This document provides rules and guidelines for spinal manual therapy. It discusses assessing joint mobility and the different types of forces and glides that can be applied by a therapist. It emphasizes restoring mobility first before performing other techniques and outlines various rules for safe and effective mobilization, including loading the patient in painful positions, maintaining a pain-free approach, and pushing to the end range of motion. Assessment involves screening for red flags, classifying pain, and evaluating range of motion, posture, and neurological function.

2. What we
are going to
cover today
• Rules of Spinal Manual Therapy
• Different glides & force applied
• Assessment gross
• Assessment in segments

3. • All joint have certain amount of joint
play
• Normally joint surfaces glide & roll
upon each other during active &
passive movement
IF GLIDEING IS NOT THERE IT
WOULD LEAD TO
COMPRESSION & INJURY

4. Ensure Mobility First
• Decreased gliding component contributes to joint hypo mobility
• Check for the joint gliding then perform manipulation, PNF,
weight training, stretching etc
RESTORE THE MOBILITY FIRST

5. Rules of Mobilization

6. Rule 1
Loading strategy
• Treating the patient in loading
and painful position is the most
effective way to treat, perform
offending movement in a pain –
free way

7. Rule 2
PHALS
• Movement must be pain free. If not
change the
pressure/hold/angle/level/side (spine)
Clue – change PHALS

8. Rule 3
Force application
• Check resultant vector/ angle
of push/ pull/ parallel position
of the treatment belt to the
floor/ angle and position your
forearm

9. Rule 4
Sustain Glide
• Maintain sustain glide unless
and until you are returning to
the starting position

10. Rule 5
Go Active Way
• Encourage the patient for the
active exercises instead of
passive movements

11. Rule 6
Push to the End Range
• Making free end range is
the motto of the
mobilization and
manipulation. Once the
end range pushes to the
physiological end range
then pain will decrease

12. Rule 7
Overpressure
• End range passive overpressure will
ensure about the increase in range of
motion and decrease in Pain
sensation
• This passive over pressure can be
given by the therapist as well as by
the therapist

13. Rule 8
Parallel, Perpendicular
• Be parallel to the treatment plane
• Be perpendicular to the movement plane

14. Rule 9
Synchronize
• Synchronize properly with patient
movement and you should not block
the patient’s movement by your
position and hand grip

15. 10
Pressure
• Amount of pressure exert on articular
pillar or spinous process should be
minimal. Magnitude of the pressure
giving varies between every
individuals. You will have to judge the
amount of pressure on individual body
structure. Area of contact and the area
of pressure differ

16. Rule 11
Stabilization
• To obtain good amount of
mobilization up to the end range you
will have to stabilized the patient first

17. Rule 12
Planes of movement
• Give proper amount of translation
movement and avoid rotatory movement.
• Rotatory movement produce effect in
transverse plane. We need to ensure
sagittal plane movement and transverse
plane movement differently, not at the
same time

18. Rule 13
‘The Pain’ or ‘New Pain’
• Patient came to you with a Pain.
Now you are doing the several test
to get the diagnosis or for the
relieving test, in the entire test
process you will have to ask is there
is any ‘new pain’ or ‘the pain’ persist
as same intensity
• There may be a chance of new pain
after performing repeated exercises
in case of mechanical pain

19. Rule 13
ROM
• Check range of motion in
every review, change in ROM
is the key indication for the
directional preference and
pain reduction

20. Rule 14
make Independent
• Emphasis on self treatment
by self exercises. It can be
patient generated force or
patient overpressure
SELF TREATMENT
Self Exercises
Patient
Overpressure

21. Rule 15
Re - Assess
• Re - assess all the time and
screen for directional
preference and exercise
protocol
• Change only one exercise at a
time

22. Different Glides & Force applied by
Therapist

23. Postero-anterior pressure on
the spinous process fig 1
PA pressure on articular pillar fig 2

24. • Transverse pressure on
lateral surface of the spinous
process
fig 3

25. inclined towards patient head
fig 4
inclined towards patient feet
fig 5
PA pressure on spinous process

26. PA pressure on the
articular pillar
inclined laterally away from the
spinous process fig 6
inclined medially
towards spinous process fig 7

27. PA central
cephalad(towards head)
fig 8
fig 9

28. PA unilat pressure
inclined laterally
fig 10
inclined
medially
fig 11

29. Transverse pressure
inclined to postero anterior
fig 12 A & B

30. House of thoughts or confusion?
• Which one to select?
• Should we assess first?
• Should we apply only one house of
thoughts?
• Or we should combine and deliver?
• Hippocrates (460 BC – 370 BC)
• Cato, Galen
• Bone setter
• Hutton’s manipulation
• D.D.Palmer, B.J.Palmer
• A.G.Timbrell Fisher
• James Cyriax
• John Mennel
• F.M.Kaltenborn
• G. Maitland
• R. McKenzie
• B.R.Mulligan

31. Then what to choose?
Go by
choose your treatment according to that
before that know the biomechanics

32. Assessing and Decision making
• PAIN is your fiend
• Nature of pain will describe about pathology
• Types of Pain
by origin – by receptors-
local(intact outer annulus fibrosus)
referred (herniated disc) thermal
radicular (herniated disc) chemical (organ ref. pain)
central (intact outer annulus fibrosus) mechanical(structural changes/positional fault
etc)

33. Chemical vs Mechanical Pain
• Constant
• Recent onset (may be traumatic)
• Swelling, redness, heat,
tenderness(cardinal signs) may
present
• Aggravation by all movements
• No movement abolish or centralize
pain
• Dull aching pain, will present
24hrs(may be worst in morning)
• NSAIDs and rest will ease the pain
• Intermittent or constant
• If constant repeated movt will
decrease, abolish, centralize the
pain in directional preference
• There must be DP
• Loading increases the pain
• Sharp, end range & midrange pain
• It can be subacute or chronic
• Increase by some movt &
decrease by some movt (DP)

34. Causes of mechanical pain
• Abnormal stress applied to normal tissue
• Normal stress applied to abnormal tissue
• Abnormal stress applied to abnormal tissue

35. once it’s diagnosed with chemical pain
or else treat

36. • YELLOW FLAGS
• Osteopenia
• Hypermobility
• Pregnancy
• Patient on anti-coagulant
• Acute arthritis of any type
• RED FLAGS
• Osteoporosis
• Active inflammation
• Infection
• Tumor
• Tuberculosis
• Metabolic bone diseases
• Myelopathies
• Neurological deficit
• Unstable joint fracture, non united fracture
• Unwilling pt/intolerant pt
• Undiagnosed pain

37. Mobilization
Therapist
overpressure
Patient
overpressure
Force by pt
Manipulation
Totally
Independen
t
70%
Totally
dependen
t
Can apply Mulligan,
Maitland
McKenzie is the best option
here

38. • Apply mulligan to get
immediate effect.
• How will you know that
mulligan is indicated?
Pain should
decrease &
increase ROM
Change your
FLAPS
Force
Level
Angle
Pressure
Side

39. GLIDES
Sustained in
Mulligan
Oscillatory in
Maitland

40. Try to Treat in
weight bearing
position as patient
complaints of pain
in loaded only
When to treat not
loaded?
Joint is inflamed
or the SIN
(severity,
irritability &
nature of pain)
is high

41. Active movement followed by passive
overpressure
• To be done if it is not painful.
• To be given when you find out new P1 & R1
• Should be given by patient himself(best option) otherwise by
therapist
• If new P1 & R1 is not achieved, then follow FLAPS
NO PAIN NO GAIN THEORY DOESN’T WORK HERE, IT
SHOULD BE ALWAYS PAIN FREE WAY

42. Assessment

43. Goal
- Screen for red flags or other spinal pathology
- To find out Mechanical or Chemical pain
- If mechanical then classify it
- Sort out management plan
- Site and location of pain
- Fix the baseline
- Factors relieving and easing pain
- Analytical assessment
- Reassessment in every session
- Progressive assessment
-Retrospective assessment
- KISS principal

44. How to find out Red flags
• Unexplained weight loss
• H/O cancer
• Chemical pain and rest pain positive
• Generally unwell
• Persisting restriction of movement
• H/O trauma and dislocation
• Neurological deficit

45. What are the red flags?
 Osteoporosis
 Active inflammation
 Infection
 Tumor
 Tuberculosis
 Metabolic bone diseases
 Myelopathies
 Neurological deficit
 Unstable joint fracture, non united fracture
 Unwilling pt/intolerant pt
 Undiagnosed pain

46. History
• Present history
questionnaire about onset, duration, relieving and
aggravating factor, plot on body chart
• Past history
questionnaire about previous health issue or any
serious pathology
• Previous surgery or any systemic disease
• Pain location in body chart

47. Lateral shift
• Upper body is visibly shifted to one side
• Onset of shift occurred with back pain
• Unable to correct the shift by own
• Correction of shift will change in intensity of pain
• Correction will result centralization or worsening of peripheral
symptoms

48. Neurological test will tell you…
• Bladder/Bowel problem
• Paresthesia in leg
• Weakness in leg
• Radicular pain
• Chemical pain

49. What to test neurologically?
• Check for sensation
• MMT
• Reflexes
knee jerk (L3-L4)
ankle jerk (S1-S2)
• Neural tension test
• Other - walking on toes (S1)
walking on heels (L5)
Check for DURAL sign
Deep tendon reflexes should be graded on a scale of 0-4
as follows:
0 = absent despite reinforcement
1 = present only with reinforcement
2 = normal
3 = increased but normal
4 = markedly hyperactive, with clonus

50. Movement assessment
• ROM
• Pain or stiffness that stops the movement
• Quality of movement and movement pathway
• Curve reversal
• Nerve root involvement
• Other like scoliosis and LLD

51. Pain assessment
• Pain type
• VAS score
• Pain location
• Pain duration
• Pain onset
• End range pain
• Pain during motion

52. Nature of Pain
• Cramping, dull, aching
• Sharp, shooting
• Sharp, bright, lightning like
• Burning, pressure like,
stinging, aching
• Deep, nagging, dull
• Sharp, severe, intolerable
• Throbbing, diffuse
• Muscle
• Nerve root
• Nerve
• Sympathetic nerve
• Bone
• Fracture
• Vasculature

53. Posture assessment
• Observe posture in sitting & standing *(next slide)
• Sitting slouched
• Long sitting
• Sitting erect
• Standing slouched
• Standing erect
• Lying prone in extension
judge the pain location in every POSTURE
Observe for the pain in relation with correcting of Posture

54. * sitting posture –
if good then postural
component may not effect, but
keep your eyes open
if fair then need to rule out
postural component
if poor then educate for
postural correction
* standing posture –
if good in loading then should not
be postural component
if fair then need to
check for the postural correction
if poor then need to
check with the lordotic, kyphotic,
lateral shift and flat back

55. Loading
• Check for change in baseline (Pain intensity)
• Check for location changing of pain
• Check for intensity change of pain
• Centralization & peripheralization phenomenon in repeated
movement testing
• Loading decrease or increase the pain

56. After Unloading
• Baseline measurement
• Centralized or peripheralized
• Better
• Increase or produce during, returned to baseline after loading
• Decrease at the time of loading but came to baseline once
unload

57. Fixing the Baseline
• Functional activities
• ROM
• MMT
• Neurological test
baseline 1 baseline 2 baseline 3
Symptoms
increase in
loading
No change in
baseline
Improve in
baseline
Decrease
in baseline

58. Re - Assessment
• Ask about baseline
• Ask about 24hours pattern
• Check for the exercise given, procedure and repetition
• check for location and intensity of pain
• Confirm the diagnosis
• Change only one exercise at a time if required

59. Re Assessment questionnaire
• Do you able to manage the exercises?
• How often you do the exercises?
• Have you done your exercise before coming here?
• What do you feel at your back and extremity when you are doing the
exercises?
• Have you done any walking?
• Pain pattern in last 24hrs
• Do all movement and check for limitation is there or not
• Perform the exercises given

60. Cervical Spine

61. On Observation
• Functional Assessment
movement & posture
• Lateral structure
cervical curvature
forward head posture
• Anterior structure
level of the shoulders
position of the head
• Posterior structure
soft tissue (muscles)
comparison B/L

62. On Palpation
• Anterior
 hyoid
thyroid cartilage
Cricoid cartilage
SCM
Scalenes
Carotid artery
Lymph nodes
• Posterior & lateral
 occiput & superior nuchal line
 transverse process
 trapezius
 levator scapulae

63. 1 Body of mandible
2 Hyoid bone
3 Bifurcation of common carotid artery
4 Thyroid cartilage
5 Cricoid cartilage
6 Base between third and fourth tracheal rings
7 Manubrium sterni
8 Clavicle
9 Subclavian artery
1 External occipital protuberance
2 Superior nuchal line
3 Mastoid process
4 Spine of 7th cervical vertebra (vertebra prominens)

64. Functional Assessment
• Goniometry
Flexion
Extension
Lateral bending
Rotation
• Active ROM
Flexion
Extension
Lateral bending
Rotation
• MMT
Flexion
Extension
Lateral bending
Rotation
• Passive ROM
Flexion
Extension
Lateral bending
Rotation

65. Joint Stability
• Joint play assessment
Spring test
First rib mobility test

66. Neurological
screening
• Upper quarter screen
• ULTT
• Upper motor neuron lesions
Babinski test
Oppenheim test

67. Special test
• Vertebral artery test.
• Hautant's test.
• Transverse ligament stress test.
• Anterior shear test.
• Foraminal compression (Spurling's) test.
• Cervical compression test.
• Distraction test.
• Shoulder abduction test.
• Lhermitte's sign.
• Romberg's test.

68. Vertebral artery test
• Assesses the integrity of the vertebrobasilar vascular system.
• Patient supine with head supported on table and follow the progression.
• (a) Extend head and neck for 30 seconds. If no change in symptoms progress to next step.
• (b) Extend head and neck with rotation left then right for 30 seconds. If no change in symptoms progress to next step.
• (c) With head being cradled off table extend head and neck for 30 seconds. If no change in symptoms progress to next
step.
• (d) With head being cradled off table extend head and neck with rotation left for 30 seconds. Repeat same procedure
with rotation to the right.
• Patient should be continuously monitored for any change in symptoms during entire test. Caution should be used with
this test, since there is an inherent danger in test itself, therefore progressive flow should be followed.
• Performing mobilization/manipulation within cervical region without prior perfonning
• this test would be considered by most to be a breach in standard of care.
• Positive finding is dizziness, visual disturbances, disorientation, blurred speech, nausea/ vomiting, etc.

69. Hautant's test
• Differentiates vascular versus vestibular causes of dizziness/vertigo.
• Two steps to this test.
• (a) Patient sitting with shoulders at 90° and palms up. Have patient close their
eyes and remain in this position for 30 seconds. If arms lose their position, there
may be a vestibular condition.
• (b) Patient sitting with shoulders at 90° and palms up. Have patient close their
eyes and cue patient into head and neck extension with rotation right then left,
remaining in each position for 30 seconds. If arms lose there position the
condition may be vascular in nature.
• Position/movement of arms determines positive finding.

70. Transverse ligament stress
test
• Tests integrity of transverse ligament.
• Patient supine with head supported
on table. Glide CI anterior. Should be
firm end feel.
• Positive finding is soft end feel,
dizziness, nystagmus, a lump
sensation in throat, nausea, etc.

71. Anterior shear test
• Assesses integrity of upper cervical spine ligaments and
capsules.
• Patient supine with head supported on table. Glide C2-7
anterior. Should be firm end feel
• Laxity of ligaments is positive finding as well as dizziness,
nystagmus, a lump sensation in the throat, nausea, etc.

72. Foraminal
compression
(Spurling's) test
• Identifies dysfunction (typically
compression) of cervical nerve root.
• Patient sitting with head side bent
towards uninvolved side. Apply
pressure through head straight
down. Repeat with head side bent
towards involved side.
• Positive finding is pain and/or
paresthesia in dermatomal pattern
for involved nerve root.

73. cervical
compression
test
• Identifies compression of neural
structures at intervertebral foramen
and/or facet dysfunction.
• Patient sitting. Passively move head
into side bending and rotation towards
non painful side followed by extension.
Repeat this towards painful side. Be
careful since this is very similar to
vertebral artery test.
• Positive finding is pain and/or
paresthesia in dermatomal pattern for
involved nerve root or localized pain in
neck if facet dysfunction.

74. Distraction test.
• Indicates compression of neural
structures at the intervertebral
foramen or facet joint dysfunction.
• Patient sitting/supine and head is
passively distracted
• Positive finding is a decrease in
symptoms in neck (facet condition)
or a decrease in upper limb pain
(neurologic condition).

75. Shoulder
abduction test
• Indicates compression of neural
structures within intervertebral
foramen.
• Patient sitting and asked to place
one hand on top of their head.
Repeat with opposite hand.
Positive finding is a decrease in
symptoms into upper limb.

76. Lhermitte's sign
• Identifies dysfunction of spinal cord
and/or an upper motor neuron
lesion.
• Patient in long sitting on table.
Passively flex patient's head and
one hip while keeping knee in
extension. Repeat with other hip.
• Positive finding is pain down the
spine and into the upper or lower
limbs.

77. Romberg's test
• Identifies upper motor neuron lesion.
• Patient standing and closes eyes for
30 seconds. Excessive swaying
during test indicates positive finding.

78. Thoracic & Lumber
Spine

79. On Observation
• Functional assessment
Gait
Movement & posture
• General inspection
Frontal curvature
Sagittal curvature
Skin markings
• Thoracic spine
Breathing patterns
Skin folds
Chest shape
• Lumber Spine
Lordotic curve
Standing posture
Erector muscle tone
Faun’s beard (indication of spina
bifida occulta)

80. 1 Clavicle
2 Coracoid process of scapula
3 Manubrium sterni
4 Manubriosternal joint (angle of Louis)
5 Second costal cartilage
6 Body of sternum
7 Xiphisternum
8 Fifth, 6th and 7th costal cartilage (true ribs)
9 Eighth, 9th and 10th (false) ribs
1 Spine of first thoracic vertebra
2 Spine of twelfth thoracic vertebra
3 Spine of fourth lumbar vertebra
4 Lateral margin of erector spinae muscles 5 Supracristal
plane
6 Gluteus maximus

81. On Palpation
• Thoracic spine
Spinous process
Supraspinous lig
Costovertebral junction
Trapezius
Paravertebral muscle
Scapular muscle
• Lumber spine
Spinous process
Paravertebral muscle
• Sacrum & Pelvis
Median sacral crest
Iliac crest
PSIS
Gluteals
Ischial tuberosity
Greater trochanter
Pubic symphysis

82. Functional assessment
• Goniometry
flexion
Extension
Lateral bending
Rotation
• Active ROM
flexion
Extension
Lateral bending
Rotation
• MMT
Flexion
Extension
Rotation
Pelvic elevation
• Passive ROM
Flexion
Extension
Rotation
Side gliding

83. Joint
Stability
test
Joint Play
assessment
Spring test

84. Special test
Thoracic Spine
• Rib springing.
• Thoracic springing.
• Slump test.
Lumber Spine
• Slump test
• Lasegue's (straight leg raising)
test.
• Femoral nerve traction test.
• Valsava maneuver.
• Babinski test.
• Quadrant test.
• Stork standing test.
• McKenzie's side glide test.
• Bicycle (van Gelderen) test

85. Rib springing
• Evaluates rib mobility.
• Patient prone. Begin at upper ribs
applying a posterior/anterior force
through each rib progressively working
through entire rib cage. Following prone
test, position patient side lying and
repeat. Be careful with springing the 11
th and 12th ribs since they have no
anterior attachments and therefore less
stable.
• Positive finding is pain, excessive
motion of rib, or restriction of rib.

86. Thoracic springing
• Evaluates intervertebral joint mobility in thoracic spine. Patient
prone. Apply posterior/anterior glides/springs to transverse
processes of thoracic vertebra. Remember that the spinous
process and transverse process of the same vertebra may not
be at the same level in the thoracic region.
• Positive finding is pain, excessive movement, and/or restricted
movement.

87. Slump test
• Identifies dysfunction of neurologic structures supplying
the lower limb.
• Patient sitting on edge of table with knees flexed. Patient
slump sits while maintaining neutral position of head and
neck. The following progression is then followed.
• (a) Passively flex patient's bead and neck. If no
reproduction of symptoms move on to next step.
• (b) Passively extend one of patient's knees. If no
reproduction of symptoms move on to next step.
• (c) Passively dorsiflex ankle of limb with extended knee.
• (d) Repeat flow with opposite leg.
• Positive finding is reproduction of pathologic neurologic
symptoms.

88. Lasegue's
(straight leg
raising) test
• Identifies dysfunction of neurologic
structures that supply lower limb.
• Patient supine with legs resting on
table. Passively flex hip of one leg with
knee extended until patient complains
of shooting pain into lower limb. Slowly
lower limb until pain subsides then
passively dorsiflex foot.
• Positive finding is reproduction of
pathologic neurologic symptoms when
foot is dorsiflexed.

89. Femoral nerve
traction test
• Identifies compression of femoral
nerve anywhere along its course.
• Patient lies on non-painful side with
trunk in neutral, head flexed slightly,
and lower limb's hip and knee flexed.
Passively extend hip while knee of
painful limb is in extension. If no
reproduction of symptoms flex knee
of painful leg.
• Positive finding is neurologic pain in
anterior thigh.

90. Valsalva maneuver
• Identifies a space occupying lesion.
• Patient sitting. Instruct patient to
take a deep breath and hold while
they "bare down" as if having a
bowel movement.
• Positive finding is increased low back
pain or neurologic symptoms into
lower extremity.

91. Babinski test
• Identifies upper motor neuron lesion.
• Patient supine or sitting. Glide bottom end of a standard reflex
hammer along plantar surface of patient's foot.
• Positive finding is extension of big toe and splaying (abduction)
of other toes.

92. Quadrant test
• Identifies compression of neural structures at the intervertebral foramen
and facet dysfunction.
• Patient standing
• (a) Intervertebral foramen: cue patient into side bending left, rotation left,
and extension to maximally close intervertebral foramen on the left.
Repeat to other side.
• (b) Facet dysfunction: cue patient into side bending left, rotation right, and
extension to maximally compress facet joint on left. Repeat to other side.
• Positive finding is pain and/or paresthesia in the dermatomal pattern for
the involved nerve root or localized pain if facet dysfunction.

93. Stork standing test
• Identifies spondylolisthesis.
• Patient standing on one leg. Cue
patient into trunk extension. Repeat
with opposite leg on ground.
• Positive finding is pain in low back
with ipsilateral leg on ground.

94. McKenzie's side
glide test
• Differentiates between scoliotic curvature
versus neurologic dysfunction causing
abnormal curvature (lateral shift) of trunk.
• Test is performed if "lateral shift" of trunk is
noted. Patient standing. Stand on side of
patient that upper trunk is shifted towards.
Place your shoulders into patient's upper trunk
and wrap your arms around patient's pelvis.
Stabilize upper trunk and pull pelvis to bring
pelvis and trunk into proper alignment.
• Positive test is reproduction of neurologic
symptoms as alignment of trunk is corrected.

95. Bicycle (van
Gelderen) test
• Differentiates between intermittent
claudication and spinal stenosis.
• Patient seated on stationary bicycle.
Patient rides bike while sitting erect and
time how long they can ride at a set
pace/speed. After a sufficient rest period
have patient ride bike at same speed while
in a slumped position. Determination is
based on length of time patient can ride
bike in sitting upright versus sitting
slumped. If pain related to spinal stenosis,
should be able to ride bike longer while
slumped.

96. Thank You