Manual Therapy for the Upper and Lower Quadrant: What Do I Need to Know? Objectives

Manual Therapy for the Upper and

Lower Quadrant: What Do I Need to

Know?

Objectives

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1. Describe the current best evidence for

manual therapy in the management of a

variety of disorders.

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2. Recognize subgroups for which manual

therapy interventions are most

appropriate.

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3. Select and demonstrate manual physical

therapy interventions based on current

best evidence.

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4. Select appropriate exercises to augment

Interventions

Contraindications to Thrust

Manipulation

• Absolute

– Fracture/dislocation

– Instability

– Bone malignancies

– Bone infections

– CNS Disorders

– Bleeding Disorders

– Osteoporosis

• Relative

– Spondylolesthesis

– Hypermobility

– Post-surgical joints

– Benign bone tumors

– Nerve root compression

– Pregnancy

Flexion/Opening Manipulation (T3-T10)

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her chest (right above the left)

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Flexion/Opening Manipulation

(with modification for an external rib torsion)

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HVT T1/2 Distraction

•Cross the patient’s arms across his

chest opposite arm on top and roll

him toward you

•Use a pinch grip to contact spinous

process and distract T1 on T2

•Place the patient supine while

maintaining distraction

•Localize contact via cehpalad motion

of the thorax

•Apply a high velocity, low amplitude

thrust with your body in a

cephalad/posterior direction

•Tip: Patient may bridge to further

localize technique if needed

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Cross the patient’s arms

across his chest opposite arm

on top and roll him toward you

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Use a pinch grip to contact

spinous process and distract

T1 on T2

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Place the patient supine while

maintaining distraction

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Localize contact via cehpalad

motion of the thorax

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Apply a high velocity, low

amplitude thrust with your

body in a cephalad/posterior

direction

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Tip: Patient may bridge to

further localize technique if

needed

Prone CT Junction (C7-T3)

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Patient is prone with R arm flexed at the

shoulder and elbow so that the right hand

is above their head

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Place patient’s head in R rotation, L lateral

flexion and lower cervical extension so

that they are resting directly on their L eye

socket

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Apply your left thumb on the left side of

the SP or C7 – T3 as appropriate, and take

up slack

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Using right hand, make contact with the

patient’s right zygomatic arch and

introduce left lateral flexion, right rotation

and extension to the point of pre-thrust

tension

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With the left hand the thrust is towards the

patient’s right shoulder

Mid-Thoracic

Distraction Manipulation

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Extension/Closing Manipulation (T1-T2)

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head and your forearm along the side of the patient’s face

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sidebending, and right rotation to the restrictive barrier. Use your whole body to translate the patient from posterior to anterior and right to left

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Close Right T1-2

Extension/Closing Manipulation (T3-T10)

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right transverse process of the superior vertebra; rotate your hand caudally to obtain a “skin lock” and introduce an anteriorly directed force with your right hand

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1st Rib Manipulation

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amplitude thrust to the shaft of the 1st rib in a diagonal direction towards your left thigh

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Sacro-Iliac Region Manipulation:

Supine

• Translate the pelvis towards you and maximally side-bend the patient’s lower extremities and trunk to the right • Without losing the right sidebending lift &

rotate the trunk so the patient rests on their left shoulder

• Contact the patient’s right ASIS with your left hand

• Grasp the top shoulder and scapula with your right hand and rotate the trunk to the left while maintaining the right side-bending • Once the right ASIS starts to elevate,

perform a smooth thrust in an anterior to posterior direction

• Reassess symptoms and impairments

Sacro-Iliac Region Manipulation:

Supine with Alternate Operator Arm

Position

• Translate pelvis toward you and

maximally side-bend the patient’s lower

extremities and trunk to the right

• Thread your right forearm through the

patient’s arms. Rest your fingertips on

the patient’s sternum or the table. Stand

upright and rotate the trunk to the left

(maintain the right side-bending)

• Contact the patient’s right ASIS with

your left hand. When the ASIS rises

from the table, perform a smooth thrust

in an anterior to posterior direction

• Reassess symptoms and impairments

Lumbar Spine: General Neutral

“Gapping” Mobilization

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Lumbar Spine:

Segmental Neutral “Gapping”

Manipulation

• Flex the top leg until you first begin to palpate motion at L4-L5 interspace; place the patient’s foot in the popliteal fossa as shown

• Grasp the patient’s right arm and shoulder and induce right sidebending & left rotation until you begin to palpate motion at the L4-L5 interspace • Place your left thumb on the left side of the L4

SP & position the patient’s arms around your left arm

• While maintaining your setup log roll the patient towards you

• While monitoring the right side of the L5 SP, use your right arm to induce a high velocity, low amplitude (HVLA) thrust in anterior direction • Reassess symptoms and impairments

Lumbar Spine:

Flexion (Opening) Manipulation

• Flex the top leg until you first begin to palpate motion at L3-L4 motion segment; place the foot in the popliteal fossa as shown

• Flex the upper body down until you begin to palpate motion at the L3-L4 motion segment • Rotate the upper trunk to the right until you begin

to palpate motion at the L3-L4 motion segment • Place your right thumb on the right side of the L3

SP & position the patient’s arms around your right arm

• Log roll the patient towards you

• While monitoring to the left of the L4 SP, use your left arm & body to induce a high velocity, low amplitude thrust in an anterior and cephalward direction

• Reassess symptoms and impairments

Lumbar Spine:

Extension (Closing) Manipulation

• Grasp the trunk and translate towards you until you localize the extension to the L4-L5 motion segment

• Rotate the patient’s body to the right until you begin to palpate motion at the L4-L5 motion segment

• Place your right thumb or finger on the right side of the L4 SP & position the patient’s arms around your right arm as demonstrated • Log roll the patient towards you

• With your left arm induce a high velocity, low amplitude thrust in anterior and cephalward direction

• Reassess symptoms and impairments • TIP: Place the patient’s right foot in the

Thoraco-Lumbar Junction: Rotational

Manipulation

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With the patient seated and

straddling the plinth, rest the

patient’s arms on a pillow

over your left shoulder

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Reach underneath the

patient’s opposite axilla and

grasp the lateral scapula

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Use your right pisiform to

contact the right transverse

process of T12

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Induce left spinal rotation with

your left arm and body

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Engage the restrictive barrier

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Apply a low velocity, high

amplitude thrust into left

rotation

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Reassess symptoms and

impairments

Lower Extremity Distraction Manipulation

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Abduct the hip of the involved side to

maximum relaxation (typically about 15

degrees)

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Block the opposite foot with your thigh

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Apply a high velocity, low amplitude thrust

in a caudad direction through the involved

lower extremity

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Reassess symptoms and impairments

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Notes:

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This technique may be

contraindicated with certain hip and

knee pathologies

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Your cephalad hand supports the

knee to prevent hyperextension

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In very mobile individuals, you may

need to internally rotate the hip to

Cervical Spine

OA Joint

Mobilization

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With your left hand, support

the occiput below the superior

nuchal line

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Introduce OA flexion around

an imaginary transverse axis

running through the patient’s

external auditory meati

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Introduce the coupled motions

of right sidebending and left

rotation

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When the OA joint is

positioned at the restrictive

barrier, apply a posterior glide

through the occiput with the

right hand

OA Joint

Flexion Manipulation

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Flex the Right OA joint

AA Joint

Contract-Relax Technique in Rotation

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Grasp the head and fully flex the

neck to reduce available rotation

from C2–C7

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Use your index fingers to palpate

the posterior arch of C1 and

rotate the neck to the right,

engaging the restrictive barrier

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Instruct the patient to gently look

or turn the head to the left and

perform a 3-5 second isometric

contraction

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Allow the patient to fully relax

and engage the new right

rotation restrictive barrier

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Do not allow the neck to extend

during the rotation

Cervical

Gapping Manipulation in Flexion

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Use your left hand to control the

head/neck and place your right

2

_{MCP over the right facet joint}

of the motion segment

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Flex the patient’s neck and

translate from right to left to

localize movement to the

dysfunctional segment

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When the motion segment is at

the restrictive barrier, apply a low

amplitude, high velocity

translatory thrust to open the left

facet

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Tips: Ensure your right 2

_MCP

contact remains posterior to the

facet joint, not over the

transverse process. Keep your

right forearm in line with the

direction of thrust

Lower Extremity Distraction Manipulation

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Abduct the hip of the involved side to

maximum relaxation (typically about 15

degrees)

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Block the opposite foot with your thigh

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Apply a high velocity, low amplitude thrust

in a caudad direction through the involved

lower extremity

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Reassess symptoms and impairments

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Notes:

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This technique may be

contraindicated with certain hip and

knee pathologies

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Your cephalad hand supports the

knee to prevent hyperextension

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In very mobile individuals, you may

need to internally rotate the hip to

increase the motion that is

generated through the pelvis

Hip Mobilization:

Caudal Glide Progression

• Use a mobilization belt placed firmly

in the patients hip “crease”

• Flex the patient’s hip to the

restrictive barrier

• Use your body to apply a caudally

directed force to the proximal thigh

• Use an oscillatory passive

accessory mobilization force

• Adjust the amount of hip flexion,

rotation, & add/abduction to find the

position of optimal mobilization

• Reassess symptoms and

Hip Mobilization:

Anterior to Posterior Progression

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oscillatory, passive mobilizing force to the postero-lateral hip capsule through the long axis of the femur

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Hip Mobilization: Posterior to Anterior

Mobilization in Flexion, Abduction, & External

Rotation

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Hip Mobilization:

Posterior to Anterior Progression

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Grasp and support the patient’s lower

extremity with your left arm and trunk

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Place either the 1

_{web space, thenar}

eminence, or hypothenar eminence of

your right hand just inferior and medial to

the greater trochanter

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Bring the patient’s hip into varying

degrees of flexion/extension,

abduction/adduction, and

internal/external rotation to find the

vector of force that most effectively

stretches the hip

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Use your body to impart an oscillatory,

passive mobilizing force through the

proximal femur in a posterior to anterior

direction. The stretch should be felt by

the patient in the anterior hip region

Tip: To progress the technique increase the

amount of extension, adduction, and

internal rotation.

Hip Mobilization:

Internal Rotation in Extension

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Knee

Flexion

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Flex the knee

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Note end-feel,

range, pain and

resistance

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Apply mobilizing

force

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Retest

Flexion External Rotation

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Flex and externally

rotate the knee.

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Note end-feel, range,

pain and resistance

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Apply graded

mobilization

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Retest impairments

Flexion Internal Rotation

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Flex and internally

rotate the knee

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Note end-feel,

range, pain and

resistance

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Apply graded

mobilization

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Retest

impairments

Extension

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Stabilize the limb at the

ankle

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Place the heel of your

mobilizing hand over

the tib tuberosity as

shown

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Note end-feel, range,

pain and resistance

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Apply graded

extension mobilization

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Retest impairments

Extension Abduction

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Stabilize the limb at the ankle so

there is a lower leg abbduction

moment

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Place the heel of your mobilizing

lateral to the tib tuberosity as shown

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Apply an extension mobilization with

your mobilizing hand into

tibiofemoral adduction

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Note end-feel, range, pain and

resistance

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Retest impairments

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Note: This technique is named for

the distal seg ABBduction moment

Extension Adduction

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Stabilize the limb at the ankle so

there is a lower leg adduction

moment

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Place the heel of your mobilizing

medial to the tib tuberosity as shown

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Apply an extension mobilization with

your mobilizing hand into

tibiofemoral abbduction

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Note end-feel, range, pain and

resistance

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Retest impairments

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Note: This technique is named for

the distal seg Adduction moment

Proximal Tib/fib A-P

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Place your thenar

eminence on the

anterior fibular head

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Apply a force in an

anterior-posterior

direction

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Note end-feel, range,

pain and resistance

Proximal Tibio-Fibular

Joint Manipulation

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Place your 2nd MCP in the

popliteal fossa, then pull the

soft tissue laterally until your

metacarpo-phalangeal joint

(MCP) is firmly stabilized

behind the fibular head.

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Use your right hand to grasp

the foot and ankle as

demonstrated and externally

rotate the leg and flex the knee

to the restrictive barrier your.

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Once at the restrictive barrier,

apply a high velocity, low

amplitude thrust through the

tibia (direct the patient’s heel

towards his ipsilateral buttock).

“Subtalar Joint” Manipulation

(Rearfoot Distraction)

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Grasp the dorsum of the

patient’s foot with interlaced

fingers

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Provide firm pressure with both

thumbs in the middle of the

planar surface of the forefoot

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Engage the restrictive barrier by

dorsiflexing the ankle &

applying long axis distraction

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Pronate & dorsiflex the foot to

fine-tune the barrier

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Apply a high velocity, low

amplitude thrust in a caudal

direction

Dorsiflexion

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Cup the heel with one

hand

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Place other hand across

forefoot and heel

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Apply DF force by DF the

ankle and/or keeping the

foot parallel to the floor

and gliding the heel

cephalward

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Note end-range, pain and

resistance

Physiological Motion:

Ankle Dorsiflexion

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Patient position

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Prone, knee flexed 90 degrees

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Therapist position

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One hand cups proximal

calcaneus

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Other hand grasps midfoot

with forearm placed along

plantar foot

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Mobilization technique

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Graded mobilizations into

dorsiflexion with rocking

motion

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Quick “flicks” at end range for

added emphasis

Physiological Motion:

Ankle Plantarflexion

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Patient position

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Prone, knee flexed 90 degrees

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Therapist position

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One hands grasps plantar surface

calcaneus

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Other hand grasps dorsal midfoot

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Mobilization technique

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Graded mobilizations into

plantarflexion with rocking motion

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Quick “flicks” at end range for

added emphasis

Ankle Inversion (TC and STJ)

Patient position

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Prone, knee flexed 90

degrees

Therapist position

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One hand cups plantar

surface of calcaneus

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Other hand grasps plantar

midfoot

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Tips of fingers along

proximal talus (move to

proximal calcaneus for

STJ)

Mobilization technique

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Graded mobilizations into

inversion with rocking

motion

Ankle Eversion: (TC & STJ)

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Patient position

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Prone, knee flexed 90

degrees

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Therapist position

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One hand cups plantar

surface of calcaneus

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Other hand grasps

plantar midfoot

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Tips of fingers along

proximal talus (move to

proximal calcaneus for

STJ)

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Mobilization technique

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Graded mobilizations

into eversion with

Talocrual PA in prone

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Block the distal tibia

and fibula with your

caudal hand

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Cup the calcaneous

with the other hand

(or use your web

space at the talus)

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Apply a posterior to

anterior force

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Note pain and

resistance

Talo-Crural Joint

PA Mobilization in Prone

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Use your left hand to firmly

stabilize the lower leg at the

malleoli and grasp the

posterior, medial, and lateral

talus with your right hand

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Apply a posterior to anterior

oscillatory mobilization force to

the talus

Tip: Use your thigh to help

stabilize the calcaneus and to

progressively increase the

amount of ankle plantar flexion

used with this technique

Talocrual AP

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Block the posterior

distal tibia and fibula

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Contact the anterior

talus with web space

of opposite hand

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Apply an anterior to

posterior force

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Note pain and

resistance

*** Use your shoulder to

keep the ankle in

more of a neutral

position than is

shown here.

Cuboid Manipulation

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Place the tips of your

thumbs over the plantar &

medial aspect of the

cuboid

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Translate the foot in a

caudad and lateral

direction while

simultaneously ulnarly

deviating your left hand

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Ensure that you create the

fulcrum of motion and

approach the restrictive

barrier at the cuboid

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Once at the restrictive

barrier, apply a high

velocity, low amplitude

manipulative thrust in a

Talo-Crural Joint

AP Mobilization

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Tip:

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Distal Tibio-Fibular

Joint Mobilization

AP to the fibula:

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Use your left hand to stabilize

the distal tibia

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Grasp the distal fibula between

the pads of your fingers and

the thenar eminence / heel of

your right hand

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Apply an anterior to posterior

oscillatory mobilization force

to the distal fibula or tibia

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Optimize the technique by

adjusting and maintaining

various angles of ankle

dorsiflexion

PA to the fibula:

Talo-Crural Joint (TCJ) &

Subtalar Joint (STJ) Lateral Glides

TCJ Lateral Glide:

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Inferior Glide of Humerus

•With the patient’s shoulder

stabilized on the table, the

examiner guides the patient’s

arm into approximately 90º of

abduction with one hand.

•When this position is obtained,

the examiner applies an inferior

force at the proximal humerus

and assesses the amount of

mobility and symptomatic

response.

Posterior Glide of Humerus

•With the patient’s shoulder

stabilized on the table, the

examiner guides the patient’s

arm into approximately 90º of

abduction with one hand.

•When this position is obtained,

the examiner applies an posterior

force at the proximal humerus

and assesses the amount of

mobility and symptomatic

response.

Anterior/Posterior glide of

Acromioclavicular Joint

•The examiner grips the distal

clavicle with the index finger on

the superior/posterior surface

and the thumb on the anterior

surface with their thumb.

•The examiner then glides the

clavicle in an anterior and

posterior direction while assessing

mobility and symptoms response.

Anterior/Posterior glide of

Sternoclavicular Joint

•The examiner places the

hypothenar eminence on the

medial aspect of the clavicle.

•The examiner applies a

posteriorly directed force while

assessing mobility and symptoms

response.