Haley Bryson
Joint Manipulation Therapy
03/20/2013
Joint manipulation is a type of therapy directed toward the joint, in most cases synovial
joints, and is used for many purposes 1. This technique is not a new concept; it has been dated
back to Hippocrates 1. This type of therapy provides a passive movement with some force at the
joint and this manipulation is suggested to achieve therapeutic effects 1-9. Manipulation is
different than mobilization in that with mobilization it is under the control of the patient while
manipulation occurs at such a high speed that the patient cannot stop the motion 1. It is suggested
that joint manipulation can decrease pain 1, increase pressure pain thresholds, inhibit motor
neuron activity 2, and increase the force and activation within a muscle 3.
While the patient is receiving joint manipulation therapy, they may hear a cracking sound
which is known as a cavitation 1. This noise is normal for this technique and is usually caused by
an expansion of gas within the joint followed by the collapse of the gas which is what creates the
cracking sound 1. This is why it is believed that this technique may increase joint mobility, but at
the same time one must use caution because doing this repeatedly may cause an increase in
thickness at the joint capsule or it may cause the joint to become stiff1.
The indications for using joint manipulation include pain that seems to be coming from
within the joint 1. The second is a hypomobile joint in comparison to the contralateral side1. The
contraindications/precautions for joint manipulation include hypermobile joints, osteoporosis,
joint replacement that has not been able to be moved through a full ROM yet, tuberculosis, a
grade 3 ligamentous sprain, joint effusions, recent fractures, herniated disc, osteomyleitis,
osteoarthritis, pregnancy, severe scoliosis, and malignancy 1. It is suggested that if the clinician
is not definitive as to whether or not to use this therapy technique, then do not use it1.
In the article Sacroiliac Joint Manipulation Attenuates Alpha-Motoneuron Activity in
Healthy Women: A Quasi-Experimental Study by Orakifar et. al. it is said that joint manipulation
has been studied as a way to produce an inhibitory response that decreases activity in motor
neurons and affect how pain is processed2. Most of the studies that were examined, however,
have looked at the effectiveness in the superior spinal column. Therefore, the purpose of the
study is to see if joint manipulation will create an inhibition of a motor neuron activity and if the
joint manipulation will increase the pressure pain threshold within the SI joint2.
The study had 20 female participants, ages 18-30 years old2. There was one researcher
who recorded the pressure pain threshold in the participants; another measured activity within
the tibial nerve and a separate researcher performed the joint manipulation. Before the joint
manipulation was performed the researchers recorded a maximal M wave response, 10 maximal
H-reflexes, and 3 pressure pain threshold baselines. Following the joint manipulation therapy
the H-reflexes were again tested every 10 seconds for 90 seconds after the therapy and then at 5,
10, 15, 20 minutes following joint manipulation. The M-wave was also tested immediately
following the H-reflex testing. The pressure pain response was also measured at different times
post joint manipulation at 1, 5, 10, and 15 minutes2.
It was found that SI joint manipulation, the ratio of H reflex baseline and the M wave
baseline were significantly decreased for up to 20 seconds after the joint manipulation was
performed. The pressure pain threshold was shown to decrease, but this finding was not
statistically significant at any other the measured times2.
This information was in line with previous research found by the authors that suggests
that joint manipulation creates a decrease in function of the a motor neuron. However, it did not
fall in line with one of the studies that suggested that there is a 15 minute period with a motor
neuron inhibition2.
This study was an intervention based study, but looked at only women with no prior
history of low back injury or pain. There was no control group, but the study was a blind study
because one researcher measured H-reflex throughout, one measured M-waves throughout and
the other performed the joint manipulation technique. This population is in some ways similar to
the population that we will see, as they were considered healthy women ages 18-30, but the study
did not include males and was not done on individuals with SI joint pathology. This study was
published in 2012 in the Arch Phys Med Rehab journal. The procedures seemed to be one of the
only strong parts of this study because the researchers looked at what they were measuring at
multiple times after the treatment and compared them to the baseline measures. They would have
high intrarater reliability because one person performed one measure throughout the study. Data
collection techniques were proven to be reliable and valid. The results for the H-reflexes were
proven to be statistically significant, though they do not seem to be clinically significant. Since
the population was only healthy women, this does not include the population we would be
working with. While we do work with women, the population that will be receiving this type of
therapy will be individuals with some kind of pathology. Joint manipulation is a very cost
effective method as it does not require any equipment. However, the results of this study showed
that the only significant effects lasted up to 20 seconds. The short 20 second inhibition of motor
neurons does not seem to outweigh the time that will be spent doing the joint manipulation
therapy2.
In the article Lumbopelvic Joint Manipulation and Quadriceps Activation of People With
Patellofemoral Pain Syndrome by Grindstaff et al. it states that study is looking to see the effects
of joint mobilization and manipulation on PFPS3. Specifically, it is looking to see if there is
more activation and/or strength within the quad after the lumbopelvic region is treated with high
grade and low grade joint manipulation and mobilization 1 hour after the treatment3.
There were 48 volunteer participants with PFPS. Quadriceps force and activation were
measured 20, 40 and 60 minutes after intervention. Participants began with 2 maximal voluntary
contractions with electrical stimulation and then another to make sure that they were able to
generate the same maximal voluntary contraction on their own. They were then instructed to do
3 more maximal voluntary contractions with visual feedback; meaning that they could see their
own force output and then oral encouragement. The participants then jogged and ran for about
7-8 minutes. Participants were then randomly assigned to 1 of 3 groups; the high grade joint
manipulation and mobilization, side-lying PROM, and prone extension PROM. Once patients
received their assigned treatment they again ran for 2-3 minutes and activation and force output
was measured. Data was then collected at the time intervals above3.
There was no difference between which treatment patients received and the
amount of force or activation that was achieved. Although there were some differences in force
and activation over the time intervals when the data was collected, the force output of the quad
did not change immediately after the last bout of running. Instead, the force output declined at
the 20, 40, and 60 minutes post intervention. Activation of the quad was found to decrease
immediately after the intervention and was found to be the same as the baseline measures in all
of the time intervals following3.
The results showed that the activation and force output really did not change or decrease
over the course of this study. It is thought that this could possibly be due to fatigue. This study
was also looking at running mechanics, hence the reason why the participants ran twice during
the intervention, which is what could have contributed to the fatigue. It is also assumed that
every participant was giving their maximal output during the trial, when in fact they may not
have been. These findings do not suggest that force or activation of the quad were affected by
joint manipulation3.
In this study, one of the mentioned limitations was that they did not have a true control
group that didn’t receive any treatment so they were really just comparing within different
interventions. This population may include a portion of the population that we will be working
with. There was no given age range, but the study mentioned that the mean age was 24.6 years +
or - 8.9 years, similar to the population we work with, but not quite the same. Another limitation
was that the PFPS was self diagnosed, patients had to fit into a certain criteria, meaning they had
to be able to reproduce their symptoms by compressing the patella, going up and down stairs,
performing isometric quad contraction, performing a squat, and/or long periods of sitting. The
study was published in 2012 in The Journal of Athletic Training. Procedures were performed the
same way for everyone and the interventions were described in a way that one could easily
reproduce the intervention. Quad activation was measured by EMG and force output was
measured through a force plate, both are considered to be reliable and valid. I do not find these
results to be clinically significant because it was found that all three interventions essentially had
the same outcomes; none of which were in favor of the patient. I would not want to spend time
doing any of these treatments when none seemed to be able to improve the quad activation or the
force output of the quad3.
The article Immediate effects of a tibiofibular joint manipulation on lower extremity Hreflex measurements in individuals with chronic ankle instability by Grindstaff et. al. states that
individuals with chronic ankle instability tend to have a decrease in activation in the peroneus
longus and the soleus4. This is thought to be caused by guarding, a reflexive response to protect
the area. In this study the researchers are looking to see if a proximal and/or distal joint
manipulation will have an effect on the activation of the peroneus longus and the soleus4.
There were 43 subjects used for the study with an average age of 25.6 ± 7.7 years, all of
whom had chronic ankle instability and had a 5º decrease in ankle dorsiflexion ROM in
comparison to the contralateral limb. The H-reflex and M-wave were measured using surface
EMG. The H-reflex and M-wave baseline measures in the peroneus longus and the soleus
muscles were collected first. These measures were recorded three times to get a max H-reflex
and to get the max M-wave, then the two max numbers were combined and used as an H-reflex
to M-wave ratio. After this information was acquired, the participants were assigned to one of
three treatment groups; proximal tibiofibular joint manipulation, distal tibiofibular joint
manipulation, and no treatment. There were two different physical therapists that performed the
joint manipulation and one researcher who recorded all the information. The H-reflex and the
M-wave were recorded immediately after the intervention then 10, 20, and 30 minutes after the
intervention4.
When looking at the peroneus longus muscle the H/M ratio over time was not statistically
significant over time, but when the groups were combined at 20 and 30 minutes post
intervention, there was a significant decrease in the H/M ratio. When looking at the soleus
muscle the H/M ratio over time was statistically significant between groups. There was a
statistically significant increase in the H/M ratio when performing the distal joint manipulation at
every time period except at 20 minutes post intervention. When the groups were combined there
was a statistically significant decrease in the soleus H/M ratio at 30 minutes post intervention.
This means that when the distal joint manipulation was performed, there was an increase in the
activation of the H reflex and M wave, but no intervention seemed to do this at the peroneus
longus4.
This group is again similar to the group that we most commonly work with, about the 1830 years of age range. This article was published in The Journal of Electromyography and
Kinesiology in 2011. The joint manipulations were all performed by 1 of 2 therapists and then
all of the recorded outcome measures were taken by the same person. I think this is a strong suit
for this study. One of the things that also makes this article stand out from some of the others is
that there was a true control group that did not receive any treatment at all. Chronic ankle
instability was determined by FAAM survey (score of 85%) and three on the ankle instability
instrument, both were valid and reliable for determining functional ankle instability. The soleus
muscle was the only one that had a statistically significant increase in activation post joint
manipulation. However, as mentioned by the researchers, the clinical implications of this are
unknown at this time. I would say that this is a step in the right direction and perhaps patients
with chronic ankle instability may benefit from joint manipulation and then a strengthening
regimen for the soleus. Perhaps these steps would decrease instability. To me, this treatment is
effective if the patient would benefit from an increase in soleus muscle activation; otherwise, the
results of this study suggest that there are really no other benefits4.
The article The immediate effects of atlanto-occipital joint manipulation and suboccipital
muscle inhibition technique on active mouth opening and pressure pain sensitivity over latent
myofascial trigger points in the masticatory muscles by Oliveira-Campelo et. al. says that
previous research on this area of the body suggests that joint manipulation therapy will help to
alleviate trigger point pain within the area5. The authors of this study have found no prior
research of this technique used on the trigeminal muscles. The purpose of this study is to look at
the effects of atlanto-occipital joint manipulation and the effects on the pressure pain sensitivity,
as well as active mouth opening at the masseter and temporalis muscles5.
There were 122 participants recruited for this study ages 18-30; these were all volunteer
based. All of the participants had to be screened for a trigger point in the area and only those
with the trigger points were included in this study. The participants were randomly assigned to
groups that included the joint manipulation group, the suboccipital release group and the no
intervention group. The two treatment groups were both treated by the same clinician; one
received the manipulative therapy and the other received the suboccipital release, while the
control group came in and stayed on the table for the amount of time it would take to do a
treatment and then their “post intervention” data was collect5.
It was found that there is a statistically significant increase in the pressure pain threshold
after the joint manipulation therapy was performed. The authors also found that there was an
increase in the AROM opening of the mouth. It is however suggested by the authors that these
results are most likely not clinically relevant at this point because of the small effective size.
However, it is a starting point for more research and may be used to see if we as clinicians are
able to provide the same results. The results were also not looked at over time and were only
looked at immediately following the intervention so the results may or may not be very
temporary5.
This study looked at a similar population to the population that we will be working with.
It was published in The Journal of Orthopedic and Sports Physical Therapy in 2010. The
procedures were performed by one clinician and one who did data collection, so this was a
double-blinded study. The outcome measure for pressure pain threshold was done with an
algometer which has been proven reliable and valid for recording pressure pain threshold. The
active mouth opening measurements were performed with a tape measure, but this technique has
been recorded as having high intrarater reliability. This treatment seemed to be successful in
increasing the pressure pain threshold and increasing the active mouth opening. However, it
seems to be only a temporary fix and not a long term solution to the problem. For temporary
pain relief, I think this is a good treatment, but looking to the future I think other methods that
could get to the root of the problem and solve it would better serve the patient5.
It is stated in the article The effect of two manipulative therapy techniques and their
outcome in patients with sacroiliac joint syndrome by Kamali et. al. that there have been past
studies that joint manipulation at the SI joint will help to decrease inhibition and increase the
threshold of motor neurons6. So far the authors have no knowledge of a study that has performed
comparing two different joint manipulation interventions at the SI joint. The purpose of this
study is to compare the difference between two different types of joint manipulation
interventions and their effects at the SI joint6.
This study included 32 female patients ages 20-30. These women were already attending
physical therapy for low back pain, but had not received any joint manipulation therapy at the SI
joint for at least one month. The participants were then randomly assigned to either the SI joint
manipulation therapy group or the lumbar and SI joint manipulation therapy group. The patients
were then asked their pain level on a scale of 1-100. Then they were also asked to fill out the
Oswestry low back pain disability questionnaire which determined functional disability. These
two outcome measures were first recorded immediately after intervention, 48 hours later, and
one month later6.
It was found in both the SI joint manipulation therapy group and the lumbar and SI joint
manipulation therapy group, that there was a statistically significant decrease in the visual analog
scale of pain at all time intervals following intervention. It was also found that there was a
statistically significant improvement in functioning at 48-hours and one month post intervention.
There was no difference between functioning or pain values over time between the SI joint
manipulation only and the SI joint and lumbar joint manipulation therapy groups6.
There is one extraneous variable that was not mentioned throughout the study and it was
that the patients were recruited from a physical therapy clinic. It was not mentioned if this factor
was somehow controlled for or if the patients were asked to stop going to therapy during the
course of their treatment. If this is not accounted for, it cannot be determined whether or not the
long term effects from this study were attenuated through the intervention or through physical
therapy. This study also had no control group to compare findings to, so perhaps time could
have been a factor in the functional improvements seen within groups. The population was only
females which mean that the results of this study cannot really be generalized to males. The data
collection techniques were proven to be reliable and valid. The procedures were performed by
the same clinician in the same way, so it seems that the procedures were performed fairly well.
The results of this study were clinically significant, but not necessarily clinically significant. If
the patients were getting better because of the activities that were being performed at the
physical therapy clinic instead of the onetime joint manipulation therapy technique, this to me
suggests that the immediate pain release is beneficial for the patient and may help them with pain
control, but overall should possibly be used in conjunction with physical therapy6.
In the article Effects of a Proximal or Distal Tibiofibular Joint Manipulation on Ankle
Range of Motion and Functional Outcomes in Individuals With Chronic Ankle Instability by
Beazell et. al. the authors suggest that chronic ankle instability affects about 30% of people who
have suffered from a lateral ankle sparin7. It is suggested here that part of the reason is because
of the way the fibula is positioned. The purpose of this study is to look at the effects of a
proximal and distal joint manipulation at the tibiofibular joint on functional ability and
dorsiflexion ROM7.
Participants were volunteers that qualified as having CAI; the authors used 43
participants to complete the study. The participants had to fill out the FAAM, which has high
reliability for functional ankle instability. This was the first task and was used as a baseline
score. Then ankle weight bearing ROM dorsiflexion was measured, participants then completed
the single leg stance portion of the BESS test on a foam pad, and last the step down test. The
participants were then assigned to the proximal tibiofibular joint manipulation group, the distal
tibiofibular joint manipulation group, and the control group. The baseline score collector was
blinded as to which treatment group the participants were in. The clinician doing the joint
manipulation was also blinded to the previous scores of each participant. The outcome measures
were then taken again immediately following the procedure and then 7, 14, and 21 days after the
intervention. At each time point, the patient again received the intervention and completed the
same outcome measures7.
It was found that when all the groups were combined, across time, there was a significant
increase in ankle dorsiflexion. There were no statistically significant differences between the
any of the groups across time when comparing the BESS test, step down test, or the FAAM7.
This article was published in 2010 in The Journal of Orthopedic and Sports Physical
Therapy. In this study the participants were volunteers from the college and a nearby clinic. So
these demographics are similar to the patients that we would be working with. The procedures
were done to the best of the researchers abilities. The researchers were double blinded and all
assessments were used with the same equipment and in the same room. All the interventions
were done by one clinician and all of the outcome measures were recorded by a different
clinician throughout the entire process. In this study it was found that the only statistically
significant difference was found in the increase in ankle dorsiflexion which occurred over all
groups. It is suggested by the authors that this could have been due to all of the functional
testing that was done by each participant. The step down test and weight bearing dorsiflexion
ROM measure both require the patient to go to their end range of motion in dorsiflexion. This is
perhaps a variable they should have controlled for and then compared the improvements of the
joint manipulation groups and the control group. I would not use this for an athlete with chronic
ankle instability as it has been shown here in two different studies to be rather ineffective;
especially since the only improvements seen within the groups were also seen within the control
group7.
In the article Effects of lumbopelvic joint manipulation on quadriceps activation and
strength in healthy individuals by Grindstaff et. al. it states that previous research has suggested
that lumbopelvic joint manipulation has had an effect on the force output and activation of
several different muscles8. Most of that research, however, has only looked at the immediate
effects. The purpose of this study is to see if lumbopelvic joint manipulation and mobilization
will increase the activation and force output of the quad in healthy individuals for up to one
hour8.
There were 42 participants within the study, all of which were considered healthy and
had no history of lumbar spine pathology within the past six months. The researchers then
gathered all of the baseline information from each of the participants. This included the quad
force output using an isometric contraction using a biopac machine, and then quadriceps
activation was recorded using the burst super-imposition technique which stimulates a muscle
contraction through an electrical impulse. Following this, the central activation ratio was
calculated for each participant. The test leg for each participant was determined by coin toss and
participants were randomly assigned to one of three groups; the lumbopelvic joint manipulation
group (high grade mobilization group), the lumbar flexion/extension PROM group (low grade
joint mobilization) and the prone extension group (sham group). The outcome measures were
then again taken immediately after intervention and then 20, 40, and 60 minutes following
intervention8.
It was determined that there was not a statistically significant difference between the
treatment groups and quad activation or force output, nor was there a statistically significant
difference between quad force output and activation over time8.
It was not mentioned in this study if the clinician performing the intervention was also
the one that collected the outcome measures. The upside to this study is that the subjects were
blinded because the control group did a prone lumbar extension, which they most likely thought
was some kind of intervention that helps to control for some bias. This group is similar to the
population that we will be working with, which is about 18-30. However this study only used
individuals who were asymptomatic which is not a population we treat. The procedures were
done by an experienced clinician on equipment that was proven valid and reliable. The results
showed that there was no statistically significant difference between the groups or in time. This
to me seems to be a relatively ineffective way to increase quadriceps force output and activation.
Although this treatment is rather cost effective since you do not need to purchase any equipment,
if it does not work, it is not worth the time8.
It is stated in the article Short-Term Effects of Kinesio Taping Versus Cervical Thrust
Manipulation in Patients With Mechanical Neck Pain: A Randomized Clinical Trial by
Saavedra-hernández et. al. that there are some studies that suggest that cervical pain is becoming
almost as prevalent as low back pain9. Most people who suffer from mechanical neck pain seek
a physical therapist first and their most common treatment is joint manipulation, although most
studies suggest that there seems to be no difference between joint manipulation and no
intervention at all. Currently, there is little information on the effects of kinesiotape on
mechanical neck pain. The purpose of this study is to determine the short term effects of joint
manipulation and kinesio tape on mechanical neck pain9.
Participants were patients at a physical therapy clinic in Spain and it was determined that
all met the criteria for mechanical neck pain. There were 80 participants recruited for the study
with an age range from 18 to 55. Each patient had a baseline outcome measure recorded. The
outcome measures included subjective pain level, the Neck Disability Index, a body diagram to
determine the location and distribution of pain, and cervical ROM. They were also screened for
nystagmus, Horner syndrome, gait abnormailities, and any ligamentous instability in the cervical
region. The patients were then randomly assigned to the joint manipulation or Kinesio-taping
group. The researcher who collected all of the outcome measures was blinded to which
treatment each participant received. Outcome measures were taken at baseline and seven days
following the intervention9.
It was found that patients who received the joint manipulation therapy had a statistically
significant increase in cervical rotation in comparison to the kinesiotape group. It was found that
there were no statistically significant changes in cervical flexion, extension, or lateral flexion
between the two groups, but both groups showed improvements. It also showed that there was
no statistically significant difference between the two groups in the amount of disability or
subjective pain, but both decreased similarly. Five of the patients within the study had adverse
effects; three from joint manipulation including an increase in pain and fatigue, and two from the
kinesiotape with reported skin irritation; the symptoms subsided after 24 hours. It is suggested
by the authors that the changes in cervical ROM were very small and of little clinical
significance9.
All of the outcome measures were considered valid and reliable measures for their
particular outcomes. The procedures were done the same for all persons, except for the obvious
difference in intervention. The population was not similar to the group we would be working
with; the study did include a younger population but the average age for each group was 45 years
old. This experiment was double blinded and was not compared with a control group, so it
cannot be determined if the improvements were because of time or because of the actual
intervention. Which brings up the point that these participants were all being seen for
mechanical neck pain in a physical therapy clinic and it was not mentioned if they stopped
therapy while participating in this study or not, which also means that a control group could have
been found to have similar results if they were participating in a similar rehab program. This
study was published in the Journal of Orthopedic and Sports Physical Therapy in 2012. As the
authors mentioned the differences in cervical ROM for both groups were not really clinically
significant as they were very small, but the change in rotation was greater for the group with the
joint manipulation. Both groups showed similar statistically significant improvements in
subjective pain reports and disability. The clinical relevance of this to me means that in this
particular scenario, if the patients’ main complaint is pain, I would most likely use the
Kinesiotape intervention because the adverse effects were just skin irritation versus an increase
in pain. On the other hand if the patient came in complaining of a lack of ROM, I would try the
joint manipulation because both improved similarly with more rotational benefits coming from
joint manipulation. If cost were a factor, I would also choose the joint manipulation therapy as
there is some cost involved with kinesiotape. I wouldn’t use either of these methods as a sole
treatment for a patient; it would be in conjunction with stretching and strengthening activities9.
In the athletic training world I feel that this rehab technique is not necessarily useful.
According to this body of research, it is determined that the treatment was relatively ineffective;
in most cases only as effective as a control group with no intervention, or had very little effect
and for relatively short periods of time[2-9]. The good thing about joint manipulation therapy is
that it does not require any equipment and it also does not require a lot of time; most of these
studies indicated 1-2 minutes[2,3,7-9]. In most of the articles it was suggested that the previous
research indicates that this treatment did have some effects, but I don’t think any of these studies
sided with the previous research [2-9]. The further I got into this body of research, the more I
thought that this technique seems to be like a “quick fix” and doesn’t really get to the root of the
problem, which perhaps could be addressed through a rehabilitation exercise protocol and
therapeutic modalities. The bad thing about joint manipulation is that is has a relatively high
number of contraindications. With that being said, I don’t necessarily think that we are doing
our jobs as clinicians if this is the only “rehab” we are doing with patients. Masking the problem
does not make it go away and we are there to get athletes back to what they were before the
injury not to just cover it up. I think that used in conjunction with other techniques and if a
patients feels that it is beneficial to them, it should be used. Otherwise it is suggested by the
majority of these articles that it is essentially ineffective.
References:
1. Houglum PA. Therapeutic Exercise for Musculoskeletal Injuries. 3rd Edition. Champaign, IL:
Human Kinetics; 2010.
2. Orakifar N, Kamali F, Pirouzi S, Jamshidi F. Sacroiliac Joint Manipulation Attenuates AlphaMotoneuron Activity in Healthy Women: A Quasi-Experimental Study. Archives Of Physical
Medicine & Rehabilitation [serial online]. January 2012;93(1):56-61.
3. Grindstaff T, Hertel J, Ingersoll C, et al. Lumbopelvic Joint Manipulation and Quadriceps
Activation of People With Patellofemoral Pain Syndrome. Journal Of Athletic Training [serial
online]. January 2012;47(1):24-31. Available from: SPORTDiscus with Full Text, Ipswich, MA.
Accessed March 24, 2013.
4. Grindstaff T, Beazell J, Sauer L, Magrum E, Ingersoll C, Hertel J. Immediate effects of a
tibiofibular joint manipulation on lower extremity H-reflex measurements in individuals with
chronic ankle instability. Journal Of Electromyography And Kinesiology: Official Journal Of
The International Society Of Electrophysiological Kinesiology [serial online]. August
2011;21(4):652-658. Available from: MEDLINE, Ipswich, MA. Accessed March 24, 2013.
5. Oliveira-Campelo N, Rubens-Rebelatto J, Martí N-Vallejo F, Alburquerque-Sendí N F,
Fernández-de-Las-Peñas C. The immediate effects of atlanto-occipital joint manipulation and
suboccipital muscle inhibition technique on active mouth opening and pressure pain sensitivity
over latent myofascial trigger points in the masticatory muscles. The Journal Of Orthopaedic
And Sports Physical Therapy [serial online]. May 2010;40(5):310-317. Available from:
MEDLINE, Ipswich, MA. Accessed March 24, 2013.
6. Kamali F, Shokri E. The effect of two manipulative therapy techniques and their outcome in
patients with sacroiliac joint syndrome. Journal Of Bodywork & Movement Therapies [serial
online]. 2012;16(1):29-35. Available from: CINAHL, Ipswich, MA. Accessed March 24, 2013.
7. Beazell J, Grindstaff T, Sauer L, Magrum E, Ingersoll C, Hertel J. Effects of a Proximal or
Distal Tibiofibular Joint Manipulation on Ankle Range of Motion and Functional Outcomes in
Individuals With Chronic Ankle Instability. Journal Of Orthopaedic & Sports Physical Therapy
[serial online]. February 2012;42(2):125-134. Available from: SPORTDiscus with Full Text,
Ipswich, MA. Accessed March 24, 2013
8. Grindstaff T, Hertel J, Beazell J, Magrum E, Ingersoll C. Effects of lumbopelvic joint
manipulation on quadriceps activation and strength in healthy individuals. Manual Therapy
[serial online]. August 2009;14(4):415-420. Available from: CINAHL, Ipswich, MA. Accessed
March 24, 2013.
9. Saavedra-hernández M, Castro-sánchez A, Arroyo-morales M, Cleland J, Lara-palomo I,
Fernández-de-las-peñas C. Short-Term Effects of Kinesio Taping Versus Cervical Thrust
Manipulation in Patients With Mechanical Neck Pain: A Randomized Clinical Trial. Journal Of
Orthopaedic & Sports Physical Therapy [serial online]. August 2012;42(8):724-730. Available
from: SPORTDiscus with Full Text, Ipswich, MA. Accessed March 24, 2013.