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78 m a s s a g e & b o d y w o r k j u l y / a u g u s t 2 0 1 8 GRADE IV JOINT MOBILIZATION It is interesting to note that "regular" stretching of a joint that applies the stretch force to the end of the client's passive range of motion can technically be described as Grade III joint mobilization, because stretching is a form of joint mobilization. Grade IV joint mobilization is different because it is much more specifically applied and is usually thought of as increasing the nonaxial glide motion of a joint. To perform Grade IV joint mobilization, the therapist must locate the specific level to be mobilized and apply the stretch force to that level. As with any stretching, joint mobilization is performed once the tissue is brought to tension, meaning to the tissue-tension mechanical barrier at end range of motion. All slack in the superficial tissues (skin, subcutaneous fascia, and any musculature between the skin and the bone being contacted) must be first removed so that the bone is securely contacted under the therapist's hand. This aspect of Grade IV joint mobilization is often a bit challenging for massage therapists because they are accustomed to directing their attention to the soft tissues between the skin and bone, not pushing through those soft tissues to "trap" the bone against their contact. Once this contact is achieved, the mobilization force is gently applied with oscillation motions, usually a millimeter or two and held for only a fraction of a second. As with massage or regular stretching, there is no hard-and-fast rule for how many oscillation repetitions to perform. One good guideline is to perform the mobilization technique for sets of 3–5 mobilizations or perhaps sets of 10–15 seconds of repetitions. Ethics and Legality Note: Please make sure you are legally and ethically allowed within the scope of your license/certification to practice any manual therapy technique, including Grade IV joint mobilization, before employing it in your practice. Further, no kinesthetic technique should be added to your practice unless you have had in-person training with a professional continuing education instructor skilled in that technique. It is important to emphasize that Grade IV joint mobilization is employed with slow oscillations, never a fast thrust. A fast thrust applied to joint stretching defines a Grade V joint mobilization, which is only legally and ethically allowed for certain manual therapy professions, such as chiropractic and osteopathic physicians and physical therapists. Precautions and Contraindications Every technique has precautions and contraindications. Joint mobilization is contraindicated if there is hypermobile/unstable tissue at the region being mobilized (including, but not limited to, a herniated disc or osteoporosis). JOINT MOBILIZATION As effective as stretching can be to reduce the degree of a scoliotic curve, it may not be sufficiently effective at stretching some of the tight/taut myofascial tissues of the client's spine because the stretch force is spread out over the entire region of the scoliotic curve. If a more specific stretch force is needed, perhaps to stretch the tissues at a specific segmental joint level of the spine, Grade IV joint mobilization techniques can be used instead (see "Grade IV Joint Mobilization," below). Grade IV joint mobilization of the spine, performed with slow oscillations, is a form of joint stretching that is much more specifically applied so that it better targets the intrinsic fascial tissues of the facet joints of the spine at a specific level. For this reason, joint mobilization might be better termed arthrofascial stretching. Joint mobilization of the spine also targets the intrinsic musculature of the spine such as the rotatores, intertransversarii, and interspinales. There are many different joint mobilization techniques that may be directed toward mobilizing the client's scoliosis. Image 9 demonstrates a side-lying technique. The client is placed in side-lying position on her left side so that the Side-lying Grade IV joint mobilization technique. The lumbar scoliotic convexity is oriented upward and the spinous process/lamina of the lumbar spine is contacted with the pisiform of the hypothenar eminence. Tissue tension is reached and the mobilization force is added down toward the table. 9