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THE JOURNAL
OF ORTHOPAEDIC AND SPORTS
PHYSICAL
THERAPY
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

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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 joint mobilization course, this researcher projected that the hypothesis, stated in the next
paragraph, would not be rejected. The results
obtained should indicate if the instruction of
Maitland's grades (I-IV) for posterior mobilization at the glenohumeral joint for the undergraduate physical therapy student is a valid instructional goal.
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,
kinesthetically, and can perform assigned
grades with a 90% accuracy level.

The problem investigated in this study involved

the validity of instructing undergraduate physical
therapy students in the use of Maitland's grades
(I-IV) in joint mobilization. The type mobilization
utilized in this experiment was posterior mobilization at the glenohumeral joint with a standard
grip while the subject was supine. Students were
evaluated to determine their ability to: 1 ) accurately identify Maitland's grades (I-IV) when
viewed on videotape, 2) accurately identify the
grades kinesthetically when the technique was
being applied to themselves, and 3) perform the
assigned grade on a fellow student. The experiment followed a basic introductory course in joint
mobilization.
This problem was selected because the fine
distinction of movement between Maitland's
grades (I-IV) raised doubt about the undergraduate physical therapy
ability to recognize the demonstrated and practiced skills of
joint mobilization for Maitland's grades (I-IV),
From previous observations and participation in

HISTORICAL BACKGROUND

From the Medical University of South Carolina. Charleston. SC 29401.

Miss Rollins was a physical therapy student.
$ Mr. Robinson 1s Associate Professor ~nPhysical Therapy.

214

Previous studies of the effectiveness of the

instruction of joint mobilization techniques were
not found. The graded Maitland mobilization
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
the science of the movements involved, but also
the skill of using the proper degree of mobiliza-

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JOSPT Spring 1980

215

COMPREHENSION OF MAITLAND'S GRADES

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 background begins with the definition of joint play.
Joint play is defined by Mennel12 as a passive
movement at a joint between the articular surfaces 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 patient'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 communication between practitioners easier and more precise. Maitland illustrated (Fig. 1) and described
his grading system in Peripheral Manipulation'
as follows: Grade I: a mobilization of small amplitude at the beginning is used. Grade II: a
mobilization of large amplitude is performed in
the central portion of joint play with no mobilization 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
grade
more vigorous movement getting a Ill
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 obtained 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 knowledge to the individual patient and his condition
at a particular joint.
Maitland has outlined several guidelines necessary 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, complete relaxation is necessary. The patient should
always be comfortable, and the therapist should
also maintain a comfortable position. The therapist's position and grasp should feel secure to
the patient. A smooth movement should be used
to assure the patient that sudden painful movements will not be employed by the therapist. The
therapist must maintain control of the mobilization 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 condition 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

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216

ROLLINS AND ROBINSON

and 13 females), and 16 senior physical therapy

students (three males and 13 females). The senior 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 glenohumeral pathology and had no complaints of discomfort during or after the mobilization.
The equipment used included a plinth, a towel
for draping, a stopwatch, and videotaping equipment. The experimental setup is illustrated in
Figure 2.

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

JOSPT Vol. 1, No. 4

oratory sessions were also held in which Maitland's grades (I-IV) were demonstrated to the
students and practiced by the students on classmates 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 humeral 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 palpate movement of the humeral head while the
other finger pads were positioned on the posterior 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 applying 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

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JOSPT Spring 1980

COMPREHENSION OF MAITLAND'S GRADES

217

Fig. 3.

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 mobilizer'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

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 decided that the study would be completed in two
series. Series 1 involved student mobilizers and
subjects for the purpose of evaluating the student's technique, the student's ability to kinesthetically determine the grade, and the student's
ability to identify the grade visually. Series 2
involved the instructor as a mobilizer and students as subjects. This series was used to evaluate the student's ability to identify Maitland's
grades as well as the subject's ability to kinesthetically 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 posterior mobilization. For the first series, the in-

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ROLLINS AND ROBINSON

JOSPT Vol. 1, No. 4

Fig. 4.

structor's identification of grades was used as

the standard to evaluate student technique. Students and the instructor were given test sheets
for both series 1 and 2. All those involved in
identifying grades on the videotape were instructed 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 involved 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-

ted while the videotape was in progress. The

students were then asked if there were any questions.
Series 1
In the first series of the experiment, six mobilizers and subjects were randomly chosen from
the class. The grades assigned to these six
student mobilizers were assigned in random order; 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

219

COMPREHENSION OF MAITLAND'S GRADES

to deduce what the final grade in a section of

four was before viewing the mobilization.
Before videotaping, the instructor briefly demonstrated the posterior mobilization technique
for the glenohumeral joint. Each of the six mobilizers 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 began 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 1 0 seconds. The
subject nonverbally signaled the grade he or she
believed the mobilizer to be performing to another individual who recorded the signaled
grades without the mobilizer knowing the subject'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 videotape was viewed by the class. After the student
mobilizer completed four grades, the next mobilizer and subject went through the same procedure until all six student mobilizers and subjects 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
N identifications of corresponding
grade

Grade reported
Grade assigned

II

111

IV

TABLE 2
Series 1, visual accuracy, senior class
N identifications of corresponding
grade

Grade reported
Grade assigned

Series 2
In series 2, the instructor performed four mobilization grades on each of six randomly selected students. The instructor was given 24
randomly ordered grades to perform. The instructor followed the same procedure as the
student mobilizers. The second series was
viewed by the junior and senior classes to determine each class's ability to visually determine
Maitland's grades (I-IV) with the possibility of
student technique error eliminated. The first series 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 accuracy using series 2 figures.

TABLE 3
Series 1, kinesthetic accuracy, junior class
N identifications of corresponding
grade

Grade reported
Grade assigned

TABLE 4
Series 2, visual accuracy, junior class
N identifications of corresponding
grade

Grade reported
Grade assigned

II

111

IV

84
84
84
84

1
II
111

100

IV

94
5

5
95
1

1
92

ROLLINS AND ROBINSON

TABLE 5
Series 2, visual accuracy, senior class
N identifications of corresponding
grade

Grade reported
Grade assigned

II

111

IV

TABLE 6
Series 2, kinesthetic accuracy, junior class

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N identifications of corresponding
grade

Grade reported
Grade assigned

II

111

IV

DISCUSSION
The results obtained using the previous experimental procedure indicate that when
properly instructed, the instruction of Maitland's
grades I-IV for posterior mobilization at the glenohumeral 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 correctly distinguish between Maitland's grades IIV when visualized. The kinesthetic accuracy
was found to be 91.7% (series 2). The performance level of accuracy was 91.7% (series 1).
The figures obtained indicate the hypothesis that
undergraduate physical therapy students instructed 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 perform grades with a 90% accuracy level, cannot
be rejected.
Using series 2 for analyzing the student's visual 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

JOSPT Vol. 1, No. 4

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 identification possible and, thus, needs to be
stressed when demonstrating these grades. Finally, grades I and ll tended to be confused by
the senior class. These grades are in the beginning 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 mobilization, 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 identifications 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 mobilization identification was incorrect. The largest
degree of incorrect identification was of confusing 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 amplitude. 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 ) experimentation involving joint mobilization'at other
joints and mobilization of the glenohumeral joint
for different joint play movements such as inferior or anterior mobilization; 2) multiple class

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JOSPT Spring 1980

COMPREHENSION OF MAITLAND'S GRADES

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 determine the magnitude of joint play in a joint with
shoulder pathology could be analyzed; 5) relat-

221

ing Maitland's mobilization grades to the stimulation of joint receptors as classified by W ~ k e . ~

REFERENCES
1. Maitland GD: Peripheral Manipulation. Boston, Butterworths,
1977
2. Mennell J: Joint Pain: Diagnosis and Treatment Using Manipulative Techniques. Boston. Little Brown and Company, 1964
3. Wyke B: The neurology of joints. An Royal Coll Surg Engl 25:41,
1967