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0196-6011/80/0104-0214$02.00/0

THE JOURNALOF ORTHOPAEDIC AND SPORTSPHYSICALTHERAPY Copyright @ 1980 by The Orthopaedic and Sports Medicine Sections of the American Physical Therapy Association

Evaluation of Undergraduate Physical Therapy Students' Comprehension of Maitland's Grades (I-IV) for Posterior Mobilization of the Glenohumeral Joint

CAROL A. ROLLINS*.t; JAMES L. ROBINSON,*$ MA

In this study, the instruction of undergraduate students in Maitland's grades (I-IV) for posterior glenohumeral mobilization as a valid instructional goal was investigated. Undergraduate students were instructed in Maitland's mobilization grades I-IV at various joints before the experimentation. Students selected were mobilized by the instructor. A random assignment of grades was given to the instructor before mobilization. The mobilization subject secretly identified the grade as the mobilization was being videotaped. The videotape was played to the class of undergraduate students who were asked to identify the grades visually. The accuracy of the student's ability to identify the assigned grades visually and kinesthetically was determined to be within the projected 90% accuracy level; therefore, the hypothesis was substantiated.

The problem investigated in this study involved the joint mobilization course, this researcher pro-

jected that the hypothesis, stated in the next

the validity of instructing undergraduate physical

therapy students in the use of Maitland's grades paragraph, would not be rejected. The results

(I-IV) in joint mobilization. The type mobilization obtained should indicate if the instruction of

Maitland's grades (I-IV) for posterior mobiliza-

zation at the glenohumeral joint with a standard tion at the glenohumeral joint for the undergrad-

grip while the subject was supine. Students were evaluated to determine their ability to: 1) accu-

rately identify Maitland's grades (I-IV) when When instructed in Maitland's grades (I-IV) for

posterior joint mobilization at the glenohumeral joint with the subject supine and using a standard grip, the undergraduate physical therapy student can identify Maitland's grades (I-IV) visually,

assigned

grades with a 90% accuracy level.

utilized in this experiment was posterior mobili-

uate physical therapy student is a valid instruc- tional goal.

viewed on videotape, 2) accurately identify the

kinesthetically when the technique was

being applied to themselves, and 3) perform the assigned grade on a fellow student. The experi- ment followed a basic introductory course in joint mobilization. This problem was selected because the fine distinction of movement between Maitland's

grades

kinesthetically,

and

can

perform

HISTORICAL BACKGROUND

grades (I-IV) raised doubt about the undergrad- uate physical therapy ability to recog-

nize the demonstrated and practiced skills

of

joint mobilization for Maitland's

grades (I-IV),

From previous observations and participation

Previous studies of the effectiveness of the instruction of joint mobilization techniques were not found. The graded Maitland mobilization

in techniques were completely described in the text

Peripheral Manipulation by Maitland.' In using joint play evaluation and treatment, the physical therapy student must not only study

From the Medical University of South Carolina. Charleston. SC 29401. the science of the movements involved, but also

t Miss Rollins was a physical therapy student.

$ Mr. Robinson 1s Associate

Professor ~nPhysical Therapy.

the skill of using the proper degree of mobiliza-

214

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JOSPT Spring 1980

COMPREHENSION OF MAITLAND'S GRADES

215

tion with the proper patient and condition. As in other fields, the scientific basis of a study is readily acquired with concentration. However, the development of a skill takes practice and attention to detail. With joint mobilization, the scientific back- ground begins with the definition of joint play. Joint play is defined by Mennel12 as a passive movement at a joint between the articular sur- faces that is necessary for complete and painless range of motion. Such joint play movements cannot be voluntarily accomplished by a normal individual with normal joint range of motion. Joint play varies slightly from individual to individual even with a normal joint. Joint dysfunction is defined by Mennel12 as a condition involving decreased range of motion or pain or both with an accompanying loss of joint play. The degree of joint mobilization used for treating joint dysfunction varies with the pa- tient's condition. Maitland' developed a grading system to identify the degree of mobilization used by a practitioner. The grading system helps to standardize treatment and make communica- tion between practitioners easier and more pre- cise. Maitland illustrated (Fig. 1) and described his grading system in Peripheral Manipulation' as follows: Grade I: a mobilization of small am- plitude at the beginning is used. Grade II: a mobilization of large amplitude is performed in the central portion of joint play with no mobili- zation taking place at either limit of the range. If the grade II movement is performed near the beginning of the range the grade is referred to as "11-". A grade of "II+" is assigned when grade II is performed near the end of the range. Grade Ill: a mobilization of large amplitude that is at the end of the range of joint play and continues to the limit of joint play. The + and -

grades are assigned according to the degrees of vigor of mobilization at the end of the range; the more vigorous movement getting a Ill + grade and the gentle movement getting a Ill- grade. Grade IV: a mobilization of small amplitude at the end of the range: and the grade is assigned + and - values according to the vigor of movement at the end of the range as in grade Ill. Once the scientific basics are mastered, the skills of mobilization must be acquired. The use of skilled techniques requires that the physical therapist first must master the concepts and clinical entities of joint play, joint dysfunction, normal and abnormal range of motion, and the anatomical structure of the joint mobilized. This knowledge combined with the information ob- tained kinesthetically for a particular patient by the therapist is the union of the science with the skill which each therapist should develop. The skill develops with application of scientific knowl- edge to the individual patient and his condition at a particular joint. Maitland has outlined several guidelines nec- essary to develop the skill of using mobilization in the treatment of patients with joint dysfunction. The ability to gain patient confidence is very important in this form of treatment. Once the patient feels secure, he will relax much more easily, and for mobilization to be effective, com- plete relaxation is necessary. The patient should always be comfortable, and the therapist should also maintain a comfortable position. The thera- pist's position and grasp should feel secure to the patient. A smooth movement should be used to assure the patient that sudden painful move- ments will not be employed by the therapist. The therapist must maintain control of the mobiliza- tion at all times. Maitland explained that after mastering the basic techniques, variation of techniques may be used by the therapist. This variation involves correlating basic skills with the patient's condi- tion and the therapist's developed skills. In this research paper, the basic scientific skills used in the standard manner were evaluated because normal subjects were used, and little time had elapsed for the students to develop individual techniques.

EQUIPMENT AND METHOD

The participants in this experiment consisted of an associate professor of physical therapy, 15 junior physical therapy students (two males

216

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and 13 females), and 16 senior physical therapy students (three males and 13 females). The sen- ior students were involved only in identifying Maitland's grades. The junior students directly involved with the mobilizations had an age range from 19-26 years with a mean age of 22 years. The height of the junior students had a range from 60-71 inches. The average height was 64.5 inches. The weight range was 105-185 pounds with a mean weight of 132 pounds. The junior students showed no signs of general health problems. The students who served as subjects had no previous history of glenohu- meral pathology and had no complaints of dis- comfort during or after the mobilization. The equipment used included a plinth, a towel for draping, a stopwatch, and videotaping equip- ment. The experimental setup is illustrated in Figure 2.

Instruction

Initially, undergraduate physical therapy stu- dents were instructed in the basic skills of mo- bilization. The instruction included, among other topics, a lecture series discussing Maitland's grades (I-IV) and their clinical application. Lab-

oratory sessions were also held in which Mait- land's grades (I-IV) were demonstrated to the students and practiced by the students on class- mates with normal joint play. The grip and technique taught to the students and used in this experiment were described as follows. When mobilizing the glenohumeral joint posteriorly, the grip involved grasping the hu- meral head so that the thenar eminence of the mobilizer was in contact with the skin covering the anterior portion of the humeral head. The finger pads of the same hand were positioned so that one finger pad, usually the index finger pad, was located at the posterior joint space to pal- pate movement of the humeral head while the other finger pads were positioned on the poste- rior surface of the humeral head as illustrated in Figure 3. The other hand of the mobilizer was used to support the brachium by grasping its dorsal surface just proximal to the elbow joint. The movement for joint play involved taking up tissue slack at the glenohumeral joint, and then the humeral head was moved posteriorly by ap- plying a force through the thenar eminence of the mobilizer. The movement was palpated by the mobilizer's finger pad located at the posterior part of the joint space. The upper extremity of

JOSPT Spring 1980

COMPREHENSION OF MAITLAND'S GRADES

21 7

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the mobilizer supplying the dorsally directed force was positioned so that the force applied through a line parallel with the long axis of the forearm would be in the same plane as the desired posterior movement of the head of the humerus on a fixed glenoid cavity. The mobi- lizer's other upper extremity was used to move the brachium with the humeral head to prevent a pivoting motion at the joint as illustrated in Figure 4.

Pilot Study

After the instruction period, a pilot study was performed. In this study, eight students were randomly chosen from the class to perform four randomly assigned mobilization grades on eight other randomly chosen classmates. The grades were assigned so that each grade appeared eight times in the series of 32, but not every grade was performed by each student mobilizer. The grades performed were videotaped and played back to the class with instructions for the class to identify the grades. Students were not allowed to identify grades in which they were involved. Students were not allowed to change their identification of grades after another grade

Fig. 3.

was viewed; and no talking was allowed while the videotape was in progress. The pilot was performed to predetermine videotape difficulties, to allow the students to become relaxed when being videotaped, and to evaluate the proposed experimental method.

The Study

After the pilot study was reviewed, it was de- cided that the study would be completed in two series. Series 1 involved student mobilizers and subjects for the purpose of evaluating the stu- dent's technique, the student's ability to kines- thetically determine the grade, and the student's ability to identify the grade visually. Series 2 involved the instructor as a mobilizer and stu- dents as subjects. This series was used to eval- uate the student's ability to identify Maitland's grades as well as the subject's ability to kines- thetically recognize Maitland's grades (I-IV). The junior and senior classes identified the grades on the videotape on different occasions. The instructor graded both series with the junior class. Before senior class viewing, the instructor demonstrated Maitland's grades (I-IV) for pos- terior mobilization. For the first series, the in-

ROLLINS AND ROBINSON

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structor's identification of grades was used as the standard to evaluate student technique. Stu- dents and the instructor were given test sheets for both series 1 and 2. All those involved in identifying grades on the videotape were in- structed to circle the number on their answer sheet that corresponded to the mobilizafion grade seen on the videotape. It was explained that the joint play would be demonstrated three times; and the grade would be demonstrated for 10 seconds with a blank section of tape to allow time for grading the mobilization. Students in- volved in the mobilization were not allowed to grade that mobilization. Students were told the grades were in random order. Students were instructed not to change grades after the next mobilization had begun. Talking was not permit-

Fig. 4.

ted while the videotape was in progress. The students were then asked if there were any ques- tions.

Series 1

In the first series of the experiment, six mobi- lizers and subjects were randomly chosen from the class. The grades assigned to these six student mobilizers were assigned in random or- der; however, each mobilizer performed each of the four grades. Neither the instructor nor the students identifying the grades were aware that each student performed each grade until after identifying the grades on the videotape. This procedure was followed to allow each mobilizer to be evaluated for technique for each grade without those identifying the grades being able

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JOSPT Spring 1980 COMPREHENSION OF MAITLAND'S GRADES 219

to deduce what the final grade in a section of four was before viewing the mobilization. Before videotaping, the instructor briefly dem- onstrated the posterior mobilization technique for the glenohumeral joint. Each of the six mo- bilizers was given a card with the four grades they were to perform. The mobilizer was allowed to determine the mobilization subject's joint play before the videotape began. The videotape be- gan by showing the subject's shoulder. After the mobilizer grasped the subject's shoulder, the narrator announced the test number and said, "This is the available joint play." The mobilizer demonstrated the joint play three times as the narrator counted, "One, two, three." Next the narrator said, "This is the grade." The mobilizer demonstrated the grade for 10 seconds. The subject nonverbally signaled the grade he or she believed the mobilizer to be performing to an- other individual who recorded the signaled grades without the mobilizer knowing the sub- ject's estimate. Then 12-1 5 seconds of blank tape were used to separate each grade to allow time for identification of grades when the video- tape was viewed by the class. After the student mobilizer completed four grades, the next mo- bilizer and subject went through the same pro- cedure until all six student mobilizers and sub- jects had been videotaped.

Tables 1-6 illustrate the visual and kinesthetic accuracy of each class according to the grade of mobilization. The table is arranged so that the percentage of students identifying a grade I as a grade I is listed in the column 1, row 1. The percentage of students reporting grade II for a grade I is listed in column 2, row 1. The table follows this order through the other grades. Therefore, ideal results would have 100% on the diagonal from upper left to lower right in each table.

TABLE 1

Series 1, visual accuracy, junior class

Grade reported

II

%

111

N identifica-

tions of corre-

Grade as-

sponding

signed

I

grade

IV

TABLE 2

Series 1, visual accuracy, senior class

Grade as-

signed

Grade reported

N identifica- tions of corre- sponding grade

Series 2

In series 2, the instructor performed four mo- bilization grades on each of six randomly se- lected students. The instructor was given 24 randomly ordered grades to perform. The in- structor followed the same procedure as the student mobilizers. The second series was viewed by the junior and senior classes to deter- mine each class's ability to visually determine Maitland's grades (I-IV) with the possibility of student technique error eliminated. The first se- ries was viewed by both groups ta allow the students to become familiar with grading the videotape.

RESULTS

Of the 720 grades of mobilization identified, there were 681 correct identifications by the students visually giving an overall accuracy of 94.5%. The junior class had a 95.2% accuracy and the senior class had a 94.0% accuracy. The junior class exhibited a 91.7% kinesthetic ac- curacy using series 2 figures.

TABLE 3

Series 1, kinesthetic accuracy, junior class

N identifica- tions of corre- sponding grade

Grade as-

signed

Grade reported

TABLE 4

Series 2, visual accuracy, junior class

N identifica-

Grade reported

tions of corre-

Grade as-

sponding

signed

I

II

111

IV

grade

%

84

1

100

84

II

94

5

1

84

111

5

95

84

IV

7

1

92

ROLLINS AND ROBINSON

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TABLE 5

Series 2, visual accuracy, senior class

N identifica-

tions of corre-

sponding

grade

Grade as-

signed

Grade reported

I II

111

IV

TABLE 6

Series 2, kinesthetic accuracy, junior class

N identifica-

tions of corre-

sponding

grade

Grade as-

signed

DISCUSSION

Grade reported

I II

111

IV

The results obtained using the previous ex- perimental procedure indicate that when properly instructed, the instruction of Maitland's grades I-IV for posterior mobilization at the gle- nohumeral joint for the undergraduate physical therapy student is a valid instructional goal. As projected at the beginning of the paper, some confusion arose in the distinction of Maitland's grades; but the overall visual accuracy of 94.5% illustrated that the students were able to cor- rectly distinguish between Maitland's grades I-

IV when visualized. The kinesthetic accuracy

was found to be 91.7% (series 2). The perform- ance level of accuracy was 91.7% (series 1). The figures obtained indicate the hypothesis that

undergraduate physical therapy students in- structed in Maitland's grades (I-IV) for posterior joint mobilization at the glenohumeral joint with the subject supine using a standard grip can identify Maitland's grades I-IV visually and kinesthetically when demonstrated and can per- form grades with a 90% accuracy level, cannot

be rejected.

Using series 2 for analyzing the student's vis- ual ability to identify mobilization grades, one finds on reviewing the results that the grades most often confused are grade IV confused as grade I, grade II confused as grade Ill, and grade Ill confused as grade II. For the junior class, 7% of the grade IV mobilizations were identified as

grade I. There are several possible causes for the 7% error. These causes include the student giving the incorrect identification may have lost attention and missed the first movement of the

mobilization. Grade IV has the same amplitude as a grade I, however, grade IV is performed at the end of the range. Grades II and Ill were frequently confused. These two grades have similar amplitude; however, grade Ill should be easily distinguished from grade II because grade Ill occurs toward the end of the range, whereas grade II occurs in the beginning of the range. Careful observation of the entire joint play before the grades should have made the correct iden-

tification possible and, thus, needs to be stressed when demonstrating these grades. Fi- nally, grades I and ll tended to be confused by the senior class. These grades are in the begin- ning of the joint play range, but grade I is very small and grade II is larger. Because the soft tissue of the joint must be taken up before mo- bilization, the grades could easily be confused. The amplitude must be carefully observed to determine grade I or II. When analyzing the kinesthetic accuracy of the students who were mobilization subjects, one observes that all errors were within one grade of the assigned grade. There were fewer identifi- cations from the students being mobilized that would show a larger error for fewer mistakes. Consequently, a 17% error of assigning a grade I mobilization a grade I1 is noted when one mo- bilization identification was incorrect. The largest degree of incorrect identification was of confus- ing grades I and II and grades II and Ill. Series 1 was used by the instructor to analyze student technique. The professor indicated the grade the student mobilizer was performing on the videotape. The student was either correct or incorrect. Out of the 24 grades performed, 22 were correctly identified as the grade the student mobilizer was to perform. Both errors involved the student mobilizing with too large an ampli- tude. In once instance, a student performed a grade II instead of grade I. In the other instance, a grade Ill was performed instead of grade II.

Further Study

Suggestions for further study include: 1) ex- perimentation involving joint mobilization'at other joints and mobilization of the glenohumeral joint for different joint play movements such as infe- rior or anterior mobilization; 2) multiple class

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JOSPT Spring 1980 COMPREHENSION OF

studies in which the videotape in this experiment would be viewed by physical therapy students at other schools to assess the reliability of results obtained in this experiment; 3) the videotape could also be viewed by clinicians throughout the country to determine reliability in graded mobilization skills; 4) the student's ability to de- termine the magnitude of joint play in a joint with shoulder pathology could be analyzed; 5) relat-

MAITLAND'S GRADES

221

ing Maitland's mobilization grades to the stimu- lation of joint receptors as classified by W~ke.~

REFERENCES

1.

Maitland GD: Peripheral Manipulation. Boston, Butterworths,

1977

2.

Mennell J: Joint Pain: Diagnosis and Treatment Using Manipu-

lative Techniques. Boston. Little Brown and Company, 1964

3.

Wyke B: The neurology of joints. An Royal Coll Surg Engl 25:41,

1967