MAITLAND MOBILIZATION

MPT 1
 INTRODUCTION
• The concept was introduced Geoffrey Douglas
Maitland in the year 1960.
• Born in 1924 in Australia
• Completed his training as a physical therapist in
1949
• Founder of the Maitland Mobilization Techniques
• Maitland recognized that “ pain is influenced by
variety of factors and it presents in many
different ways”.
• Maitland says of the concept “ It did not come to
me fully developed, but as a living thing,
developing and extending”
 INTRODUCTION
• The Maitland Concept of Manipulative Physiotherapy
[as it became to be known], emphasizes a specific way
of thinking, continuous evaluation and assessment and
the art of manipulative physiotherapy (“know when,
how and which techniques to perform, and adapt
these to the individual Patient”) and a total
commitment to the patient.
The application of the Maitland concept can be on the
peripheral or spinal joints, both require technical
explanation and differ in technical terms and effects,
however the main theoretical approach is similar to
both.
 KEY TERMS
• Accessory Movement - Accessory or joint play movements are
joint movements which cannot be performed by the individual.
These movements include roll, spin and slide which accompany
physiological movements of a joint. The accessory movements are
examined passively to assess range and symptom response in the
open pack position of a joint.
• Physiological Movement - The movements which can be achieved
and performed actively by a person and can be analyzed for
quality and symptom response.
• Injuring Movement - Making the pain/symptoms 'come on' by
moving the joint in a particular direction during the clinical
assessment.
• Overpressure - Each joint has a passive range of movement which
exceeds its available active range. To achieve this range a stretch is
applied to the end of normal passive movement. This range nearly
always has a degree of discomfort and assessment of dislocation
or subluxation should be acquired during the subjective
assessment.
Fundamental Components
 KEY CONCEPT OF MAITLAND
TECHNIQUE
1. Patient centred approach to dealing with
movement disorders
2. The Brick Wall approach and the primacy of
Clinical Evidence
3. Paradigm of identifying and maximizing
movement potential
4. The science and art of assessment
 Patient centred approach to dealing
with movement disorders
 This key component is based around a personal commitment to the patient.
 Personal commitment implies:
a) Developing a level of concentration such that the physiotherapist feels mentally
and physically challenged throughout each episode of care
b) Developing a skilled understanding of verbal and non-verbal communication and
being prepared to critically appraise one’s own clinical skills
c) Using the patient’s own terminology
d) Creating an interpersonal environment
 The central core or theme of the Concept is a positive personal commitment to
understand what the person (patient) is enduring.
 Therefore the Maitland Concept is a patient-driven model.
 It is inclusive and places the patient and their main problems at the center of
everything the manipulative physiotherapist will do or say.
 The body's capacity to give information about how the patient is affected by these
problems (symptoms, activity limitations, etc.) is the key to the planning, selection
and progression of manipulative physiotherapy intervention.
 pain response to accessory movements performed in loose-packed
positions and at the end of range of physiological movements
 pain response to 'combined movement' tests
 pain response to the testing of 'functional corners'
 pain response to movement, both physiological and accessory,
performed while the joint surfaces are held compressed together
 test movements requiring overpressure to establish normality .
 not thinking of range of movement without relating the pain
response to it and vice versa
 movement diagrams for the purpose of learning and teaching.

Mobilization / manipulation techniques :

 A technique is the brainchild of ingenuity.
 Two styles of technique are specific to the Concept:
a) Performing a movement in an oscillatory manner within a range of
movement where there is no stiffness, muscle spasm or pain .
b) Using compression as a component of a treatment technique.
 SCIENCE AND ART OF ASSESSMENT
• Repeated assessment and ongoing analytical assessment
are the means of evaluating and reflecting on everything
done during the clinical decision-making process.
• Assessment is the epitome of the Concept.
• Therefore this process of evaluation involves the clinical
science of measurable change and the art of decision
making about treatment, often based on clinical experience
and intuition.
• Assessment is used at the initial consultation in a manner
which determines the effects of the disorder on the patient
as a person and to identify relevant movement
impairments and consequent activity limitations.
• The second application of assessment is in clinically
proving the value of treatment techniques by repeated,
detailed assessment and re-assessment of the patient's
symptoms and signs.
 DEFINITION
• Mobilization: Passive movement performed in such a
manner and speed that at all times they are within the
control of the patient so that movement can be
prevented if the patient so chooses.
• Manipulation:
1. A passive movement consisting of a high velocity thrust
within the joints anatomical limit performed at such a
speed that renders the patient powerless to prevent it.
2.Manipulation under anaesthetic (MUA) is a medical
procedure performed with the patient under
anaesthetic and used to stretch a joint to restore a full
range of movement by breaking adhesions
 MOBILIZATION
• Mobilization include passive oscillatory
movement (2-3/sec) of small amplitude applied
anywhere in a range of movement or sustained
stretching with or without tiny amplitude
oscillation at the limit of the range.
• Rhythms : slow/smooth or quick/staccato.
• Oscillation or sustained stretches may consist of
accessory movement, shaft rotation,
physiological movement and combination of any
of these.
Oscillatory movements or sustained stretches may
consist of :
• Accessory movement: movements that a person
cannot perform independently but can be
performed on them by someone else. E.g;
roll,spin and slide. These movements are
important as the quality of physiological
movement depends on it.
• Shaft rotation: passive ratation of bones about
their long axis gives rise to shaft rotation and
accompanying accessory movement within a
joint.
• Physiological movement: movements that a
person can carry out actively.
• Movement combinations: these are the techniques which involve
combining accessory and physiological movements at the same
time. Example- extension of 1st carpometacarpal joint with a
posteroanterior accessory movement.
• Joint movement : Joint movement includes all of the intra articular
structures, the capsule and all of the contractile tissues which move
during every passive and active movement of a joint.
• Neurodynamics: It is interaction between mechanical and
physiological functions of the nervous system
• Neural movement: It relates to nerves and their infrastructure as
well as the connective tissue which supports them and the
connective tissue of the vertebral canal foraminal canal and
peripheral through which they pass
 PRINCIPLES OF ASSESSMENT
1.Analytical assessment at the first consultation
2.Pretreatment assessment
3.Assessment and reassessment during and
immediately after each treatment session
4.Progressive assessment
5.Retrospective assessment
6.Final analytical assessment
 RED FLAGS
1. Features of cauda equina syndrome
2. Significant trauma
3. Systematically unwell, weight loss
4. History of cancer
5. Fever
6. Intravenous drug use
7. Steroid use
8. Sever, unremitting nighttime pain
9. Marked morning stiffness
10.ESR>25
11.Xray: vertebral collapse or bone desruction
 YELLOW FLAGS
The presence of relevant yellow flagsshould lead
to different approaches to treatment rather
than denying therapy or shifting patients over
to psychiatrist.
1.Central pain (psychogenic pain)
2.Causative agents and contributing factors
3.Psychopathology
4.Life problems
5.Secondary gain
 PRINCIPLES OF EXAMINATION
Physical examination should include the following
• Present pain
• Observation: alingment faults, deformities, structural
deformities, swelling.
• Injuring movement
• Differenciation test: special tests
• Active movements : range/pain (symptoms) response/
quality of movement
• Combined movements
• Overpressure
• Isometric tests
• Palpation
• Passive movement
SUBJECTIVE EXAMINATION
1. place the patient at the center of
everything that the clinician wishes to do
2. identify the kind of disorder, the site,
nature, behavior and history of the
patient's symptoms
3.identify how the patient is affected and has
been affected by the disorder
(impairment/ disability)
4. establish the extent of the physical
examination required and the desired
effect of treatment based on the severity,
irritability and nature of the symptoms
and the stage of the disorder
5. identify precautions and contraindications
for treatment identify the structures at
fault (the source/the cause of the source
of the symptoms)
OBJECTIVE EXAMINATION
1) stablish, with asterisks, the signs relevant
to the patient's disorder
2) test the clinical and theoretical
hypotheses identified in the C/O
3) analyze movements in terms of their
range/ symptom response / quality
4) apply an appropriate amount of
examination (short of symptoms, up to
the onset of symptoms, to the limit of
range, to the limit of range with
overpressure added) reproduce symptoms
5) find comparable signs
SUBJECTIVE EXAMINATION OBJECTIVE EXAMINATION

6.hypothesize about the mechanisms of 5. establish the source, cause of the

symptom production (nociception, source and contributing factors to the
peripheral neurogenic, central, disorder
autonomic, affective) 7. exclude structures not at fault
7. identify the factors contributing to the 8. confirm or rule out the need for
disorder caution with special testing (e.g.
8.hypothesize about the pathology neurological examination, vertebral
involved artery testing) follow a logical,
9. identify clues to possible treatment methodical, comprehensive, relevant
techniques (e.g. the injuring and integrated format
movement, functional 9. record in a logical methodical way
demonstration, or strategies which
the patient has developed)
10.establish factors which help to make a
forecast for a favorable or
unfavorable prognosis
11. record findings in a logical methodical
way.
INDICATIONS
1) Pain, muscle guarding and spasm
2) Reversible joint hypomobility
3) Positional faults or subluxations
4) Progressive limitations
5) Functional immobility

CONTRAINDICATIONS AND PRECAUTIONS

1)Hypermobility
2)Joint effusion
3)Inflammation
 PRINCIPLE S AND METHOD OF
MOBILIZATION/ MANIPULATION
TECHNIQUES
• For appropriate mobilisations
type of glide
 the direction
 correct speed
• .
• Directions of mobilization –
Analysis of movement directions and techniques which aim to
return movement impaired directions to their ideal state
are fundamental requirements of the Maitland conept.
In examination, range, symptom response and quality of
movement are inextricably linked together
Other additional components which may be added to the
movement direction being treated are distraction and
compression.
When patient has a lot of pain, or if the disorder is very
irritable, the joint surfaces may need to be kept apart. This
distaction is very small movement ( less than 1mm) and
does not resemble tractio forces.
Compression is other matter. The circumstances under which
this is used apply to chronic disorders
 METHODS OF MOBILISATION /
MANIPULATION
• Starting position of the patient: completely
relaxed without placing strain on the supporting
structures of the joint.
• Starting position of the physiotherapist.
• Localisation of the forces: proper grip, embrace
the part to be moved.
• Application of the forces: arms and body of the
therapist should be the prime movers. Right
direction of the applied pressure, e.g; series of
ball set in rubber.
• Application of pressure should not be painful.
• Sections of the thumb that can be used to
transmit the pressure to the vertebra: tip of
the thumb, palmar joint of the tip of the
thumb, palmar surface of the central area of
the distal phalanx ,the anterior surface of the
base of the thumb.
 CONCAVE CONVEX RULE
• Each joint has a different movement arc in a different
direction to other joints and therefore care needs to be
taken when choosing which direction to manipulate; this is
where the concave-convex rule comes into use.
• Choosing the direction of the mobilisation is integral to
ensuring the desired clinical outcome for which a
knowledge of Arthrokinematics is important. In summary:
• When a convex surface (Humeral Head) moves on a stable
concave surface (Glenoid Fossa) the gliding of the convex
articulating surface occurs in the opposite direction to the
motion of the bony lever (the Femur)[7].
• The opposite can be said for
• When a concave surface (Tibia; talocrural joint) is moving
on a stable convex surface (Talus) gliding occurs in the same
direction of the bony level[7].
 GRADES OF MOVEMENT
a)grade I – small amplitude movement performed at the
beginning of the available range.
b)grade II – large amplitude movement performed
within a resistance free part of the available range.
c) grade III - a large amplitude movement performed into
the resistance or up to the limit of the available of
range.
d) grade IV – small amplitude movement performed into
resistance r up to the limit of the available range.
e) grade V- small amplitude high velocity thrust at the
end of the available range.
• Different movement directions have a
different end feel, to which the grades of
movement will be adapted.
a) grades in hypomobile joint.

I III

A L B
II IV
• b) grades in relation to hypermobile
asymptomatic range.

I III

B H
A
II IV
• c) grades in hypermobile range with slight
limitation and hard end feel.

I III

A B H
II IV L
 MOVEMENT DIAGRAM
• Movement diagram - a two
dimensional pictorial or
mental image, a dynamic
map showing the
physiotherapist's
perceptions of the extent
and relationship between
joint signs (usually pain,
spasm free resistance, and
protective muscle spasm)
during the assessment of a
particular passive movement
direction of a joint.
Movement diagrams serve
as a self-learning process, a
teaching medium and a
means of communication.
Rhythm of mobilisation or manipulation:
a) Broken rhythm- For patients with difficulty in relaxing
completely. They tense their muscles periodically. Changing
amplitudes must be used to trick the muscles.
b) Stationary holding – To increase the ROM of a stiff joint
which is painful at the limit, the movement should be
applied slowly within the available range up to the point
when pain becomes a limiting factor. This new position
should be held until the pain subsides, after which a further
slow stretch is added until the pain increases again.
c) Slow smooth oscillatory movement – change in direction
of movement should be imperceptible. Used for disorders
which cause a lot of pain(grade I and II).
d) Staccato rhythm – when performing quicker, sharper ,
staccato movements the speed into the range should be
quicker than the return movement and varied. Best suited
to stiff joints and grades III and IV.
• Duration of technique:
a) Techniques to reduce pain will be performed
for shorter duration (up to 2 min, once or
twice).
b) Techniques for joint stiffness may need to be
performed for several minutes.
c) There are no set rules for how long or how
many times a technique should be performed.
It depends on the effects the technique has on
the patients symptoms and movement signs
during and after its performance.
Frequency – 100 -120 movements per minute
 Clinical application:

• Grades of movement in various conditions:

a) Through range pain – grade II- to III+
b) Intraarticular pathology - grade II- to III or III-
c) end of range pain – IV to IV+ or IV++
d) Treatment soreness – II or III- to III or III+
painless.
THANK
YOU