of a manipulation technique.
    <ul>
      <li>Although it is not common practice, research suggests instrumented manakins and force gauges that visually display the amount of force during a technique can improve <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> when used consistently.</li>
    </ul>
  </li>
</ol>

<p>Research investigating <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is not ubiquitously bad or good for the palpation of anatomical landmarks, joint stiffness <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation, or therapist force during mobilization/manipulation. This implies that developing reasonably objective and accurate conclusions will require more nuanced than a binary judgment of &quot;is&quot; or &quot;is not&quot; <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> (e.g. the &quot;position stand&quot; above). Although it may be possible to find a few studies to reinforce a positive or negative bias, the only academically honest method of analysis is to review all peer-reviewed, published, original studies, and attempt to develop conservative, and reasonably objective conclusions that account for the varied research findings. Those individuals who have attempted to promote a binary summary judgment of &quot;is&quot; or &quot;is not&quot; <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> for these techniques, have either demonstrated a lack of knowledge of the body of research or have purposefully chosen to promote an academically dishonest position to serve their own bias, position or business.</p>
<p>Based on the review below, coming to a summary judgment of &quot;is not reliable&quot; for these techniques, would require someone to consider <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> as if diagnosis and <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> will be based on a single full-body palpatory exam without additional <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> or information, treatment is limited to a single mobilization or manipulation, and that <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> requires <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> within 5mm or a few Newtons of force without consideration of patient outcomes. The idea that any professional would have someone lay on a treatment table, <a id="base-of-support" data-tip="1196" target="_blank" href="/glossary-term/base-of-support" class="glossary">base</a> intervention on palpation alone, attempt to fix every issue with a single mobilization/manipulation, and/or that the human body is so fragile that any variance in force would result in injury, is so far from the reality of practice, that these summary judgments not only lack <a id="validity" data-tip="1511" target="_blank" href="/glossary-term/validity" class="glossary">validity</a>, they are laughable. At the very least, if <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is going to be determined based on a strict standard of stand-alone use, and discrete, narrow margins of agreement, then it is worth considering the possibility that no <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> or intervention in our field will reach acceptable levels of <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> in peer-reviewed, published original research. It should have been a &quot;red flag&quot; for our colleagues, that when certain professionals and publications claimed these techniques were not <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a>, these claims and publications were missing any comparison to other techniques; and further, no suggestions were made for alternate techniques that demonstrated <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> or efficacy in original research. The pursuit of <a id="evidence-based-practice" data-tip="1532" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based practice</a> is the intent to bias practice toward those techniques that are the most well-supported, and/or have demonstrated the largest positive impact on patient outcomes (measured using <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a>, objective <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a>). The &quot;pursuit of <a id="evidence-based-practice" data-tip="1538" target="_blank" href="/glossary-term/evidence-based-practice" class="glossary">evidence-based</a> practice&quot; is a statement of relativity, that implies we choose the best of our options, not dismiss techniques without a <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> replacement. Dismissing techniques based on a few research studies, without evidence of a <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> replacement, is no different than dismissing research in favor of opinion.</p>

<p>An effort was made to improve transparency and clarity with a set of uniform terms. This required that the terminology used by the researchers was carefully matched to a standardized set of definitions and/or descriptions. Wherever possible, subjective language (e.g. adequate, reasonable, acceptable, etc.) was replaced with study findings, appropriate language based on objective criteria, or was omitted completely.</p>
<p><strong>Word Choice: <em>&quot;Rating <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">Reliability</a> Based on Kappa Value&quot; -</em></strong> The language used to describe k-values (k-factors) and the percent agreement are listed in the table below. This table was constructed by comparing several published tables and using the most common terminology.</p>
<ul>
  <li><strong>Cohen&apos;s kappa coefficient (&#x3BA;)</strong> - A statistical analysis used to measure <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for qualitative items. It is generally thought to be a more robust measure than a simple percent agreement calculation, as &quot;&#x3BA;&quot; takes into account the possibility of agreement occurring by chance.</li>
</ul>
<table>
  <tbody>
    <tr>
      <td>Language Used (Rating)</td>
      <td>&quot;K&quot; Value</td>
      <td>Percent Agreement</td>
    </tr>
    <tr>
      <td>None</td>
      <td>0 - .20</td>
      <td>0 - 4%</td>
    </tr>
    <tr>
      <td>Minimal</td>
      <td>.21 - .39</td>
      <td>4-15%</td>
    </tr>
    <tr>
      <td>Poor (Weak)</td>
      <td>.40&#x2013;.59</td>
      <td>15&#x2013;35%</td>
    </tr>
    <tr>
      <td>Moderate</td>
      <td>.60&#x2013;.79</td>
      <td>35&#x2013;63%</td>
    </tr>
    <tr>
      <td>Good (Strong)</td>
      <td>.80&#x2013;.90</td>
      <td>64&#x2013;81%</td>
    </tr>
    <tr>
      <td>Excellent (Almost Perfect)</td>
      <td>.90 or more</td>
      <td>82&#x2013;100%</td>
    </tr>
  </tbody>
</table>
<p><strong>Word Choice: <em>&quot;Therapist&quot;</em> as a suffix</strong> - The suffix &quot;therapist&quot; is used when describing <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. Studies use terms including intra-rater, intra-tester, intra-examiner, intra-clinician etc., which can make it more challenging to differentiate between &quot;intra-&quot; and &quot;inter-&quot; while reading. We hope the use of one suffix throughout this review improves clarity, and we thought that the word &quot;therapist&quot; most reflected the majority of the audience interested in this topic.</p>
<ul>
  <li><strong>Reliability</strong> refers to the ability of a <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> or <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> to accurately measure with consistency. <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">Reliability</a> falls into to two broad categories:
    <ul>
      <li><strong>Inter-</strong>therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">Reliability</a> - the agreement (or lack of) between two or more testers performing the same <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a>.</li>
      <li><strong>Intra-</strong>therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">Reliability</a> - the agreement (or lack of) between tests when repeated by the same tester multiple times.</li>
    </ul>
  </li>
</ul>
<p><strong>Word Choice:</strong> <em>&quot;<strong>Joint Motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> by Palpation&quot;</strong></em> was developed to encompass the variety of terms used in the literature. It is not that any of the terms used in the literature lack clarity unto themselves; however when comparing various studies, the variety of terminology can reduce clarity. For example, passive intervertebral <a id="arthrokinematics" data-tip="1860" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">accessory motion</a> (PAIVM), spine motion palpation, <a id="arthrokinematics" data-tip="1860" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">accessory motion</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a>, and <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> stiffness <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> may all be used to describe the same protocol. Additionally, it is the Brookbush Institute&apos;s position that <strong><em>&quot;Joint Stiffness <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> by Palpation&quot;</em></strong> should become the preferred term, as the term &quot;stiffness&quot; represents a consistent, <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a>, and well-defined variable that can be objectively measured in terms of force. Some of the variations in findings from research investigating this topic can be attributed to the poor definitions, boundaries, and measures implied by terms like &quot;joint position&quot;, &quot;subluxation&quot;, or &quot;dysfunction&quot; when it&apos;s used to describe an ill-defined combination of pain, stiffness, and position.</p>
<ul>
  <li><strong>Joint Stiffness <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> by Palpation -</strong> The use of manual pressure to <a id="assessment" data-tip="1486" target="_blank" href="/glossary-term/assessment" class="glossary">assess</a> joint resistance (and/or stiffness with pain) during passive <a id="arthrokinematics" data-tip="1701" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">arthrokinematic motion</a>.</li>
</ul>
<p><strong>Discrete versus Continuous Data</strong> - In this review there is a section that discusses whether it is appropriate to analyze <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> based on discrete or continuous data. The definitions used in this review are conventional definitions. The definitions are stated here only as a reminder.</p>
<ul>
  <li><strong>Discrete</strong> - Data which have a defined set of values. These values cannot be infinitely divided. For example, the number of students in a classroom (you cannot have 1.5 students), or the tip of each spinous process (you cannot have a spinous process for the vertebrae L3.7)</li>
  <li><strong>Continuous</strong> - Data which can be an infinite number of values between two values. For example, the length of a piece of string could be an infinite number of values between 3 and 4 centimeters (cm), or the distance from the center of a landmark to a practitioner&apos;s palpation could be an infinite number of values between 0.5 and 1.7652cm.</li>
</ul>

<h3>Palpation of Boney Landmarks</h3>
<ul>
  <li><strong>Relative Location:</strong> Using imaging techniques to define the relative location of an anatomical landmark may not match the instructions for identifying landmarks by palpation. Further, palpation using relative location will not result in a single point, but a small range of likely possibilities.</li>
  <li><strong>Location and Physical Characteristics:</strong> The <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of landmark palpation may vary depending on the landmarks location, as well as various physical characteristics; relative location to other landmarks (discussed above), including landmark depth, body mass index (BMI), joint motion, and bone/joint structure.</li>
  <li><strong>Better Intra-therapist than Inter-therapist Reliability:</strong> Studies demonstrate better intra-therapist than inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, matching a trend noted in the body of research regarding manual <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> and techniques. This trend may imply that <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is achievable, but more research and effort is needed to align education, practitioner internal <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> of reference, and palpation protocols between various practitioners.</li>
  <li><strong>Measurement Issues:</strong> Two studies demonstrating low inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> used a reference that was not based on a recognized or objectively developed &quot;gold standard&quot; reference. These studies highlight a key issue with several of the available <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> studies, in which the inherent dependence of <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> on a reference standard was not given enough consideration, potentially affecting confidence in study results.</li>
  <li><strong>How Accurate is Accurate Enough?:</strong> Using discrete measures, e.g. the tip of a spinous process, to determine <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> does not accurately represent a practitioner&apos;s ability to reliably identify a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> area, e.g. a spinal segment. Several studies demonstrate good to excellent inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> when a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> area, or continuous measure is used during analysis.</li>
</ul>
<h3>Reliability of Joint Motion Assessment by Palpation</h3>
<h4><strong>Inter-therapist versus Intra-therapist Reliability</strong></h4>
<ul>
  <li><strong>Cervical Spine, Thoracic Spine, and 1st Rib</strong> - <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> by palpation of the cervical spine, thoracic spine, and first rib exhibit poor to moderate inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, moderate to good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and thoracic spine <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> is likely less <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than cervical spine or first rib <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a>.</li>
  <li><strong>Lumbar Spine</strong> - <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> by palpation of the lumbar spine in symptomatic individuals exhibits poor to moderate inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and moderate to good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. Further, <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> of asymptomatic patients may trend toward worse inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, but better intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>.</li>
  <li><strong>Extremities</strong> - The number of studies demonstrating moderate to good inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of extremity joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation may suggest they are more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of the spine. However, these studies also demonstrate the same trends of intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> being better than inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>.</li>
</ul>
<h4><strong>Pain versus Stiffness</strong></h4>
<ul>
  <li><strong>Cervical and Lumbar Spine</strong> - It is likely reasonable to conclude that identifying a dysfunctional segment based on pain has moderate to good inter-therapist and intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, which is better inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> that demonstrated by most studies identifying dysfunction of a segment based on <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a>. Further, studies imply that joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation of symptomatic patients is more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of asymptomatic patients.</li>
</ul>
<h4><strong>Factors Affecting palpation</strong></h4>
<ul>
  <li><strong>Pre/Post <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> -</strong> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> of joint motion by palpation may have more utility for identifying changes in <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> following intervention.</li>
  <li><strong>Education -</strong> Practitioners are likely to believe additional education is important, and education is positively correlated with confidence in <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> findings; however, additional education is likely weakly correlated with increased inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> via palpation. One potential reason for these findings may be significant differences in the information and technique described by various education organizations.</li>
  <li><strong>Technique -</strong> Awareness of normal pain pressure <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>, the addition of a reference device, elimination of any visual occlusion, and the use of a consistent hand grip should be considered during <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>, and/or when developing research methods for investigating the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> via palpation.</li>
</ul>
<h4><strong>Joint Motion Assessment Reliability Relative to Other Assessments</strong></h4>
<ul>
  <li><strong>Comparison and Combination</strong> - Range of motion (ROM) <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> and special tests are generally more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation. However, studies including a combination of <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> most often demonstrate moderate or better inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation. Further, the good to excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of combined <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> may be evidence that clusters of <a id="assessment" data-tip="1483" target="_blank" href="/glossary-term/assessment" class="glossary">evaluations</a> increase the <a id="predictive-values" data-tip="1738" target="_blank" href="/glossary-term/predictive-values" class="glossary">predictive value</a>, <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and utility of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation, and/or that palpation exams may be beneficial in achieving excellent to perfect <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of diagnosis and categorization of symptoms and impairments.</li>
</ul>
<h4><strong>Measurement Issues with Studies Investigating the Reliability of Assessing Joint Motion by Palpation</strong></h4>
<ul>
  <li><strong>Correlation with Outcomes - </strong>Ideally, research would aid in improving the variable that correlates an <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> with the implementation of the technique that is most likely to improve patient outcomes. This implies that the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation should be based on the ability to identify the &quot;most treatable&quot; segment, and not the ability to accurately name an anatomical landmark.</li>
  <li><strong>Number of Assessors -</strong> Additional research is needed to determine if results from joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation from a larger group of examiners would begin to pool around mean values. The pooling of mean values may aid in identifying those attributes most likely to improve <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. Unfortunately, most research to date has compared 2 or 3 examiners, which may exaggerate the differences between examiners, and negatively skew <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> findings.</li>
  <li><strong>Examiner/Therapist Confidence</strong> - A therapist&apos;s confidence in findings significantly affects expected inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> during joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation. For example, good inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> has been demonstrated when therapist confidence is high.</li>
  <li><strong>Range of Agreement and Analysis</strong> - <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">Reliability</a> should be based on analysis of a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> definition of agreement. That is, research analysis should include a well-differentiated definition of a &quot;positive finding&quot;, a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> range, and ideally, should describe <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">Reliability</a> within a continuous interval scale.</li>
</ul>

Palpation of Boney Landmarks

<h4><strong>Intra-therapist and Inter-therapist Reliability</strong></h4>
<ul>
  <li><strong>Cervical Spine</strong> - Cervical mobilizations exhibit good to excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for peak force, mean peak force, amplitude, and oscillatory frequency, and inter-therapist force variance may be relatively high but moderately <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> when considering grade III and IV mobilization forces as a group. These studies also demonstrate that the difference in force used for grades I/II and III/IV mobilizations may be reliably differentiated. Additionally, substantial <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> has been demonstrated for the pre-manipulative position and rotation component used during cervical manipulations.</li>
  <li><strong>Thoracic Spine</strong> - Future research may anticipate higher <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for peak and mean force values and less <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for the rate of force development.</li>
  <li><strong>Lumbar Spine</strong> - Studies demonstrate more inter-therapist variance than intra-therapist variance, more variance for grade III mobilizations than grade IV mobilizations, and considerable overlap in forces between grades I-II and grades III-IV. Further, excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and potentially moderate or better inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> may be an achievable skill (especially for mean dosage and mean peak force).</li>
  <li><strong>Knee Joint</strong> - Knee mobilizations exhibit good to excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and moderate inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. Further, comparing grade III and IV mobilizations revealed similar mean peak forces, but significant differences in amplitude and dosage.</li>
  <li><strong>Ankle Joint</strong> - Inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is moderate or better for mean peak force, but poor for mean minimal force. However, the lack of minimal force <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> seems to have no impact on mobilization outcomes, as near perfect <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for improving ankle dorsiflexion ROM was also demonstrated.</li>
  <li><strong>Shoulder - </strong>Talbott et al. demonstrated good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, differentiation of force between grades, and total motion of 3.0mm for grade I, 8.2mm for grade II, and 10.7mm for grade III during Kaltenborn <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> (AP) shoulder mobilization technique (96).</li>
</ul>
<h4><strong>Factors Affecting Reliability of Therapist Force</strong></h4>
<ul>
  <li><strong>Gender</strong> - On average, women produce less initial force, peak force, and rate of force development during manipulations, and less peak force during mobilizations; however, women generally also exhibit less variability in forces.</li>
  <li><strong>Experience</strong> - Students and experienced clinicians exhibit good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> but poor inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, may reliably differentiate between higher and lower grade mobilizations, students and experienced therapists exhibit similar <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of perception of error, and peak force and rates of force development generally increase with experience.</li>
  <li><strong>Unexpected Influences</strong> - Thumb pain, the direction of force applied, visual occlusion, grip used (thumb or pisiform), and plinth padding may have a significant effect on perception of stiffness and therapist force.</li>
  <li><strong>Improved <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">Accuracy</a> with Force Gauges</strong> - Therapists may improve their error perception, the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">Accuracy</a> of administering a pre-determined load, and increase intra-therapist and inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> with use of instrumented manikins, or potentially a film force gauge.</li>
</ul>
<h4><strong>Measurement Problems and the Reliability of Therapist Force</strong></h4>
<ul>
  <li><strong>Therapist Force based on Expert Reference -</strong> An effort has been made to establish a reference range for therapist force for mobilizations and manipulations based on mean force data; however, using an expert therapist as a reference range may be a reasonable standard until additional research can be performed to establish ideal ranges based on larger data sets and/or the consideration of additional variables.</li>
  <li><strong>Therapist Force based on Outcomes -</strong> Mean peak force is likely more critical than mean minimal force. Further, there is likely a relatively wide range of effective forces, with better outcomes correlated with more force or force above a certain low-end threshold.</li>
  <li><strong>Additional Considerations for Developing a Reference Range</strong> - Patient characteristics, the rate of force development, and the duration of a manipulation should be considered when developing an ideal range for therapist force, and pain intensity, nature of symptoms, and assumptions about factors contributing to comfort should be given less consideration or dismissed from consideration.</li>
  <li><strong>What and Who are We Measuring -</strong> A wider range of forces may not only be practical, but recommended, and further, <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> may be improved with better instructions for performing the technique. Last, as might be expected in any professional setting, the most capable 1/3 of professionals exhibit good to excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and the bottom 1/3 exhibit greater variance.</li>
</ul>
<h3>Outcomes</h3>
<h4><strong>Assessed Level versus Random Allocation</strong></h4>
<ul>
  <li><strong>Outcomes -</strong> Segmental <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> may not refine implementation enough to have a significant effect on short-term outcomes; however, segmental <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> may result in improvements in long-term outcomes. Further, mobilizations/manipulations improved both short-term and long-term outcomes when compared to controls, following both random and assessed allocations.</li>
  <li><strong>Study Considerations</strong> - It is worth considering that the <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> and allocation protocols in these studies happened within a few vertebrae (only cervical segments or only lumbar segments), that multiple segments often exhibit altered stiffness in symptomatic individuals, and that mobilizations/manipulations may affect more than one segment. This may have resulted in a large degree of overlap between treatment groups, and imply that studies with larger participants groups are needed to improve study <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> enough to identify differences beyond those masked by group overlap.</li>
</ul>
<h4><strong>Assessment Based on Broader Categories</strong></h4>
<ul>
  <li><strong>Differentiation</strong> - Differentiating between <a id="hypermobility" data-tip="1677" target="_blank" href="/glossary-term/hypermobility" class="glossary">hypermobility</a> and <a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a>, upper and lower cervical spine, and/or ensuring adequate maximal force during mobilization may be sufficiently accurate to significantly improve outcomes.</li>
</ul>

Reliability of Palpation of Bony Landmarks

<p>Various studies have investigated the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of accurately palpating bony landmarks. Several of these studies imply that more consideration should be given to the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of instructions that use relative location to aid in identifying a structure. Chakraverty et al. demonstrated that a line connecting the <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> portions of the two <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> iliac spine (PSIS) crossed the L4 or L4&#x2013;5 spinal levels on imaging in 86.7% of cases (75 patients, 49 female); however, when the same method was used during palpation, the L3 or L3&#x2013;4 spinal level was identified in 77.3% of cases (1). P&#xF3;voa et al. demonstrated that the flexion/extension <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> resulted in palpation of the C7 spinous process in 54.5% of cases, C6 in 22% of cases, with most remaining palpations ranging from C5 to T2 (2). Haneline et al. determined that the mean spinal level corresponding with the <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> angle of the scapula was midway between the T8&#x2013;T9 interspace and the upper T9 body (range, lower T7 to upper T10) (3). Similarly, Cooperstein et al. demonstrated that the <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> angle of the scapula, with the patient in standing, was in-line with the T8 spinous process. However, when using this cue as a method to locate the T8 spinous process during palpation, practitioners palpated a range of segments from T7 -T10. Further, Cooperstein et al. determined that the <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> angle of the scapula was in-line with the spinous process of T9 (with variation) when a patient was lying <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> with arms by their sides (4). In summary, using imaging techniques to define the relative location of an anatomical landmark may not match the instructions for identifying landmarks by palpation. Further, palpation using relative location will not result in a single point, but a small range of likely possibilities. This includes PSIS level with the spinous process of L3 - L5 and potentially higher segments, the most prominent lower cervical vertebrae during palpation is likely C6 or C7 but may be higher segments, and the <a id="inferior" data-tip="1569" target="_blank" href="/glossary-term/inferior" class="glossary">inferior</a> angle of the scapula is level with the spinous process of T7 -T10 during standing, and is likely to align slightly lower during <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> lying.</p>

<p>Several physical factors may have an effect on the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of palpating landmarks. Simmonds et al. demonstrated that <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> varied significantly when comparing palpation of different landmarks, with higher <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and less variance for more superficial and easier to identify landmarks (e.g. the ASIS), and less <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> with higher variance for deeper and less distinct landmarks (e.g. the transverse process of L4) (5). In a study mentioned above, P&#xF3;voa et al. demonstrated that the palpation of C7 was more accurate when the patient had a body mass index (BMI) of less than 25 kg/m2, and the most prominent spinous process coincided with the vertebrae with the least motion during the cervical flexion/extension <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a> (2). Harlick et al. also demonstrated that an increase in soft tissue thickness, or less pronounced spinous processes decreased <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, whereas age, sex and BMI did not alter <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (6). Additionally, Page et al. demonstrated moderate <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> when using palpation to identify the center of a thoracic transverse process, and the use of ultrasound did not improve <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> (7). The <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of landmark palpation may vary depending on the landmarks location, as well as various physical characteristics; relative location to other landmarks (discussed above), including landmark depth, body mass index (BMI), joint motion, and bone/joint structure.</p>

<p>The body of research on palpation, joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>, and therapist force during mobilization/manipulation implies a trend toward <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> being higher for the same therapist repeating a technique (intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>), when compared to two or more therapists performing the same technique (inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>). Although Billis et al. used a questionable reference standard (discussed below) for palpation of spine level, the difference between poor inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is worth noting (8). Similarly, McKenzie et al. demonstrated that inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was fair when judged based on the ability to identify a <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> spinous process; however, the intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for identifying the same spinous process was good to excellent (9). These studies imply better intra-therapist than inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, matching a trend noted in the body of research regarding manual <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> and techniques. This trend may imply that <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is achievable, but more research and effort is needed to align education, practitioner internal <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> of reference, and palpation protocols between various practitioners.</p>

<p>Much of the controversy regarding the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of manual techniques likely stems from debatable measurement and analysis methods. Two studies in particular highlight very questionable methodologies. Pattyn et al. demonstrated that identifying the location of the <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> femoral epicondyle, greater trochanter, mastoid process, and acromion process had low to fair reliability; however, this study investigated the distance of a practitioner&apos;s marking on a photograph from a reference point marked on the photograph by the researchers prior to investigation. There was no attempt at establishing a gold-standard for <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of the reference point based on a reasonably objective measure (e.g. MRI or x-ray). It was little more than the researcher&apos;s best guess, implying this study only measures a clinician&apos;s ability to predict where the researcher&apos;s thought the landmark was on a 2-dimensional image (10). Billis et al. demonstrated poor inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, but good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for palpation of spinal level. However, this study also included a similar error to the study above in which <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> and inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was based on a distance from a pre-set skin marking that was not based on a standardized protocol or acceptable gold-standard (8). Two studies demonstrating low inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> used a reference that was not based on a recognized or objectively developed &quot;gold standard&quot; reference. These studies highlight a key issue with several of the available <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> studies, in which the inherent dependence of <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> on a reference standard was not given enough consideration, potentially affecting confidence in study results.</p>

<p>Several studies discussed throughout this course demonstrate that the threshold for accurate palpation, or range of agreement, has a significant effect on findings. In a study mentioned above, Harlick et al. demonstrated that the inclusion of +/- 1 spinal level improved <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> from poor to good for palpation of a lumbar spinous process (6). McKenzie et al. demonstrated that inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was only fair when judged based on the ability to identify the tip of a spinous process; however, the inter-therapist variance was rarely more than the width of a single vertebrae, suggesting that the ability to identify a single segment is likely good to excellent (9). Using a methodology including continuous measure (instead of discrete measure), Robinson et al. demonstrated that identification of the L5 lumbar spinous process was 67% <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> within 10mm and 87% <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> within 20mm (11). Note, the height of lumbar body and disc (1 segment), is between 30 - 40mm, which again suggests that the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> demonstrated to identify a segment was likely good to excellent (11). Using discrete measures (e.g.  the tip of a spinous process ) to determine <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> does not accurately represent a practitioner&apos;s ability to reliably identify a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> area (e.g. a spinal segment). These studies demonstrate good to excellent inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> when a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> area, or continuous interval measure, is used during analysis.</p>

<ul>
  <li><strong>Relative Location:</strong> Using imaging techniques to define the relative location of an anatomical landmark may not match the instructions for identifying landmarks by palpation. Further, palpation using relative location will not result in a single point, but a small range of likely possibilities.</li>
  <li><strong>Location and Physical Characteristics:</strong> The <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of landmark palpation may vary depending on the landmarks location, as well as various physical characteristics; relative location to other landmarks (discussed above), including landmark depth, body mass index (BMI), joint motion, and bone/joint structure.</li>
  <li><strong>Better Intra-therapist than Inter-therapist Reliability:</strong> Studies demonstrate better intra-therapist than inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, matching a trend noted in the body of research regarding manual <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> and techniques. This trend may imply that <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is achievable, but more research and effort is needed to align education, practitioner internal <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> of reference, and palpation protocols between various practitioners.</li>
  <li><strong>Measurement Issues:</strong> Two studies demonstrating low inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> used a reference that was not based on a recognized or objectively developed &quot;gold standard&quot; reference. These studies highlight a key issue with several of the available <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> studies, in which the inherent dependence of <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> on a reference standard was not given enough consideration, potentially affecting confidence in study results.</li>
  <li><strong>How Accurate is Accurate Enough?:</strong> Using discrete measures, e.g. the tip of a spinous process, to determine <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> does not accurately represent a practitioner&apos;s ability to reliably identify a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> area, e.g. a spinal segment. Several studies demonstrate good to excellent inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> when a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> area, or continuous measure is used during analysis.</li>
</ul>

Reliability of Joint Motion Assessment by Palpation

<h4><strong>Cervical and Thoracic Spine</strong></h4>
<p><a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> of the cervical spine, first rib, and thoracic spine by palpation has been investigated in several studies. Rossettini et al. demonstrated that physical therapy students assessing passive intervertebral motion (PIVM) of the cervical spine in individuals with non-specific neck pain exhibited better intra-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> than inter-rater reliability; however, <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> overall was poor (12). Smedmark et al. compared the results of two equally experienced physical therapists assessing 1st-rib stiffness, demonstrating that inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was fair to moderate (13). Potter et al. demonstrated that intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for identifying a dysfunctional segment of the thoracic spine in asymptomatic individuals was moderate to good (14). Ghoukassian et al. investigated the Johnson and Friedman percussion scan of the thoracic spine, demonstrating very poor inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for determining the most fixated spinal level (15), and a follow-up of the study with more thorough statistical analysis by Cooperstein et al. reported higher kappa values but still demonstrated poor inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (16). Last, a study by Christensen et al. investigated the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> of spinal biomechanic dysfunction of T1 - T8 spine, but added a standardized written procedure and &quot;expanded&quot; definitions of agreement that included +/- 1 segment. Similar to other studies intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was better than inter-therapist reliability; however, inter-therapist was still poor to moderate (17). In summary, these studies likely imply that <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> by palpation of the cervical spine, thoracic spine, and 1st rib exhibit poor to moderate inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, moderate to good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and thoracic spine <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> is likely less <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than cervical spine or first rib <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> (supported by additional studies below).</p>
<h4><strong>Lumbar Spine</strong></h4>
<p>Additional studies have investigated the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of lumbar spine <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation. Lynette et al. investigated <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> comparing two therapists performing lumbar spine, passive intervertebral motion (PIVM) during flexion while in side-lying using a double-leg technique on 6 participants with a history of low back pain and current symptoms. The findings demonstrate that intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was moderate (66.67% and 75.00% with agreement greater than chance of 41.89% and 61.29%), and inter-therapist agreement was poor to moderate (48.61% with agreement greater than chance was 18.35%.) (18). Mootz et al. investigated <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> comparing two chiropractors using manual palpation to evaluate the presence of fixations in asymptomatic students, demonstrating poor to zero inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, moderate intra-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for upper and lower lumbar segments, less but moderate intra-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for mid-lumbar segments (19). Gonnella et al. investigated the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of lumbar PIVM exam with 5 experienced therapists, assessing 5 asymptomatic physiotherapy students, comparing blind and unblind <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> on two different days. Findings demonstrated that inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was poor; however, intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was good (20). Additionally, a study mentioned above by Potter et al. demonstrated intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for identifying a dysfunctional segment in the lumbar spine of asymptomatic individuals was excellent for the lumbar spine (16). Owens Jr. et al. compared stiffness and pain <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> from 3 experienced chiropractors performing lumbar central PA mobilizations, demonstrating low <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> between clinicians regarding which segments were stiff or tender. Further analysis, also demonstrated that mean stiffness values were similar for symptomatic and asymptomatic individuals (21). These studies may imply that <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation of the lumbar spine in symptomatic individuals exhibits poor to moderate inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and moderate to good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. Further, <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of asymptomatic patients may trend toward worse inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, but better intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>.</p>
<h4><strong>Extremities</strong></h4>
<p>Research may suggest that the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of extremity joint motion by palpation is better than <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of the spine by palpation. van Dujin et al. investigated the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> testing of the glenohumeral joint by 3 physical therapists on 18 participants, 10 of which had a history of shoulder dysfunction, demonstrating that intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was moderate to good, and inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was moderate (22). Lin et al. investigated the intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of end-range stiffness in the <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> (AP) and <a id="posterior" data-tip="1565" target="_blank" href="/glossary-term/posterior" class="glossary">posterior</a> to <a id="anterior" data-tip="1566" target="_blank" href="/glossary-term/anterior" class="glossary">anterior</a> (PA) directions of the glenohumeral joint of patients with diagnosed frozen shoulders (mean duration 6.5 months). Findings demonstrated good to excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, as well as a <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> increase in end-range <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> and passive abduction range of motion (ROM) following mobilization (23). Hayes et al. demonstrated that intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was generally good for <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of end-feel, pain and resistance, of the knee and shoulder, of symptomatic individuals, especially relative to subject pain following <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> and in consideration of unbalanced distributions. However, interrater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was generally poor, even when considering these factors (24). Staes et al. investigated the intra-therapist and inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of two skilled therapists testing available motion and end feel of the carpal joints of asymptomatic students, demonstrating intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was better than inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, but both were good to very good (25). In summary, the number of studies demonstrating moderate to good inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of extremity joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation may suggest they are more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of the spine. However, these studies also demonstrate the same trends of intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> being better than inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>.</p>

<h4><strong>Use as a Pre/Post Assessment</strong></h4>
<p>Additional studies have demonstrated that palpation may be more accurate for identifying changes post manipulation. An RCT by Lakhani et al. demonstrated that palpation is more <a id="sensitivity" data-tip="1227" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitive</a> and <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> for identifying changes in segment stiffness after manipulation, when compared to identifying stiffness prior to manipulation. Further, this study demonstrated that <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of segment stiffness was more accurate for symptomatic individuals (32). An RCT by Haas et al. demonstrated that &quot;end-play response&quot;, defined as a change from restricted to normal end-play, immediately following a manipulation, had a moderate post-intervention <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> value, resulting in a 60% response recorded in the treatment group, and a 37% response in a sham-control group (33). These studies imply <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of joint motion by palpation may have more utility for identifying changes in <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> following intervention.</p>
<h4><strong>Education</strong></h4>
<p>Additional studies have investigated the effects of education on confidence and <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. An initial study by Cook et al. found no correlation between poor inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation and age, gender, background, frequency of use, years of experience, or education (34). However, a follow up study by Cook et al. demonstrated that confidence in diagnosis of abnormal stiffness of the cervical spine was positively correlated with a background that included a manual therapy <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> (Cyriax, Maitland, McKenzie, NAIOMPT, Osteopathic, Paris, and others) (35). Downey et al. demonstrated that physiotherapists with additional manual therapy training, exhibited moderate <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for determining the lumbar segment to be treated using central PA PIVM assessment; however, the ability to name the exact segment had <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> less than chance (36). Additionally, Cook et al. demonstrated that a survey sample of 369 physical therapists in the United States considered lumbar coupling biomechanics important or very important; however, agreement on coupled directions for all lumbar segments was worse than chance (37). These studies likely imply that practitioners believe additional education is important, and education is positively correlated with confidence; however, additional education is likely weakly correlated with increased inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. One potential reason for these findings may be significant differences in the information and technique described by various organizations. (Note, these studies also demonstrate that demographics likely have little effect on <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation).</p>
<h4><strong>Technique</strong></h4>
<p>Several factors related to <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> technique and protocols may also play a role in <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. Keating et al. tested C6, T4, T6, and L4 on 50 asymptomatic participants, demonstrating that pain pressure <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> increases from the lumbar to the cervical spine, which may suggest that lower segments exhibit more <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> than higher segments is a clinically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> finding (38). Chiradejnant et al. investigated the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of 2 therapists using central PA pressure to <a id="assessment" data-tip="1486" target="_blank" href="/glossary-term/assessment" class="glossary">assess</a> the lumbar stiffness of 41 asymptomatic individuals compared to the pre-set stiffness levels (marked from -5 to 5) of a reference device. Using the reference device resulted in moderate to good inter-therapist and intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (39). Maher et al. demonstrated that visual occlusion had no impact on the ability to identify landmarks during PA mobilizations of the spine; however, blocking a therapist&apos;s vision resulted in higher mean ratings of stiffness (40). Another study by Maher et al. compared pisiform and thumb grips for central PA <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>, demonstrating that both were equally effective for discriminating between different forces; however, the thumb grip resulted in a bias toward perceiving the stimulus as more stiff (41). In summary, awareness of normal pain pressure <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>, the addition of a reference device, elimination of any visual occlusion, and the use of a consistent hand grip should be considered during <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>, and/or when developing research methods for investigating the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> via palpation.</p>

<p>It is important that the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of palpation is considered relative to other <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a>, and/or in conjunction with other <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a>.</p>
<h4><strong>Comparing Assessments:</strong></h4>
<p>Several studies have investigated the independent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of various exams within a set of <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> that may be commonly performed together during an <a id="assessment" data-tip="1481" target="_blank" href="/glossary-term/assessment" class="glossary">evaluation</a>. Fraser et al. investigated the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of ankle/foot <a id="assessment" data-tip="1481" target="_blank" href="/glossary-term/assessment" class="glossary">evaluation</a>, demonstrating excellent inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for ratings of perceived difficulty and motor performance including short-foot, toe-spread-out, and hallux exercises, but poor to moderate <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for toe extension and <a id="arthrokinematics" data-tip="1861" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">joint play</a> <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> (42). A study mentioned above by Fjellner et al. investigated the inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of various <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> for the cervical spine performed by two physical therapists, demonstrating that general range of motion (ROM) <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> (<a id="goniometry" data-tip="1523" target="_blank" href="/glossary-term/goniometry" class="glossary">goniometry</a>) were more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than joint stiffness <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> by palpation; however, several of the palpatory joint stiffness <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> demonstrated moderate to good <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was higher for symptomatic individuals (29). Schneider et al. investigated the inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of 2 examiners, demonstrating moderate <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for the lumbar <a id="prone" data-tip="1561" target="_blank" href="/glossary-term/prone" class="glossary">prone</a> <a id="stability" data-tip="1193" target="_blank" href="/glossary-term/stability" class="glossary">instability</a> <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a>, moderate to good <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for identification of a painful segment via palpation, and poor <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for identifying a <a id="hypomobility" data-tip="1676" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobile</a> segment by palpation (43). Maigne et al. compared the <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of two practitioners on 59 middle-aged patients with cervical pain, demonstrating good inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for ROM and pain during ROM, and moderate <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> and joint palpation. The number of <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> <a id="latent-trigger-point" data-tip="1134" target="_blank" href="/glossary-term/latent-trigger-point" class="glossary">tender points</a> also demonstrated moderate correlation with questionnaire scores (neck pain and disability) (44). Viikari-Juntura et al. investigated the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> between two examiners during a conventional neurological examination, palpations, and tests for the provocation or relief of radicular symptoms on 52 cervical patients, demonstrating that special tests and ROM exams were likely more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> based on palpation; however, many palpation tests demonstrated moderate to good <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. Further, the researchers noted that poor standardization of examination procedures and changes in the patients&apos; attention were considered main factors contributing to the lower <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> during some <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> (45). Piva et al. demonstrated moderate to excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for active ROM and passive intervertebral motion (<a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a>) of the upper cervical spine, moderate <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of the mid-cervical spine, and poor <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> in the lower cervical spine; however, kappa values were likely depressed in the lower cervical spine due to the lower frequency of symptoms (46). A study by Aartun et al. may imply that clinical testing for the spine is less <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> on adolescents; however, similar to other studies, ROM and functional exams exhibited more <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> than palpatory exams (47). Last, another study mentioned above by Schneider et al. compared <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> from 2 physiotherapists performing exams on two separate occasions, for 56 patients diagnosed with cervical blocks. Inter-tester and Intra-tester <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was good to substantial for all exams including cervical range of motion (ROM; 6 directions), extension-rotation <a id="assessment" data-tip="1482" target="_blank" href="/glossary-term/assessment" class="glossary">test</a>, manual spinal examination, and palpation for paraspinal tenderness from C2 through C7 (26). These studies demonstrate that ROM <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> and special tests are generally more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation. However, it is also worth noting that all of these studies demonstrated moderate or better inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation. These studies (and the studies below) may imply that the <a id="predictive-values" data-tip="1738" target="_blank" href="/glossary-term/predictive-values" class="glossary">predictive value</a>, <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and utility of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation increases when when used with a combination of <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> that may be commonly observed during a clinical <a id="assessment" data-tip="1481" target="_blank" href="/glossary-term/assessment" class="glossary">evaluation</a>.</p>
<h4><strong>Palpatory Exam in Conjunction with other Assessments</strong></h4>
<p>Additional studies either directly demonstrate or imply <a id="base-of-support" data-tip="1197" target="_blank" href="/glossary-term/base-of-support" class="glossary">support</a> for the notion that joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation has moderate to excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> when used with a combination of <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> that may be commonly observed during a clinical <a id="assessment" data-tip="1481" target="_blank" href="/glossary-term/assessment" class="glossary">evaluation</a>. Pool et al. demonstrated moderate inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> between two experienced physiotherapists assessing the cervical spine for general <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a>, intersegmental <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a>, and pain. Variable <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was noted for joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation; however, <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> increased significantly when palpation provoked symptoms (48). Bertilson et al. demonstrated that knowing a patient&apos;s medical history did not have a significant effect on the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation of the cervical spine and shoulders; however, it did increase the number of positive findings. Additional research is needed to determine if medical history increased <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> in a way that did not increase inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (49). Another study mentioned above by Cleland et al. compared the inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of 4 therapists performing a complete history and physical examination of 22 patients that had been selected for a <a id="prospective-study" data-tip="1414" target="_blank" href="/glossary-term/prospective-study" class="glossary">prospective study</a> investigating mechanical neck pain. Findings indicate that inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was moderate to excellent for most examinations including subjective <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>, ROM, <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> length, <a id="muscle-cell" data-tip="1781" target="_blank" href="/glossary-term/muscle-cell" class="glossary">muscle</a> strength, and <a id="posture" data-tip="1658" target="_blank" href="/glossary-term/posture" class="glossary">posture</a>, and moderate to good inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for pain provocation during PA passive <a id="arthrokinematics" data-tip="1860" target="_blank" href="/glossary-term/arthrokinematics" class="glossary">accessory motion</a> of the upper and lower cervical segments and thoracic segments, but poor inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for mid-cervical segments (27). Hanten et al. investigated inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation of the upper cervical spine by two examiners assessing 2 groups of 20 participants who had meet initial criteria for cervicogenic headache, based on International Headache Society (IHS) criteria. Moderate to good inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was found on 11 out of 15 <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> tests, including 100% agreement on consecutive days for whether the subject met the IHS criteria (50). Last, a multi-center study by Jull et al. demonstrated perfect inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for determining which participants met the qualification for inclusion in a cervicogenic headache study, and 70% agreement on the 2 most dysfunctional joints (51). In summary, these studies may be evidence that clusters of <a id="assessment" data-tip="1483" target="_blank" href="/glossary-term/assessment" class="glossary">evaluations</a> increase the <a id="predictive-values" data-tip="1738" target="_blank" href="/glossary-term/predictive-values" class="glossary">predictive value</a>, <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and utility of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation, and/or that palpation exams may be beneficial in achieving excellent to perfect <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of diagnosis and categorization of symptoms and impairments.</p>

<p>There are several &quot;measurement issues&quot; that should be considered when interpreting the research investigating the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation.</p>
<h4><strong>Correlation with Outcomes</strong></h4>
<p>One issue with research investigating the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation, is consideration regarding the goal of <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>. Mentioned above, Downey et al. demonstrated that therapists with additional manual therapy training exhibited moderate inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for determining the lumbar segment to be treated using central PAs; however, the ability to name the exact segment had <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> less than chance (36). If the segment in need of mobilization has been accurately identified, does it matter whether the therapist believes the segment is L2, L3, or L4? Ideally, research would aid in improving the variable that correlates an <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> with implementation of the technique that is most likely to improve patient outcomes. This implies that the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation should be based on the ability to identify the &quot;most treatable&quot; segment, and not the ability to accurately name an anatomical landmark.</p>
<h4><strong>Number of Assessors</strong></h4>
<p>Another issue concerning <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> measures is the number of examiners being compared. A study by Marcotte et al. investigated the inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and force used by 24 examiners assessing segmental rotation from c2 - c7, and despite differences in force ranging from 4.0N - 41N/cm2 (light to moderate), good inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was demonstrated for identifying a <a id="hypomobility" data-tip="1676" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobile</a> segment (52). The variable investigated in this study, inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for identifying a dysfunctional segment by palpation, has perhaps demonstrated the most variability of any findings in this review. However, it is worth noting that most of those studies examine a relatively large group of participants, but only 2 or 3 examiners. This may result in an exaggeration of the difference between a small number of examiners; for example, different university education, different continuing education, different internal <a id="model" data-tip="1471" target="_blank" href="/glossary-term/model" class="glossary">models</a> of anatomical features, or differences in technique. Increasing the participant pool from 10 to 1000 individuals is unlikely to <a id="compensation-pattern" data-tip="1697" target="_blank" href="/glossary-term/compensation-pattern" class="glossary">compensate</a> for potential differences between a few examiners. Additional research is needed to determine if results from joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation from a larger group of examiners would begin to pool around mean values. The pooling of mean values may aid in identifying those attributes most likely to improve <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>.</p>
<h4><strong>Assessor Confidence</strong></h4>
<p>Studies demonstrate that confidence in findings should also be considered in studies investigating inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. Cooperstein et al. used a continuous measures analysis, that allowed for sub-typing based on examiner confidence, demonstrating that when two examiners were very confident in identifying a &quot;fixated&quot; segment between T3 - T10, the inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was good. In cases that resulted in low examiner confidence, inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was poor (53). Similar findings were noted in another study by Cooperstein et al., demonstrating that on average examiners agreed on which segment(s) were most fixated, and the amount of agreement increased with examiner confidence (54). A study that may highlight this relationship, Humphreys et al. compared the inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of 24 chiropractic students asked to identify the most <a id="hypomobility" data-tip="1676" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobile</a> cervical segments, blinded to the fact that the 3 participants being assessed had congenitally blocked segments. The study findings demonstrated that student inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for correctly identifying the congenitally blocked segment was moderate to good (55). Note, this study included student examiners who might be expected to have lower inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, but findings demonstrated good inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, perhaps due in part to a methodology that included a large number of examiners (discussed above), and a segment that can be confidently labeled as &quot;stiff&quot;. In summary, a therapist&apos;s confidence in findings significantly effects expected inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> during joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation. For example, good inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> has been demonstrated when therapist confidence is high.</p>
<h4><strong>Range of Agreement and Analysis</strong></h4>
<p>Another issue with <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> studies is how <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a>, and/or the range of agreement, was defined and analyzed. In a study mentioned above, Jull et al. performed a multicenter study with participants being treated for cervicogenic headache, demonstrating that independent examiners exhibited 70% agreement for dysfunctional segments when agreement was based on the two most dysfunctional joints (51). Choosing the two most dysfunctional segments may aid in more accurately reflecting practice, as &quot;most&quot; implies certain confidence in a finding that may be differentiated from similar but less <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> findings, and choosing 2 segments more accurately represents the tendency of therapists to treat more than one joint. Further, Christensen et al. investigated inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> based on a standardized written procedure for the detection of altered spine biomechanics in the upper 8 segments of the thoracic spine. The findings demonstrated that &quot;expanding&quot; the definition of agreement to include +/- 1 segment resulted in numbers that were significantly better than most studies (good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, but poor inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>) (17). A methodology that includes testing based on a standardized written protocol, that can be refined with further research, should be adopted by more studies. Further, a range of agreement ( +/- 1 segment) may be more practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a>, considering that stiffness in one facet is likely to affect at least two segments (above and below), and often multiple segments with in a narrow range will exhibit dysfunction. Note, this study did not use a well differentiated definition of a positive finding. Conversely, Walker et al. investigated the inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> between 2 clinicians assessing T5&#x2013;T12 for segmental pain and/or stiffness using two methods (written versus practitioner&apos;s choice) on 25 symptomatic and asymptomatic patients. Inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for the 2 clinicians was low for pain and stiffness, even when agreement was set at +/- 1 segment on either side (56). Note, this study did not use a differentiated definition of a positive finding. These studies demonstrate that a well-differentiated definition of a positive finding, and a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> range of agreement, may have a significant impact on the outcomes reported by studies investigating the inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of joint motion by palpation.</p>
<p>Perhaps the most <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> study regarding <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a>, measurement, and analysis of <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> as it relates to joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> via palpation, is a study mentioned above by Cooperstein et al. (53). In the Cooperstein et al. study, 4 different analyses were done comparing the results of two examiners assessing 34 minimally symptomatic lumbar spine patients. Three of the 4 <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> analyses demonstrated that on average the examiners agreed on which segment was most fixated, and that the amount of agreement increased with examiner confidence (53). The <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> analysis that did not result in average agreement was the inter-class correlation coefficient (kappa values), a discreet measure analysis, which is the analysis used in the majority of peer-reviewed, published <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> studies. Note, the other study by Cooperstein et al. mentioned above also analyzed data using continuous interval measures, accounted for confidence, and also demonstrated good inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (54). Although the first 3 studies mentioned in this section demonstrate somewhat contradictory findings, all 3 used the inter-class correlation coefficient (kappa values). It is likely reasonable to suggest that reducing a clinician&apos;s <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of stiffness to a binary decision, without consideration of the clinician&apos;s confidence in the <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>, is likely a poor representation of practice. At the very least, if discrete measure analysis is necessary, the study methodology should attempt to maximize examiner confidence in findings with a differentiated definition of a &quot;positive finding&quot;, and include a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> range of agreement. For example, asking clinicians to choose the 2 (practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> range) most (differentiated positive finding) dysfunctional segments, as was the case in the Jull et al. study (51). It is troubling that the gross majority of the studies in this review do not consider the continuous nature of &quot;stiffness&quot; as an assessed value, whether <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> can be expected if a therapist is asked to select one from several potentially stiff joints, and/or what the therapist&apos;s confidence level was regarding the <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of dysfunction of the selected joint. In summary, <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> should be based on analysis of a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> definition of agreement. That is, research analysis should include a well differentiated definition of a &quot;positive finding&quot;, a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> range, and ideally, should describe <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> within a continuous interval scale.</p>

<h4><strong>Inter-therapist versus Intra-therapist Reliability</strong></h4>
<ul>
  <li><strong>Cervical Spine, Thoracic Spine, and 1st Rib</strong> - <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> by palpation of the cervical spine, thoracic spine, and first rib exhibit poor to moderate inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, moderate to good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and thoracic spine <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> is likely less <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than cervical spine or first rib <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a>.</li>
  <li><strong>Lumbar Spine</strong> - <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> by palpation of the lumbar spine in symptomatic individuals exhibits poor to moderate inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and moderate to good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. Further, <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> of asymptomatic patients may trend toward worse inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, but better intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>.</li>
  <li><strong>Extremities</strong> - The number of studies demonstrating moderate to good inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of extremity joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation may suggest they are more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of the spine. However, these studies also demonstrate the same trends of intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> being better than inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>.</li>
</ul>
<h4><strong>Pain versus Stiffness</strong></h4>
<ul>
  <li><strong>Cervical and Lumbar Spine</strong> - It is likely reasonable to conclude that identifying a dysfunctional segment based on pain has moderate to good inter-therapist and intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, which is better inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> that demonstrated by most studies identifying dysfunction of a segment based on <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a>. Further, studies imply that joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation of symptomatic patients is more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> of asymptomatic patients.</li>
</ul>
<h4><strong>Factors Affecting palpation</strong></h4>
<ul>
  <li><strong>Pre/Post <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> -</strong> <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">Assessment</a> of joint motion by palpation may have more utility for identifying changes in <a id="mobility" data-tip="1455" target="_blank" href="/glossary-term/mobility" class="glossary">mobility</a> following intervention.</li>
  <li><strong>Education -</strong> Practitioners are likely to believe additional education is important, and education is positively correlated with confidence in <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> findings; however, additional education is likely weakly correlated with increased inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> via palpation. One potential reason for these findings may be significant differences in the information and technique described by various education organizations.</li>
  <li><strong>Technique -</strong> Awareness of normal pain pressure <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a>, the addition of a reference device, elimination of any visual occlusion, and the use of a consistent hand grip should be considered during <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>, and/or when developing research methods for investigating the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> via palpation.</li>
</ul>
<h4><strong>Joint Motion Assessment Reliability Relative to Other Assessments</strong></h4>
<ul>
  <li><strong>Comparison and Combination</strong> - Range of motion (ROM) <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> and special tests are generally more <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> than joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation. However, studies including a combination of <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> most often demonstrate moderate or better inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation. Further, the good to excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of combined <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> may be evidence that clusters of <a id="assessment" data-tip="1483" target="_blank" href="/glossary-term/assessment" class="glossary">evaluations</a> increase the <a id="predictive-values" data-tip="1738" target="_blank" href="/glossary-term/predictive-values" class="glossary">predictive value</a>, <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and utility of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation, and/or that palpation exams may be beneficial in achieving excellent to perfect <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of diagnosis and categorization of symptoms and impairments.</li>
</ul>
<h4><strong>Measurement Issues with Studies Investigating the Reliability of Assessing Joint Motion by Palpation</strong></h4>
<ul>
  <li><strong>Correlation with Outcomes -</strong>Ideally, research would aid in improving the variable that correlates an <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> with implementation of the technique that is most likely to improve patient outcomes. This implies that the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation should be based on the ability to identify the &quot;most treatable&quot; segment, and not the ability to accurately name an anatomical landmark.</li>
  <li><strong>Number of Assessors -</strong> Additional research is needed to determine if results from joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation from a larger group of examiners would begin to pool around mean values. The pooling of mean values may aid in identifying those attributes most likely to improve <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. Unfortunately, most research to date has compared 2 or 3 examiners, which may exaggerate the differences between examiners, and negatively skew <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> findings.</li>
  <li><strong>Examiner/Therapist Confidence</strong> - A therapist&apos;s confidence in findings significantly effects expected inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> during joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> by palpation. For example, good inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> has been demonstrated when therapist confidence is high.</li>
  <li><strong>Range of Agreement and Analysis</strong> - <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">Reliability</a> should be based on analysis of a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> definition of agreement. That is, research analysis should include a well differentiated definition of a &quot;positive finding&quot;, a practically <a id="relevance" data-tip="1505" target="_blank" href="/glossary-term/relevance" class="glossary">relevant</a> range, and ideally, should describe <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">Reliability</a> within a continuous interval scale.</li>
</ul>

<table>
  <tbody>
    <tr>
      <td>Note, the difference between grades I and II, and the difference between grades III and IV is amplitude, not peak force. The peak force for grades I and II is pressure up to the initiation of symptoms, and the peak force for grades III and IV is the end range of passive arthrokinematic motion. Grades II and III are larger amplitude techniques, while grades I and IV are low amplitude techniques. It should be expected that peak force, and potentially mean peak force, are similar when comparing grades I and II, or grades III and IV. Further, more variance in forces should be expected for larger amplitude techniques, as they inherently use a wider range of therapist force.</td>
    </tr>
  </tbody>
</table>

<h4><strong>Cervical Spine</strong></h4>
<p>Studies have investigated the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and relationships between various force parameters during cervical spine mobilization. Snodgrass et al. investigated the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of 10 experienced physiotherapists performing central and <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> PA mobilizations for the cervical spine, demonstrating poor to moderate inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, but good to excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for peak force, mean force, amplitude, and oscillatory frequency for all grades. Further, these forces reflected generally accepted/published norms (57). Another study by Snodgrass et al. investigated therapist force during cervical mobilizations performed by 116 therapists, demonstrating high variability between therapists (low inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>), good to excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (0.84-0.93), and peak forces increased from grades I to IV, ranging from 22 to 92 N (58). An et al. demonstrated that the mean peak force used during grades III and IV central posteroanterior (PA) mobilization on C3, C4, and C5 were not significantly different from one another, or between physical therapists. This may imply that inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is moderate or better for mean peak force during grade III and IV cervical mobilization when these grades are analyzed together (59). Ngan et al. investigated kinematic parameters of cervical manipulations performed by 3 therapists on 8 asymptomatic subjects, with 1 therapist performing manipulation on all subjects on 2 separate occasions. Although kinematic parameters between therapists, participants, and sessions varied widely, there was a consistent use of de-rotation prior to thrust of a mean of 4.8 degrees, head to torso angle was relatively consistent for all practitioners and participants, and technique between therapists was similar (97). Gianola et al. compared 2 manual therapists performing high velocity upper cervical manipulations on fresh cadaver specimens, demonstrating substantial <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for the rotation component, but low <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for the sagittal and frontal plane components (98). Note, a study mentioned below demonstrates greater variability for higher amplitude techniques, which should be expected. These studies suggest that cervical mobilizations exhibit good to excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for peak force, mean peak force, amplitude, and oscillatory frequency, and inter-therapist force variance may be relatively high but moderately <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> when considering grade III and IV mobilization forces as a group. These studies also demonstrate that the difference in force used for grades I/II and III/IV mobilizations may be reliably differentiated. Additionally, substantial <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> has been demonstrated for the pre-manipulative position and rotation component used during cervical manipulations</p>
<h4><strong>Thoracic Spine</strong></h4>
<p>Studies investigating therapist force during thoracic spine treatment most often include manipulation, however, one study was located that investigated therapist forces during mobilizations. Forand et al. compared the forces applied during a thoracic manipulation by male and female practitioners, demonstrating that only preload force during lower thoracic manipulation was significantly lower for females. All other force parameters were similar (60). Pasquier et al. demonstrated that gender and experience may influence therapist force during thoracic manipulation, including men exhibiting more force and more variability, woman exhibiting lower rates of force development, lower peak force and less variability, and more experienced students and instructors exhibiting less force with less variability than less experienced students (61). Cambridge et al. compared 3 clinicians performing thoracic spine manipulation, demonstrating strong correlations between most aspects of force; however, weaker correlations were noted between therapists for slope and loading rate (the quick acceleration at the beginning of a manipulation) (62). Gagnon et al. demonstrated that physiotherapy students performing PA thoracic spine mobilizations used higher mean forces for grades III and IV when compared to grades I and II, and further that experienced physiotherapists applied greater force than physiotherapy students across all grades, despite similar oscillation frequency (63). Although these studies do not specifically mention the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of therapist force, expected <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> may be implied by the amount of variance and strength of correlations demonstrated in these studies. For example, findings demonstrated strong correlations between therapists for mean force, peak force, and duration, but weaker correlations for pre-load force and rate of force development. This may imply that future research can expect to find higher <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for peak and mean force values and less <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for the rate of force development.</p>
<h4><strong>Lumbar Spine</strong></h4>
<p>Three studies were located investigating <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and variance of forces used during lumbar manipulation and mobilization. Harms et al. investigated 30 experienced therapists performing five mobilization procedures on the lumbar spine, demonstrating an inter-therapist peak force variance of 63 - 347 N; however, the 30% of therapists with the highest intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> were consistently within 5% of the originally recorded force, and the least consistent therapists demonstrated variability of 34% (64). This may imply that excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is attainable, and/or that <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is a skill that may be developed. Choi et al. investigated forces exhibited by a single therapist performing mobilizations on the lumbar segments of L1 - L3 of 20 participants, demonstrating similar peak forces during grade III and IV mobilization, similar force parameters for all segments using grade IV mobilizations, and larger variances in forces during grade III mobilizations (65). Note, larger variance in forces for grade III mobilizations should be expected due to the higher amplitude used during this techniques. Chester et al. used a simulated lumbar spine to investigate forces during Maitland mobilizations grades I - IV, demonstrating considerable inter-therapist variability in peak force, considerable overlap in forces between grades I-II and grades III-IV, and significantly less intra-therapist variance (66). In summary, these studies investigating lumbar mobilization forces demonstrate more inter-therapist variance than intra-therapist variance, more variance for grade III mobilizations than grade IV mobilizations, and considerable overlap in forces between grades I-II and grades III-IV. Further, excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and potentially moderate or better inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> may be an achievable skills (especially for mean dosage and mean peak force).</p>
<h4><strong>Knee</strong></h4>
<p>The studies investigating the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of therapist force during knee mobilizations suggest moderate or better <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is attainable. Silvernail et al. investigated therapist force during knee mobilizations by a single therapist on 20 participants, demonstrating greater oscillation frequency and mean force for grade IV mobilizations when compared to grade III mobilizations, greater mean peak-to-peak amplitude for grade III, and excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for force, peak-to-peak amplitude and oscillation frequency (67). Tragord et al. investigated forces used by 6 therapists during knee mobilizations for 14 patients with osteoarthritis, demonstrating good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and moderate inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for mean peak forces and differentiation between grade III and IV mobilizations. Comparison of forces during grade III and IV mobilizations demonstrated small differences in mean peak force, significant increase in amplitude for Grade III mobilizations, and significant increases in dosage for Grade IV mobilizations (68). These studies investigating therapist force during knee mobilizations demonstrate good to excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and moderate inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. Further, comparing grade III and IV mobilizations revealed similar mean peak forces, but significant differences in amplitude and dosage.</p>
<h4><strong>Ankle</strong></h4>
<p>Therapist force during ankle mobilizations has been investigated in two similar studies. de Souza et al. compared 2 practitioners performing ankle mobilizations, demonstrating a positive inter-therapist correlation for maximal force, but no correlation for minimal force (68). Similarly, Venturini et al. compared 2 practitioners performing a 30-second, grade III ankle mobilization, demonstrating good inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for maximal force, but poor inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for minimal force. This study also demonstrated near-ubiquitous improvements in ankle dorsiflexion ROM for all participants following ankle mobilizations by either practitioner (69). These studies suggest that inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is moderate or better for mean peak force, but poor for mean minimal force. However, the lack of minimal force <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> seems to have no impact on mobilization outcomes, as near-perfect <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for improving ankle dorsiflexion ROM was also demonstrated.</p>
<h4><strong>Shoulder</strong></h4>
<p>A study by Talbott et al. demonstrated good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, differentiation of force between grades, and total motion of 3.0mm for grade I, 8.2mm for grade II, and 10.7mm for grade III during Kaltenborn <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> (AP) shoulder mobilization technique (96).</p>

<h4><strong>Gender</strong></h4>
<p>Four studies mentioned above suggest gender may result in differences in therapist force. Forand et al. demonstrated preload force was significantly lower for females; however, all other force parameters were similar during lower thoracic manipulation (60). Similarly, Pasquier et al. demonstrated that men exhibited higher mean peak force and mean rates of force development; however, women exhibited less variability in force during thoracic manipulations (61). Additionally, several studies by Snodgrass et al. investigating therapist force during cervical mobilizations performed by students and experienced therapists, demonstrating correlations between more force and mobilizations performed by male therapists or on male patients (57, 58, 71, 72). These studies may imply that on average, women produce less initial force, peak force, and rate of force development during manipulations, and less peak force during mobilizations; however, women generally also exhibit less variability in forces.</p>
<h4><strong>Experience</strong></h4>
<p>Several studies have compared the influence of student and clinician experience on therapist force during mobilization and manipulations. Snodgrass et al. investigated forces applied by students performing central and <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> PA joint mobilizations on the cervical spine, grades I - IV, using an instrumented table. Findings demonstrated that mean peak force increased from grades I - IV, inter-student <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was poor, but intra-student <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was good. Higher forces were correlated with a student being earlier in their learning process (71). In another study by Snodgrass et al., 116 physiotherapists were compared to 120 physiotherapy students performing cervical mobilizations, demonstrating students generally applied lower forces at slower oscillation frequencies than practicing physiotherapists (contradicting the previous study) (72). Gagnon et al. demonstrated that physiotherapy students performing PA lumbar mobilizations applied lower mean forces for grades I and II than grades III and IV and that experienced physiotherapists used similar oscillation frequency but greater mean force for all grades when compared to students (63). Derian et al. compared differences in lumbar manipulation kinematics for experienced practitioners and student physical therapists, demonstrating that experts exhibited increased downward and linear pelvic velocity and increased modulation of <a id="ground-reaction-force" data-tip="1397" target="_blank" href="/glossary-term/ground-reaction-force" class="glossary">ground reaction forces</a> (73). Last, Loranger et al. compared force and perception of error from students and experienced clinicians attempting to achieve 300N of force during a thoracic manipulation on an instrumented manakin following a practice period. The findings demonstrate that error rate was similar; however, preload forces were significantly less for 1st-year students when compared to all other groups, time-to-peak force decreased from 1st-year students to 5th year students to experienced clinicians, and thrust force and thrust rate significantly increased with experience from 1st-year students to experienced professionals (74). These studies suggest that students and experienced clinicians exhibit good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> but poor inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, may reliably differentiate between higher and lower grade mobilizations, students and experienced therapists exhibit similar <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of perception of error, and peak force and rates of force development generally increase with experience.</p>
<table>
  <tbody>
    <tr>
      <td>
        <h4><strong>Unexpected Influences:</strong></h4>
        <p>Several of the studies mentioned above have demonstrated a variety of additional factors that influence therapist force during mobilization and manipulation. Several studies by Snodgrass et al. demonstrated correlations between force and thumb pain (57, 58, 71), including correlations between thumb pain and higher forces for students, but thumb pain and lower forces for experienced therapists (71). One of these studies also demonstrated a correlation between force and the direction of force applied, including forces being more vertical and <a id="cephalad" data-tip="1558" target="_blank" href="/glossary-term/cephalad" class="glossary">cephalad</a> when applied to C7 compared to forces applied to C2, and forces being more <a id="medial" data-tip="1568" target="_blank" href="/glossary-term/medial" class="glossary">medial</a> and <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> during <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> mobilizations (58). Two studies mentioned above under &quot;Assessment of Joint Motion by Palpation&quot; may also influence therapist force. Maher demonstrated that visual occlusion did not affect the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of palpation, but did result in higher mean ratings of stiffness (40). And, the use of a thumb grip or pisiform grip during central PAs of the lumbar spine did not affect reliability; however, the thumb grip did result in a bias toward more perceived stiffness (41). Another study by Maher et al. demonstrated that the amount of plinth padding resulted in significant differences in stiffness curves (loading curve and the displacement at 30 N) exhibited during PA mobilizations of the thoracic and lumbar spine (75). In summary, these studies demonstrate that thumb pain, direction of force applied, visual occlusion, grip used (thumb or pisiform), and plinth padding may have a significant effect on perception of stiffness and therapist force.</p>
      </td>
    </tr>
  </tbody>
</table>
<h4><strong>Improved Accuracy with force gauges:</strong></h4>
<p>Additional studies have investigated the influence of adding instrumented manakins and force gauges to education and practice, on the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and variance of therapist force. As mentioned above, Loranger et al. demonstrated no difference between students and experienced therapists in the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of perceived error following practice with an instrumented manakin (74). Conversely, Bj&#xF6;rnsd&#xF3;ttir et al. demonstrated inexperienced therapists had a more accurate perception of load errors than experienced therapists when performing manipulations on an instrumented <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a>. Additionally, this study demonstrated that both students and experienced clinicians improved <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> and <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for achieving a pre-determined peak force following repeated trials on an instrumented manakin with visual feedback from force gauges in real-time (76). Similarly, Triano et al. demonstrated that experienced clinicians exhibited good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and further reduced variance and errors for achieving a pre-determined load, following practice using instrumented manakins and force gauges in real-time (77). Although instrumented manakins may be too expensive (and too large to be easily stored) for many education programs and clinics, Kope et al. demonstrated that a thin film force gauge that can be worn on the thumb was <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a>, <a id="validity" data-tip="1514" target="_blank" href="/glossary-term/validity" class="glossary">valid</a>, and practical (78). This research suggests that therapists may improve their error perception, the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of administering a pre-determined load, and increase intra-therapist and inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> with the use of instrumented manikins, or potentially a film force gauge.</p>

<h4><strong>Therapist Force based on Expert Reference</strong></h4>
<p>Unfortunately, most research investigating the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> of therapist force during manipulation and mobilization does not consider the amount of force that should be applied. Owens et al. compared 11 experienced Gonstead technique method practitioners, using a force table with a simulated spine <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> to determine average forces during lumbar manipulation. Findings demonstrated a mean range between 321-515 N, mean force for light thrusts of 379 N, mean force for normal thrusts of 475 N, and heavy thrusts resulted in wide variance of forces up to 1400 N. Note, the <a id="model" data-tip="1469" target="_blank" href="/glossary-term/model" class="glossary">model</a> used in this study would seem to be a poor proxy for a human body, using a common plaster cast skeleton wrapped in semi-dense foam (e.g. cheap furniture foam) that was cut-out to roughly resembling a human torso (79). Petersen et al. demonstrated that an expert therapist performing central PA mobilizations on the L3 segment demonstrated excellent inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for minimal forces, maximal forces, and mean force for grade III and grade IV mobilizations; and further, that these forces were 85% accurate when compared to computer modeling and force data for ideal forces for each patient (80). These studies demonstrate that an effort has been made to establish a reference range for therapist force for mobilizations and manipulations based on mean force data; however, using an expert therapist as a reference range may be a reasonable standard until additional research can be performed to establish ideal ranges based on larger data sets and/or the consideration of additional variables.</p>
<h4><strong>Therapist Force based on Outcomes</strong></h4>
<p>Perhaps, more important than investigating the common range of values used by experts, would be development of therapist force recommendations based on outcomes. As mentioned above, Venturini et al. demonstrated near-ubiquitous improvements in ankle dorsiflexion ROM for all participants following ankle mobilizations by two different practitioners exhibiting good inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for peak force, but poor inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for minimal force (69). This study may imply that developing ranges for mean peak force should be prioritized. Two previously mentioned studies by Snodgrass et al. correlated a stiffer C2 facet with higher therapist mean peak force, but did not correlate the increase in stiffness or force with outcomes (57, 58). However, an additional RCT by Snodgrass et al. compared outcomes following mobilization of the most painful cervical segment with either 30N or 90N of force. The findings demonstrated that both groups exhibited improvements in pain and ROM when compared to controls (detuned laser); however, the 90 N group exhibited larger improvements in pain, ROM, and stiffness. Interestingly, the <a id="superior" data-tip="1570" target="_blank" href="/glossary-term/superior" class="glossary">superior</a> improvements exhibited by the 90N group were not immediately apparent and were only evident during follow-up (i.e. demonstrating better carry-over) (81). Last, a pilot study by Mclean et al. investigated the effects of four different levels of force applied during <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> <a id="glide" data-tip="1598" target="_blank" href="/glossary-term/glide" class="glossary">glide</a> of the elbow with the intent of improving pain-free grip strength in <a id="lateral" data-tip="1567" target="_blank" href="/glossary-term/lateral" class="glossary">lateral</a> epicondylalgia patients, demonstrating a significant difference in outcomes favoring forces greater than 1.9 N/cm (max force tested was 4.54 N/cm) (82). These studies likely imply that mean peak force is more critical than mean minimal force. Further, there is likely a relatively wide range of effective forces, with better outcomes correlated with more force or force above a certain low-end threshold.</p>
<table>
  <tbody>
    <tr>
      <td>
        <h4><strong>Author&apos;s Note:</strong></h4>
        <p>Based on these studies, recommendations for therapist force should likely result in a range above a &quot;minimally effective force&quot; and below a &quot;force correlated with a high risk of injury&quot;. This recommendation could be narrowed to an &quot;optimal range&quot; by determining the lowest force threshold that results in the largest increase in improvement by the largest percentage of people, and a high-end threshold that is correlated with an initial significant increase in the risk of injury&quot;. Based on these initial studies, it is likely that the <a id="optimal" data-tip="1571" target="_blank" href="/glossary-term/optimal" class="glossary">optimal</a> range would still be larger than the ranges used in most of the <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> studies reviewed in this article, and sufficiently wide to make good or better inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> achievable.</p>
      </td>
    </tr>
  </tbody>
</table>
<h4><strong>Additional Considerations for Developing a Reference Range</strong></h4>
<p>Additional research has highlighted a variety of additional factors that may contribute to better recommendations for therapist force during mobilizations and manipulations. Chiradejnant et al. demonstrated that forces used during mobilization were related to the patient (80 participants) and physical therapist (10 participants) characteristics; but interestingly, not pain intensity or the nature of symptoms (83). This may suggest that symptomology aids in <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>, but that mobilization/manipulation force is dictated by other factors, such as body size, gender, or joint stiffness (e.g. &quot;C2 stiffness&quot; referenced in the Snodgrass et al. studies (57, 58)). In a study by Pasquier et al., students performed a thoracic manipulation on other students, demonstrating that a subjective rating of comfort was strongly correlated with the amount of preload force and manipulation duration, and was not correlated with peak force. Interestingly, an experienced instructor grading the student&apos;s ability to deliver a &quot;comfortable manipulation&quot; exhibited a correlation between better grades and a momentary drop in preload force, and weak or no correlation with preload force or manipulation duration (84). This study demonstrates that the rate of force development and the duration of manipulation should be considered when establishing reference criteria; and further, that our subjective <a id="assessment" data-tip="1483" target="_blank" href="/glossary-term/assessment" class="glossary">evaluations</a> of factors contributing to comfort may not be accurate. In summary, these studies suggest that patient characteristics, the rate of force development, and the duration of a manipulation should be considered when developing an ideal range for therapist force; and further, that pain intensity, nature of symptoms, and assumptions about factors contributing to comfort should be given less consideration or dismissed from consideration.</p>
<h4><strong>What and Who are We Measuring</strong></h4>
<p>Similar to the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> issues described in the sections on &quot;palpation&quot; and &quot;joint motion <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> via palpation,&quot; consideration should be given to the range of agreement used during analysis, and whether study findings imply there is potential for good or better <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> to be reached. Latimer et al. used a machine to impart simulated mobilization forces to the lumbar spine of 25 asymptomatic participants, demonstrating that stiffness changed with the force imparted, that wider intervals of imparted force resulted in a larger variance in lumbar stiffness, and that wider intervals also resulted in better <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> (85). This study may suggest that an increase in the range of therapist force should be considered to aid in improving <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, despite an expected increase in variance. Ward et al. demonstrated that adjustments in the description of a joint mobilization greatly improved intra-therapist and inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for therapist force. Demonstrating that if R1 (first resistance barrier) is defined as the beginning of range, and mobilization force is divided into thirds (beginning, middle, and end range), that <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> was excellent (86). Additionally, as mentioned above, Harms et al. investigated 30 experienced therapists, demonstrating that the 30% of therapists with the highest intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> were consistent within 5% of their originally recorded force, and the least consistent therapists demonstrated variability of 34% (64). These studies demonstrate that a wider range of forces may not only be practical, but recommended, and further, <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> may be improved with better instructions for performing the technique. Last, as might be expected in any professional setting, the most capable 1/3 of professionals exhibit good to excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and the bottom 1/3 exhibit greater variance.</p>
<table>
  <tbody>
    <tr>
      <td>
        <h4><strong>Flawed Methodology:</strong></h4>
        <p>Two studies are worth mentioning due to obvious flaws in methodology. Smit et al. demonstrated that 3rd-year physiotherapy students applied more force with larger variance than 4th-year students performing grade I, C6 central PA mobilizations (87). And, Conradie et al. demonstrated good intra-rater and moderate to good inter-rater <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for a group of experienced physiotherapists performing grade I cervical mobilizations (88). The measurements of force, <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and analysis are accurately reported in these studies; however, it is surprising that this was accomplished on asymptomatic individuals using grade I mobilizations, an intervention that uses pain as a guide for force application.</p>
      </td>
    </tr>
  </tbody>
</table>

<h4><strong>Intra-therapist and Inter-therapist Reliability</strong></h4>
<ul>
  <li><strong>Cervical Spine</strong> - Cervical mobilizations exhibit good to excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for peak force, mean peak force, amplitude and oscillatory frequency, and inter-therapist force variance may be relatively high but moderately <a id="reliability" data-tip="1795" target="_blank" href="/glossary-term/reliability" class="glossary">reliable</a> when considering grade III and IV mobilization forces as a group. These studies also demonstrate that the difference in force used for grades I/II and III/IV mobilizations may be reliably differentiated. Additionally, substantial <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> has been demonstrated for the pre-manipulative position and rotation component used during cervical manipulations.</li>
  <li><strong>Thoracic Spine</strong> - Future research may anticipate higher <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for peak and mean force values and less <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for the rate of force development.</li>
  <li><strong>Lumbar Spine</strong> - Studies demonstrate more inter-therapist variance than intra-therapist variance, more variance for grade III mobilizations than grade IV mobilizations, and considerable overlap in forces between grades I-II and grades III-IV. Further, excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and potentially moderate or better inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> may be an achievable skill (especially for mean dosage and mean peak force).</li>
  <li><strong>Knee Joint</strong> - Knee mobilizations exhibit good to excellent intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> and moderate inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>. Further, comparing grade III and IV mobilizations revealed similar mean peak forces, but significant differences in amplitude and dosage.</li>
  <li><strong>Ankle Joint</strong> - Inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> is moderate or better for mean peak force, but poor for mean minimal force. However, the lack of minimal force <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> seems to have no impact on mobilization outcomes, as near-perfect <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for improving ankle dorsiflexion ROM was also demonstrated.</li>
  <li>
    <p><strong>Shoulder - </strong>Talbott et al. demonstrated good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, differentiation of force between grades, and total motion of 3.0mm for grade I, 8.2mm for grade II, and 10.7mm for grade III during Kaltenborn <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> (AP) shoulder mobilization technique (96).</p>
  </li>
</ul>
<h4><strong>Factors Affecting Reliability of Therapist Force</strong></h4>
<ul>
  <li><strong>Gender</strong> - On average, women produce less initial force, peak force, and rate of force development during manipulations, and less peak force during mobilizations; however, women generally also exhibit less variability in forces.</li>
  <li><strong>Experience</strong> - Students and experienced clinicians exhibit good intra-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> but poor inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, may reliably differentiate between higher and lower grade mobilizations, students and experienced therapists exhibit similar <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">accuracy</a> of perception of error, and peak force and rates of force development generally increase with experience.</li>
  <li><strong>Unexpected Influences</strong> - Thumb pain, direction of force applied, visual occlusion, grip used (thumb or pisiform), and plinth padding may have a significant effect on perception of stiffness and therapist force.</li>
  <li><strong>Improved <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">Accuracy</a> with Force Gauges</strong> - Therapists may improve their error perception, the <a id="accuracy" data-tip="1218" target="_blank" href="/glossary-term/accuracy" class="glossary">Accuracy</a> of administering a pre-determined load, and increase intra-therapist and inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> with use of instrumented manikins, or potentially a film force gauge.</li>
</ul>
<h4><strong>Measurement Problems and the Reliability of Therapist Force</strong></h4>
<ul>
  <li><strong>Therapist Force based on Expert Reference -</strong> An effort has been made to establish a reference range for therapist force for mobilizations and manipulations based on mean force data; however, using an expert therapist as a reference range may be a reasonable standard until additional research can be performed to establish ideal ranges based on larger data sets and/or the consideration of additional variables.</li>
  <li><strong>Therapist Force based on Outcomes -</strong> Mean peak force is likely more critical than mean minimal force. Further, there is likely a relatively wide range of effective forces, with better outcomes correlated with more force or force above a certain low-end threshold.</li>
  <li><strong>Additional Considerations for Developing a Reference Range</strong> - Patient characteristics, the rate of force development, and the duration of a manipulation should be considered when developing an ideal range for therapist force, and pain intensity, nature of symptoms, and assumptions about factors contributing to comfort should be given less consideration or dismissed from consideration.</li>
  <li><strong>What and Who are We Measuring -</strong> A wider range of forces may not only be practical, but recommended, and further, <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> may be improved with better instructions for performing the technique. Last, as might be expected in any professional setting, the most capable 1/3 of professionals exhibit good to excellent <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a>, and the bottom 1/3 exhibit greater variance.</li>
</ul>

<h3>Assessed Level versus Random Allocation</h3>
<p>A few studies have compared outcomes following mobilizations based on random allocation or therapist <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a>. Aquino et al. compared changes in pain pressure threshold and pain during active motion for 48 participants with cervical pain following either mobilization of the most painful segment as assessed by palpation, or mobilization of a randomly selected segment. Both groups exhibited similar and significant decreases in pain during palpation, and pain during motion (89). Haas et al. demonstrated that determining a <a id="specificity" data-tip="1224" target="_blank" href="/glossary-term/specificity" class="glossary">specific</a> segment based on &quot;end play&quot; did not result in better outcomes than selection of a random cervical segment; however, both groups exhibited less pain and stiffness after cervical manipulation and during a follow-up <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> 5-hours later (90). An RCT by Kanlayanaphotporn et al. compared the pain intensity and active range of motion (ROM) of patients with <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> mechanical neck pain following assessed and random protocols. The level was determined by random allocation or a blinded assessor, and the technique was then randomized to <a id="unilateral" data-tip="1551" target="_blank" href="/glossary-term/unilateral" class="glossary">unilateral</a> PA to the painful segment, <a id="contralateral" data-tip="1549" target="_blank" href="/glossary-term/contralateral" class="glossary">contralateral</a> PA, or Central PA. All mobilization groups exhibited similar and significant improvements in all outcomes (91). Karas et al. compared the outcomes of 69 patients with cervical spine pain who were randomly assigned to receive a thoracic manipulation that was consistent with the direction of their ROM loss or opposite their ROM loss, demonstrating that both groups exhibited similar improvements in pain, neck disability index, and global rating of change scores at 2-day and 2-week follow-ups (92). Last, an RCT by Donaldson et al. compared outcomes for 63 patients with mechanically reproducible lumbar pain, following mobilization of a therapist-selected segment, or a segment based on a pre-determined lumbar mobilization protocol. At 6-month follow-up there were significant but similar improvements for pain, disability, and patient acceptable symptom state scores; however, there was a significant difference between groups for global rating of change scores favoring the therapist-selected mobilization (93). Studies suggest that segmental <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> may not refine implementation enough to have a significant effect on short-term outcomes; however, significant improvements in long-term outcomes may have been demonstrated. It is worth considering that the <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> and allocation protocols in these studies happened within a few vertebrae (only cervical segments or only lumbar segments), that multiple segments often exhibit altered stiffness in symptomatic individuals, and that mobilizations/manipulations may affect more than one segment. This may have resulted in a large degree of overlap between treatment groups, and imply that studies with larger participants groups are needed to improve study <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> enough to identify differences beyond those masked by group overlap. Last, it is worth noting that all participants in all treatment groups demonstrated significant improvements (including when compared to controls), suggesting that knowing the part of the spine to be treated (e.g. cervical, thoracic or lumbar) may be enough to be effective.</p>
<h3>Assessment Based on Broader Categories</h3>
<p>Additional studies suggest that <a id="assessment" data-tip="1480" target="_blank" href="/glossary-term/assessment" class="glossary">assessments</a> may improve outcomes when they aid in narrowing choices between broader categories. Fritz et al. compared outcomes of low back pain patients assessed as <a id="hypomobility" data-tip="1676" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobile</a> or <a id="hypermobility" data-tip="1679" target="_blank" href="/glossary-term/hypermobility" class="glossary">hypermobile</a> following treatments of either manipulations or stabilization exercise. Success rates were 23.7% better for <a id="hypomobility" data-tip="1676" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobile</a> patients receiving manipulations when compared to patients receiving manipulations who were not <a id="hypomobility" data-tip="1676" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobile</a>, and success rates were 36.4% better for <a id="hypermobility" data-tip="1679" target="_blank" href="/glossary-term/hypermobility" class="glossary">hypermobile</a> patients receiving stabilization exercise when compared to patients receiving stabilization exercise who were not <a id="hypermobility" data-tip="1679" target="_blank" href="/glossary-term/hypermobility" class="glossary">hypermobile</a>. Further, failure rates for patients with <a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a> were 26% with manipulation techniques and 74.4% with stabilization exercise, and failure rates for patients with <a id="hypermobility" data-tip="1677" target="_blank" href="/glossary-term/hypermobility" class="glossary">hypermobility</a> were 83.3% for manipulation techniques and 22.2% for stabilization exercises (94). Hidalgo et al. demonstrated that asymptomatic patients assessed with upper cervical <a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a> exhibited greater improvements in cervical range of motion (ROM) following a C0/C1 mobilization (mean 17.64&#xB0;) when compared to a c7-T1 (mean 5.95&#xB0;) mobilization. Note, both mobilizations resulted in significant increases in ROM compared to controls (mean 2.45&#xB0;) (95). And, mentioned above, Venturini et al. demonstrated good inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> between 2 practitioners for maximal force applied during a 30-second, grade III ankle mobilization, poor inter-therapist <a id="reliability" data-tip="1515" target="_blank" href="/glossary-term/reliability" class="glossary">reliability</a> for minimal force; however, the effects of mobilization were consistent resulting in an increase ankle dorsiflexion ROM for all participants, regardless of which therapist performed the technique (69). These studies suggest that differentiating between <a id="hypermobility" data-tip="1677" target="_blank" href="/glossary-term/hypermobility" class="glossary">hypermobility</a> and <a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a>, upper and lower cervical spine, and/or ensuring adequate maximal force during mobilization may be sufficiently accurate to significantly improve outcomes.</p>
<h3>Section Summary</h3>
<h4><strong>Assessed Level versus Random Allocation</strong></h4>
<ul>
  <li><strong>Outcomes -</strong> Segmental <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> may not refine implementation enough to have a significant effect on short-term outcomes; however, segmental <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> may result in improvements in long-term outcomes. Further, mobilizations/manipulations improved both short-term and long-term outcomes when compared to controls, following both random and assessed allocations.</li>
  <li><strong>Study Considerations</strong> - It is worth considering that the <a id="assessment" data-tip="1478" target="_blank" href="/glossary-term/assessment" class="glossary">assessment</a> and allocation protocols in these studies happened within a few vertebrae (only cervical segments or only lumbar segments), that multiple segments often exhibit altered stiffness in symptomatic individuals, and that mobilizations/manipulations may affect more than one segment. This may have resulted in a large degree of overlap between treatment groups, and imply that studies with larger participants groups are needed to improve study <a id="sensitivity" data-tip="1226" target="_blank" href="/glossary-term/sensitivity" class="glossary">sensitivity</a> enough to identify differences beyond those masked by group overlap.</li>
</ul>
<h4><strong>Assessment Based on Broader Categories</strong></h4>
<ul>
  <li><strong>Differentiation</strong> - Differentiating between <a id="hypermobility" data-tip="1677" target="_blank" href="/glossary-term/hypermobility" class="glossary">hypermobility</a> and <a id="hypomobility" data-tip="1673" target="_blank" href="/glossary-term/hypomobility" class="glossary">hypomobility</a>, upper and lower cervical spine, and/or ensuring adequate maximal force during mobilization may be sufficiently accurate to significantly improve outcomes.</li>
</ul>

Bibliography

<p>© 2021 Brent Brookbush</p>
<p>Questions, comments, and criticisms are welcomed and encouraged</p>

Copyright

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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