Manual Therapy Techniques For The Lumbar Spine

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Introduction[edit | edit source]

This page is designed to look at .....

Low back Pain (LBP)

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Mobilisations[edit | edit source]

Joint mobilisation is a treatment technique which can be used to manage musculoskeletal dysfunction [1]Hertling et al (1996), by restoring the motion in the respective joint [2](Randall, 1992). The techniques are performed by physiotherapists, and fall under the category of manual therapy. Spinal mobilisation is described in terms of improving mobility in areas of the spine that are restricted [3](Korr 1977). Such restriction may be found in joints, connective tissues or muscles. By removing the restriction by mobilisation the source of pain is reduced and the patient experiences symptomatic relief. This results in gentle mobilisations being used for pain relief while more forceful, deeper mobilisations are effective for decreasing joint stiffness. [4] (Maitland 1986). 


Definition: Mobilisations primarily consist of passive movements which can be classified as physiological or accessory [5]. The purpose is to provide short term pain relief and to restore pain-free, functional movements by achieving full range at the joint [6].



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Background[edit | edit source]


Effects and mechanisms

Research has shown the mobilisation used as a therapy can produce significant mechanical and neurophysiological effects [7] [8] [9] [10]. The explanations of these effects - the mechanism of mobilisation - is still relatively unknown, especially in regards to the spine, and is subject to further research [11].
However, several theories have been established in accordance with effects seen, including the effects of pain relief, increasing range of motion and the influence on the autonomic nervous system.

Pain Relief
Mobilisations offer pain relief through hypoalgesia - decreasing the nervous system's sensitivity to painful stimuli. There are various potential mechanisms of this neurophysiological effect:

1) Pain gating
Pain gating refers to the theory that simulation of the mechano-receptive peripheral afferent nerves in the muscles produce sensory input that interferes with nocioceptive impulses at the spinal cord [12]. The input from the larger sensory nerves inhibits the transmission of pain through the smaller nocioceptive nerves to the brain, leading to a pain reliving result [13]. Therefore, the processes of stimulating mechanoreceptors via mobilisation produces short term pain relief through the mechanism of pain gating [14]. However, the pain gate theory only explains the pain relieving effect during the mobilisation, not any long term effects post treatment. Therefore it is hypothesised that any longer term pain reliving effects are mediated by higher brain mechanisms [15] - summarised below.

2) Descending mechanisms and supraspinal regions
Research has shown that mobilisation leads to activation of pain inhibitory pathways that originate in the midbrain and travel down the spinal cord - the descending pathways [16] [17] , Grason et al, 2012). The pathway stimulation works to provide pain relief by suppression of pain through this inhibitory mechanism.
In addition to this these descending pathways, research has shown a trend where regions of the brain responsible for central pain processing are suppressed during mobilisation [18].

3) Adaptation
It has been hypothesised that mobilisation promotes adaptations of the nervous system [19] with a decrease in the level of neural input from the painful site. Research also suggests that mobilisations increase the pain threshold levels - relative hypoalgesia [20]. It has been suggested that this could be due to electrochemical changes in the regulation of threshold potential [21].

Increasing range of motion
Mobilisations are often used with the objective to increase the range of motion of the joint through stretching of fibrous tissue [22]. This stretching may cause the tissue to 'creep'. The phenomenon of creep relates to the ability of tissues to change shape over time as a constant load is applied .The creep deformation is not permanent and, once the load is removed, the tissue will slowly resume its original length [23]. However, in the short term, this mechanical effect of mobilisation enables an increase in range of motion at the joint.

Influence on Autonomic Nervous System
Mobilisation has been found to influence sympathetic activity, affecting heart rate, blood pressure [24] and respiratory rate [25]. These sympathetic responses could possibly be linked to another evidenced effect of mobilisation - changes in blood component levels. Teodorczyk-Injeyan et al (2006) found that mobilisation effected the levels of blood components, with a reduction in inflammatory proteins. Therefore it was suggested that mobilisation could be a potential therapeutic modality to reduce inflammatory response - working as an anti-inflammatory mechanism, though the exact explanation for this process is unknown [26].


Bialosky et al (2009)[27] suggested that the mechanical and neurophysiological effects explored here are interlinked. They proposed that a mechanical force initiates a chain of neurological responses, which would then produce the outcomes associated with manual therapy.
This proposal was illustrated in their model of the mechanisms of manual therapy (see figure 1)??


The effects of mobilisation and the mechanisms responsible are not fully understood and more research is needed to provide evidence for the theories discussed. It is also important to note that variables such as the placebo effect and psychological factors may pertain to the effects seen [28]. 


Contraindications/Precautions to vertebral mobilisations[29][30]

  • Neurological:

     - Patient with arm pain and neurological signs, from two nerve routes
     - Disturbance of bladder and bowel function, or perineal anaesthesia
     - Spinal cord symptoms

  • Radiological changes:

     - Patients with rheumatoid arthritis and osteoporosis are contraindications to forceful mobilizations.

     - Any pathology leading to significant bone weakening such as tumours, infections, long-term corticosteroid medication, fracture

  • Patients with vertigo need close supervision
    • Hypermobility:

     - If a vertebra in the spine was hypermobile compared to the other vertebra, care must be taken to avoid putting excessive strain on the hypermobile joint

  • Vascular

     - Aortic aneurysm, bleeding into joints, e.g. severe Haemophilia

  • Pregnancy
    • Musculoskeletal deformity

     - Spondylolysis, spondylolithesis

Effects of mobilisation on stiffness and pain[edit | edit source]

Mobilisations involving pressure onto the vertebra can be used to increase joint range of motion, and also to produce and analgesic effect.


Manual therapy and mobilisations can be used to treat 5 symptom groups:[29][31]

  • Pain
  • Stiffness
  • Pain associated with stiffness
  • Momentary jabs of painDisorders directly related to a specific diagnosis


Stiffness– patients whose joint stiffness is limiting normal function.[32]
Select movement that needs to be stretched, for physiological movements, then accessory movements should be used, all directions utilised. Pressure applied through the thumb or pisiform against the vertebrae in the direction of the movement that is stiff.

Staccato techniques are used move a stiff joint through its maximum range before the bordering joints have time to start moving too. If there are no symptoms from the joint, then the speed of the staccato can be quicker, however, if symptoms are moderate, then the movements need to be more fluid.

There is evidence to suggest that different segments of the lumbar spine will react slightly differently, for example; when a PA is performed on L3,4 and 5, then tend to move into extension, and all three segments will move in response to a PA on the neighbouring one. However with L1 and L2, the lower L3,4 and 5 segments moved into flexion. – need to be aware of the effect of a PA mobilisation on neighbouring vertebra segments [33]


Pain– patients who have severe pain that is limiting movement[32]
The joint being treated should be positioned in a symptom free way. To decide between accessory movements and physiological movements, the one, which can be performed with the larges amplitude most comfortably for the patient, is used. If a joint is painful, oscillations in mobilisations should be smoothly and evenly so that changes between the on and off pressure cannot be detected.

Accessory movements:

  • Pressure is applied through the thumb or pisiform to produce large amplitude of movement, with very little pressure and without any degree of stiffness felt.
  • The amplitude of the movement should be as large as possible without causing any pain. As symptoms improve, then the amplitude of the movements can increase gradually, although mobilisations have been shown to have a beneficial hypoalgesic regardless of amplitude. [34]

Physiological movements – when used should not cause any discomfort

  • Any movements should be in the painless direction, in a large, slow, smooth manner, stopping before the onset of any discomfort. As the patient’s symptoms and ROM improve, the technique can be taken into a known and controlled degree of discomfort.


Mobilisations can significantly decrease localised pain in the short term, about 24 hours, and can potentially lead to a greater decrease of pain long term compared to no treatment [35]. To most effectively treat the pain, the symptomatic level of vertebra should be selected rather than a randomly selected level [36]


Grades of movement [32]
Mobilisation techniques can be performed in different positions of the range, using small or large amplitudes of movements, which are divided into four grades:


Grade Amplitude of movement:
I A small-amplitude movement near the starting position of the range

II A large-amplitude of movement that carries well into the range. It can occupy any part of the range that is free of any stiffness or muscle spasm that does move into stiffness or muscle spasm

III Also a large-amplitude movement, but one that does move into stiffness or muscle spasm

IV A small-amplitude movement stretching into stiffness or muscle spasm




Mobilisations of the Lumbar Spine
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Central Posteroanterior (PA) Mobilisation Technique[edit | edit source]

For this manual therapy technique, the patient is often positioned in prone with their arms by their side and a pillow under their abdomen for comfort [37] (Powers et al, 2009). A PA mobilization is then performed by a physiotherpist by placing their thumb or pisiform over the spinous process of a vertebrae and applying a posteroanterior force.

PAs are a commonly used manual therapy technique that has shown to be effective at reducing pain in patients with low back pain (LBP) (Shum, Tsung and Lee, 2012). So far, evidence suggests immediate pain relief following treatment, and also some evidence suggests an increased range of movement (ROM) of lumbar extention (McCollam and Benson, 1993, Shum, Tsung and Lee, 2012,  and Powers et al, 2009). However, literature is still variable on the overall effects of ROM and pain[38].


Mobilisations to increase lumbar flexion[edit | edit source]

During flexion, the superior vertebral body moves relatively anteriorly and superiorly on the inferior vertebral body[39]. Therefore, to aid flexion the mobilisation needs to be applied to the vertebra above the stiff/painful vertebra to facilitate the anterior-superior translation of the facet joints.

A Passive accessory intervertebral movement (PAIVM) is a mobilisation technique that produces movement of a mobile vertebral segment without active participation of muscles related to the movement.

This section will focus on the application of Posterioanterior mobilisations of the lumbar spine which is achieved by applying a force on to a vertebral segment in a posterioanterior direction (Back to front).

Technique:

Starting Position:

  • Patient lying in prone
  • Therapist stands to side of patient placing their pisiform/ulnar surface of hand over the selected spinous process (SP) with their wrist in full extention. Other hand placed ontop of hand to reinforce.
  • Therapist's shoulders should be directly above the SP with elbows slightly bent.

Method:

  • Therapist uses their body weight to apply a PA force to the selected SP by leaning their body over their arms and performing rocking movements to provide oscillatory movements of the vertebra.

 ('Central Posteroanterior (PA) mobilisation': With the patient lying in prone, the therapist stands to the side of the patient and places their pisiform/ ulnar surface of their hand over the spinous process (SP) of the selected vertebra with their wrist in full extension. The other hand is then placed on top to reinforce. The therapist’s shoulders should be directly above the SP with the elbows slightly bent. The therapist then uses their body weight to apply a PA force to the selected SP by leaning their body over their arms and performing rocking movements to provide oscillatory movements of the vertebra.)

On initial assessment and treatment, if the patient has very limited movement, a pillow can be placed underneath their abdomen, or the head end of plinth can be raised to position the Lumbar spine in relative extension. Similarly, if the patient cannot tollerate pressure directly through the spinous process, the therapist can apply pressure either side of the SP  with either thumb on the transverse processes.
Equally, as the patient’s pain and stiffness reduces the position of the patient can be altered to increase flexion nearer to end of range. This can be done by either lowering the foot section of the plinth or kneeling the patient on the floor by the foot of the plinth with his trunk flexed over the plinth ( approx. 20 degrees flexion) [29]

Mobilisations with Movement (MWMs)[edit | edit source]

Definition: It is a manual therapy technique which was developed by Brian Mulligan, for the treatment of musculoskeletal dysfunction [40] (Jonas 2005). It involves performing a sustained force (accessory glide) while a previously painful (problematic) movement is performed[41] (Vicenzino 2009).

Usually, the technique is indicated if, during its application the technique enables the impaired joint to move more freely without pain or impediment[42] (Mulligan, 1993).  Mulligan does not prescribe grades of movement or oscillatory movements. He prescribes taking the joint through its full range of movement and this entails taking it into resistance. When performing MWMs, the direction of the applied force is typically perpendicular to the plane of movement or impaired action and in some instances it is parallel to the treatment plane [43][44](Mulligan, 1992, 1993, 1996).

There have been reports of clinical cases and case serieswhich have described the success of MWMs in the management of various musculoskeletal conditions[45][46][47][48][49][50][51] (Stephens, 1995; Vicenzino and Wright, 1995; Hetherington, 1996; O’Brien and Vicenzino, 1998; Miller, 2000; Exelby, 2001; Folk, 2001). See Exelby, (2001) for success in MWMs in the lumbar spine.


MWMs to increase Flexion of the Lumbar Spine
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Technique 1[edit | edit source]

Starting position:

  • Patient in side lying facing therapist.
  • The patient's knees should be bent towards their chest in mid lumbar flexion and rested on the therapists hips.
  • Therapist places forearms along the patients back to palpate between adjacent spinous processes.


 Method:

  • The therapist produces flexion and extension of the lumbar spine by swaying hips left to right (and vise versa)
  • To isolate flexion, the problematic level is palpated and when passively moving the spine into flexion a sustained PA force is applied to the spinous process throughout the movement of flexion and then released.


N.B *Correct plinth height is essential for this technique.

      ** It may take multiple attempts of the MWMs to find the correct level of the lumbar spine to decrease pain and/or stiffness.

Technique 2[edit | edit source]

Starting Position:

  • Patient in standing perpendicular to therapist.
  • Therapist's need to stabilise pelvis via placing cup of hand other the ASIS.
  • Therapist to palpate between adjacent spinous processes.


Method:

  • The patient actively flexes lumbar spine and then extends to return to the neurtal position.
  • To isolate flexion, again, the problematic level is palpated and when the patient actively moves into flexion, a sustained PA force is applied to the spinous process throughout the movement.

Technique 3[edit | edit source]

Starting Position:

  • Patient in sitting, facing away from therapist.
  • The pelvis is stabilised via a belt being placed around the patients ASIS's and around the therapist's ischeal tuberosity. 
  • Therapist to palpate between adjacent spinous processes.


Method:

  • The patient actively flexes the lumbar spine and extends to a neutral position.
  • The therapist maitains the tension on the belt throughout all movement.
  • The problematic level is palpated and when the patient actively moves into flexion, a sustained PA force is applied throughout the whole movement of flexion to the spinous process.

N.B * The therapist should have bent knees and be able to lean onto the belt to increase the tension of the belt.

[52] Mulligan (1995)

Recording[edit | edit source]

Assesment.png

Prescription of Mobilisations[edit | edit source]

Thus far, there is no definitive evidence for the optimum duration, frequency or amplitude for mobilisation techniques. Most researchers have investigated subject responces' to 3 cycles of 60 second mobilisation which have shown to have immeditate effects of local and widespread analgeia[53]  [54][55]. However, the duration, rate and frequency of mobilsations should be tailored to the patient's irritability and the preference of both patient and therapist[56].Current guidlines suggest that non-specific LBP patients should recieve a 12 week course of manual therapy[57]


Moreover, it is generally agreed that the oscilliation depth and amplitude of movement is dependent on the patients symptoms.
If the patient's main symptom is pain then oscillation depth should remain shallow (<55%) and should be maintained within a pain free range (e.g. Grade I and II). However, if the patient's main complaint is of stiffness then the depth of oscillation can progress to end of range providing pain is tolerable (e.g. Grade III and IIII)


Maitland Scale of Mobilisations[58]:
Grade I - Small amplitude + slow oscillations in pain free zone (<25% ROM)
Grade II- Large amplitude + slow oscillations in pain free zone (<55% ROM)
Grade III- Large amplitude + slow oscillations mid to end of range
Grade IIII- Small amplitude + slow oscillations at end of range

References[edit | edit source]

  1. ↑ Hertling D., and R.M. Kessler. Management of Common Musculoskeletal Disorders. Baltimore: Lippincott, Williams &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Wilkins, 1996.
  2. ↑ Randall et al, 1992
  3. ↑ Korr IM (1977): The neurobiologic mechanisms in manipulative therapy. New York, Plenum Press.
  4. ↑ Maitland GD (1986): Vertebral manipulation, 5th ed. Sydney, Butterworths.
  5. ↑ Porter, S., (2005). Dictionary of Physiotherapy. London. Elsevier.
  6. ↑ Maitland, G., Hengeveld. E., Banks, K. and English, K., (2005). Maitland's Vertebral Manipulation. 7th Edition. London. Elsevier.
  7. ↑ Wright, A., (1995). Hypoalgesia post-manipulative therapy: a review of a potential neurophysiological mechanism. Manual Therapy, Vol 1, 11-16
  8. ↑ Bialosky, J., Bishop, M., Price, D., Robinson, M., and George, S., (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy, Vol 14, 531-538.
  9. ↑ Gross, A., Miller, J.,D'Sylva, J., Burnie, S., Goldsmith, C., Graham, N., Haines, T., Bronfort, G., and Hoving J., (2010). Manipulation or Mobilisation for Neck Pain. Cochrane Database of Systematic Reviews, Issue 1, 1-90
  10. ↑ Zusman, M., (2011). Mechanism of mobilization. Physical Therapy Reviews, Vol 16, (4) 233-236.
  11. ↑ Krouwel, O., Hebron, C., and Willet, E., (2010). An investigation into the potential hypoalgesic effects of different amplitudes of PA mobilisation on the lumbar spine as measured by pressure pain thresholds (PPT). Manual Therapy, Vol 15, 7-12
  12. ↑ Pickar, JG., and Wheeler, JD., (2001). Response of muscle proprioceptors to spinal manipulative like loads in the anesthetized cat. Journal of Manipulative and Physiological Therapeutics, Vol 24, 2–11.
  13. ↑ BJA., (2002). Editorial I - Gate Control Theory of pain stands the test of time. British Journal of Anaesthesia, Vol 88 (6) 755-757.
  14. ↑ Zusman, M., (1986). Spinal Manipulative Therapy: Review of Some Proposed Mechanisms, and a New Hypothesis. The Australian Journal of Physiotherapy, Vol 32 (2) 89-99
  15. ↑ Krouwel, O., Hebron, C., and Willet, E., (2010). An investigation into the potential hypoalgesic effects of different amplitudes of PA mobilisation on the lumbar spine as measured by pressure pain thresholds (PPT). Manual Therapy, Vol 15, 7-12
  16. ↑ Krouwel, O., Hebron, C., and Willet, E., (2010). An investigation into the potential hypoalgesic effects of different amplitudes of PA mobilisation on the lumbar spine as measured by pressure pain thresholds (PPT). Manual Therapy, Vol 15, 7-12
  17. ↑ Zusman, M., (2011). Mechanism of mobilization. Physical Therapy Reviews, Vol 16 (4) 233-236.
  18. ↑ Bialosky, J., Bishop, M., Price, D., Robinson, M., and George, S., (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy, Vol 14, 531-538.
  19. ↑ Refshauge, K., and Gass, E., (2004). Musculoskeletal Physiotherapy: clinical science and evidence-based practice. 2nd Edition. Oxford. Butterworth Heinemann.
  20. ↑ Wright, A., (1995). Hypoalgesia post-manipulative therapy: a review of a potential neurophysiological mechanism. Manual Therapy, Vol 1, 11-16
  21. ↑ Zusman, M., (1986). Spinal Manipulative Therapy: Review of Some Proposed Mechanisms, and a New Hypothesis. The Australian Journal of Physiotherapy, Vol 32 (2) 89-99
  22. ↑ Refshauge, K., and Gass, E., (2004). Musculoskeletal Physiotherapy: clinical science and evidence-based practice. 2nd Edition. Oxford. Butterworth Heinemann.
  23. ↑ Threlkeld, A., (1992). The Effects of Manual Therapy on Connective Tissue. Physical Therapy, Vol 72 (12) 893-902.
  24. ↑ Zusman, M., (2011). Mechanism of mobilization. Physical Therapy Reviews, Vol 16 (4) 233-236.
  25. ↑ Wright, A., (1995). Hypoalgesia post-manipulative therapy: a review of a potential neurophysiological mechanism. Manual Therapy, Vol 1, 11-16
  26. ↑ Teodorczyk-Injeyan, J., Injeyan, H., and Ruegg, R,. (2006). Spinal manipulative therapy reduces inflammatory cytokines but not substance P production in normal subjects. Journal of Manipulative and Physiological Therapeutics, Vol 29, 14–21
  27. ↑ Bialosky, J., Bishop, M., Price, D., Robinson, M., and George, S., (2009). The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Manual Therapy, Vol 14, 531-538.
  28. ↑ Ernst, E., (2000). Does spinal manipulation have specific treatment effects? Family Practice, Vol 17, 554–556.
  29. ↑ 29.0 29.1 29.2 Maitland, G.D., Hengeveld. E., Banks, K. and English, K.eds., 2005,Vertebral Manipulation, Edition 7, London, Butterworth Heinsmann.
  30. ↑ Gibbons P, Tehan P, (2001) Patient positioning and spinal locking for lumbar spine rotation manipulation. Manual Therapy, 6(3), 130-138
  31. ↑ Fabio R. (1992) Efficacy of manual therapy. Physical Therapy Vol 72, Issue 12
  32. ↑ 32.0 32.1 32.2 Maitland, G.D., Hengeveld. E., Banks, K. and English, K.eds., 2005,Vertebral Manipulation, Edition 7, London, Butterworth Heinsmann.
  33. ↑ Powers CM, Kulig K, Harrison J, Bergman G (2003). Segmental mobility of the lumbar spine during a posterior to anterior mobilization: assessment using dynamic MRI. Clinical Biomechanics 18:80-83
  34. ↑ Krouwel O, Hebron C, Wilet E, (2009) An investigation into the potential hypoalgesic effects of different amplitudes of PA mobilisations on the lumbar spine as measured by pressure pain thresholds (PPT). Manual Therapy 15:7-12
  35. ↑ Hanrahan S, Bonnie L, et al (2005) The short-term effects of joint mobilizations on acute mechanical low back dysfunction in collegiate athletes. Journal of athletic training 40(2)
  36. ↑ • Chiradejnant A, Latimer J, Maher CG, Stepkovitch N, (2002) Does the choice of spinal level treated during posterioanterior (PA) mobilisation affect the treatment outcome? Physiotherapy Theory and Practice 18, 165-174
  37. ↑ Powers, C.M., Beneck, G.J., Kulig, K., Landel, R.F. and Fredericson, M., 2008, "Effects of a Single Session of Posterior-to-Anterior Spinal Mobilization and Press-up Exercise on Pain Response and Lumbar Spine Extension in People with Nonspecific Low Back Pain", Journal of the American Physical Therapy Association
  38. ↑ Rubinstein, S.M., Assendelft, T.C.M., de Boer,M.R. and van Tulder, M.W., 2012, "Spinal Manipulative therapy for acute low-back pain (Review),Cochrane,Issue.12
  39. ↑ Palastanga, N., Soames, R. and Palastanga, Dot.,2008, Anatomy and human movement pocketbook, London, Churchill Livingstone.
  40. ↑ Jonas. (2005). Mosby's Dictionary of Complementary and Alternative Medicine, Elsevier.. Available: http://medical-dictionary.thefreedictionary.com/mobilization+with+movement. Last accessed 11th Jan 2013.
  41. ↑ Vicenzino. (2009). Mulligans: Mobilisations with movement. Available: http://www.bmulligan.com/conference/downloads/vicenzino_keynote1_MUllConf09.pdf. Last accessed 11th Jan 2013.
  42. ↑ Mulligan B. Mobilisation with movement (MWM’s). Journal offckLRManual and Manipulative Therapy 1993;1:154–6.
  43. ↑ Mulligan B. Extremity joint mobilisations combined with movements.fckLRNew Zealand Journal of Physiotherapy 1992;20:28–9.
  44. ↑ Mulligan B. Mobilisations with movement (MWM’S) for the hip jointfckLRto restore internal rotation and flexion. Journal of Manual andfckLRManipulative Therapy 1996;4:35–6.
  45. ↑ Stephens G. Lateral epicondylitis. Journal of Manual and ManioulativefckLRTherapy 1995;3:50–8.
  46. ↑ Vicenzino B, Wright A. Effects of a novel manipulative physiotherapyfckLRtechnique on tennis elbow: a single case study. Manual TherapyfckLR1995;1(1):30–5.
  47. ↑ Hetherington B. Lateral ligament strains of the ankle: do they exist?fckLRManual Therapy 1996;1(5):274–5.
  48. ↑ O’Brien T, Vicenzino B. A study of the effects of Mulligan’sfckLRmobilization with movement treatment of lateral ankle pain usingfckLRa case study design. Manual Therapy 1998;3(2):78–84.
  49. ↑ Miller J. Case study: Mulligan concept management of ‘‘tennis elbow’’.fckLROrthopaedic Division Review 2000;3:45–7.
  50. ↑ Exelby L. The locked lumbar facet joint: intervention using mobilizationsfckLRwith movement. Manual Therapy 2001;6(2):116–21.
  51. ↑ Folk B. Traumatic thumb injury management using mobilization withfckLRmovement. Manual Therapy 2001;6(3):178–82.
  52. ↑ Mulligan. (1995). Spinal Mobilisations with Leg Movement (Further Mobilisations with Movement). Journal of Manipulative Therapy. 3 (1), pg25-7.
  53. ↑ Krouwel, O., Hebron, C. and Willett, E., 2010, "An investigation into the potential hypoalgesic effects of PA mobilisations on the lumbar spine as measured by pressure pain thresholds (PPT)",Manual Therapy, Vol. 15, Pp. 7-12
  54. ↑ Goodsell, M., Lee, M and Latimer, J., 2000, "Short-Term Effects of Lumbar Posteroanterior Mobilization in Individuals With Low-Back Pain",Journal of Manipulative and Physiological Theraputics, Vol. 23, No. 5.
  55. ↑ Willett, E., Hebron,C. and Krouwel, O., 2009, "The initial effects of different rates of mobilisations on pressure pain thresholds in asymptomatic subjects", Manual Therapy, Vol.15, Pp.173-178
  56. ↑ Maitland, G.D., Hengeveld. E., Banks, K. and English, K.eds., 2005,Vertebral Manipulation, Edition 7, London, Butterworth Heinsmann.
  57. ↑ N.I.C.E guidelines, 2009, Low back pain: Early management of persistent non-specific low back pain, National Institute for Health and Clinical Excellence, Manchester.
  58. ↑ Cenage, G., 2002, "Joint Mobilization and Manipulation", Encylopedia of Nursing &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Allied Health, Vol.3, accessed 8 January 2013 at [www.enotes.com/joint-mobilization-manipulation-reference/]
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