Freddy M.

Kaltenborn

Orthopedic Manual Therapy For

Physical Therapists
Nordic System: OMT
Kaltenborn-Evjenth Concept
The Nordic System of Manual Therapy has been developed by Freddy Kaltenborn and Olaf Evjenth over
a number of years. The system has its roots in historical medicine. The Nordic system seeks to restore
normal joint mechanics. The progression of treatment is determined by monitoring the patient's symp-
toms such as pain. The aim of this article is to review the historical basis of the Orthopedic Manipulative
Therapy (OMT) Kaltenborn-Evjenth System and to present current concepts regarding the Nordic System
of Manual Therapy.

T HE word "Nordic" represents a collaboration be-

tween physical therapists and physicians in the
Nordic countries of Denmark, Finland, Iceland, Nor-
more recent times, the sources from which the Nordic
System was developed include James Mennell (1),
James Cyriax (2, 3) and Alan Stoddard (4, 5). The
way and Sweden during the years of 1954-1970 to author also acknowledges contributions from O. Hol-
develop a system of Orthopedic Manual Therapy. The ten, R. McKenzie, G. Maitland, S. V. Paris, M. Ro-
Kaltenborn-Evjenth Concept is a system that com- cabado and others. The System is continuously up-
bines many different approaches that were put to- dated as new knowledge is brought to light.
gether by Freddy Kaltenborn and Olaf Evjenth. It is The Nordic System was first presented interna-
based on the systematic review and integration of ex- tionally in 1973 and again in 1975 at meetings of the
periences from many different sources in medicine, International Federation of Orthopaedic Manipulative
physical therapy and physical education. The selec- Therapists (IFOMT) in Gran Canary and in 1977 in
tion of techniques was made to find those best suited Vail, Colorado. The Nordic System, now taught world-
for the physical therapist. wide, has a detailed plan of study with supervised
training and examinations which meet· IFOMT stan-
Historical Roots dards. More detailed information on the Nordic Sys-
tem of examination and treatment of patients can be
The principal historical roots of this system come from found in books dealing with the mobilization of ex-
as far back as Hippocrates (460-377 B. c) and Galen tremity joints (6) and the spine (7).
(131-202 A.D.). Other contributors have been Avi-
cenna, Pare, Still (Osteopathy) and many others. In
Orthopedic Manual Therapy-
Nordic System
Address all correspondence and requests for reprints to:
Freddy M. Kaltenborn This system consists of three principal components.
Bahnhofstrasse 45 The first being diagnosis the second being treatment
D-8999 Scheidegg
and the third being research (Fig. 1). The purpose of
Germany
the Nordic System of Manual Therapy is to develop

The Journal of Manual & Manipulative Therapy

Vol. 1 NO.2 (1993), 47-51 OMT Kaltenborn-Evjenth Concept / 47
 Orthopedic Manual Therapy For Physical Therapists
Nordic System: OMT Kaltenbom-EvJenth Concept

I. Physical Diagnosis (biomechanical and functional assessment)

II. Treatment

A. To Relieve Pain

1. Immobilization
- General: bed rest
- Specific: corsets, splinting, casting, taping

2. Thermo-Hydro-Electro (T-H-E) therapy

3. Special procedures
- Manual traction: pre-positioned, three-dimensional
- Vibrations, oscillations, etc.

B. To Increase Mobility

1. SonTissue Mobilization
- Massage: classical, connective tissue and functional massage,
transverse friction
- Active relaxation of muscles, e.g., hold-relax, reciprocal inhibition, etc.
• Passive stretching of shortened muscles and associated connective
tissues

Joint MobUlzatiOD
• Basic manual mobilization in the resting position of the joint
• Advanced manual mobilization in all possible joint positions
• Translatoric Thrust Technique (TIT): high velocity, short amplitude,
linear movement

3. Neural Tissue Mobilization

• To increase mobility of dura mater, nerve roots and peripheral nerves

4. Exercise
• To increase or maintain joint and soft tissue mobility

c. To Umlt Movement

1. Passive: corsets, splinting, casting, taping

2. Active: stabilization exercises

D. To Inform, Instruct and Train

Exercises and education to improve function, compensate for injuries and

prevent reinjury. Instruction in relevant ergonomics and self-care techniques,
e.g., medical exercise therapy, automobilization, autostabilization, autostretching,
back school, etc.

III. Research
Clinical trials to determine the efficacy of various, single and combined treatment methods.

Fig. 1

48/ The Journal of Manual & Manipulative Therapy, Spring 1993

treatment techniques which are specifically designed I. Occurs at another place
to: 2. Is of another quality

I. Relieve pain In the Nordic System the range of motion (hy-

2. Increase mobility pomobility, hypermobility or normal mobility) and the
3. Limit movement quality of the movement is checked with translatoric
4. Inform, instruct and train the patient motions rather than with rotary movements. If pos-
sible, each joint is examined specifically because a
Disorders of the spine are distinguished into le-
joint may be both hypomobile in one direction and
sions with neurological findings, which are treated
hypermobile in another direction.
mainly with traction, and lesions without neurological
findings which are treated according to structural find- 2. For treatment, translatoric (linear) traction and glid-
ing movements, rather than angular, rotational
ings with regard to their hypomobility or hypermo-
movements, are used to avoid compressing a joint
bility states. that is already strained by pathology (Fig. 4). The
The Nordic System divides normal bone move- translatoric movements are applied in relation to an
ments into two categories: imagined treatment plane in the joint, placed over the
concave surface (Fig. 5).
I. Standard (uniaxial, anatomical) movements A. Hypomobile joints are treated by short, transla-
2. Combined (multiaxial, functional) movements toric movements mainly at right angles (traction)
or parallel (gliding) to the imagined treatment
Combined movements are divided into:
plane of the joints (Fig. 6).
I. Coupled movements (largest range of motion and sof- B. The translatoric movements are applied slowly
test end-feel) for stretching or rapidly for manipulation.
2. Noncoupled movements (all other combined move- II. Grades of movement: Translatoric movements (trac-
ments-previously referred to in the literature as "non- tion and gliding) are divided into grades of movement.
physiological" movements) These are determined by the amount of slack the phys-
ical therapist feels when performing passive movements
(Fig. 7).
1. Grade I: Small amplitudes of movement are applied
Special Features at the beginning of the range to loosen the joint (nul-
I. Translatoric (linear) Approach To Evaluation And lify the compressive forces). Grade I is used for pain
Treatment
I. For evaluation, movement disorders are evaluated by
testing with translatoric movements for joint play and
end feel.
A. For joint play (Fig. 2), passive translatoric bone
movements are classified as:
a. Traction
b. Compression
c. Translatoric gliding
B. End feel (Fig. 3) is designated as:
a. Physiological end feels:
1. Soft
2. Firm
3. Hard
b. Pathological end feel Fig. 3

Fig. 2 Fig. 4

OMT Kaltenborn-Evjenth Concept / 49

 Fig. 7
Fig. 5

Fig. 8

Fig. 6

modulation and symptom control and is an adjunct

to all gliding procedures.
2. Grade II: A larger amplitude of movement is applied
up to the end (or within) the range, which takes
up the slack in surrounding tissue, tightening the
joint. Grade II is used for pain modulation and
symptom control and for mobilization of minor re-
strictions.
3. Grade III: A greater force is applied after the slack
is taken up to stretch tissue crossing the joint. Grade
III is used for mobilization or manipulation.
III. Convex-Concave Rule
1. Since joint hypomobility is often treated by perform- Fig. 9
ing translatoric gliding movements, it is important to
know the direction of restricted joint gliding. Deter-
mining the direction of decreased joint gliding can IV. Three-Dimensional Approach to Joint Position-
be done by the convex-concave rule or a glide test. ing: Rather than working on one plane of movement at
2. The Kaltenborn Convex-Concave Rule says that the a time, the Nordic System uses a three-dimensional ap-
convex joint surface glides opposite to the bone proach. Treatment with traction and gliding is applied
movement (Fig. 8), whereas, the concave joint sur- after the joint is positioned three dimensionally in the
face glides in the same direction as the bone moves actual resting position of the joint with treatment for pain
in relation to a base (horizontal) line (Fig. 9). This (Grade I, II) and basic mobilization (Grade III) or spe-
is a key principle of the Nordic System which always . dally positioned by the physical therapist for mobili-
attempts to restore normal articular movement. zation treatment (Fig. 10).

50/ The Journal of Manual & Manipulative Therapy, Spring 1993

 session, has always been basic to the Nordic System.
Sequencing of treatment techniques to achieve the most
efficacious results is a later innovation that has become
an important feature of the Nordic approach. For ex-
ample, prior to a mobilization procedure the physical
therapist might apply soft tissue or specific muscle ac-
tive relaxation or stretching techniques to prepare the
joint. A mobilization or manipulation might be followed
by strengthening or coordination exercises for functional
gains and protect against recurrence of injury. Any fur-
ther research in orthopedic manual therapy should con-
sider how the sequencing of techniques influences re-
sults.
Fig. 10
VIII. Trial Treatment: This performed as a diagnostic pro-
cedure to ascertain the actual biomechanical diagnosis.
IX. Ergonomic Principles Applied To Protect The Phys-
V. Test For Localization: Specific tests are used for prov-
ocation (to reproduce or aggravate the symptoms) and
ical Therapist: The Nordic System has always empha-
sized protecting the physical therapists during work. An
alleviation (to eliminate or ease) the symptoms.
VI. Protecting Joints During Mobilization And Manip- early example of this was the development in the early
ulation: Traditional approaches have limited movement 1950s of the first pneumatic treatment table specifically
in adjoining joints during manipulations by position- for physical therapy practice. Techniques and assistive
ing them at the extreme of their range of motion in the devices like fixation belts and mobilization wedges are
direction of the manipulation. In the Nordic Sys- designed with both effective treatment and physical ther-
tem, neighboring joints are positioned in the direction apist safety in mind.
opposite that of the mobilization or manipulation to X. Home Treatment-Self Care: The Nordic System has
protect them from additional strain. This method has introduced a concept of home treatment and self care
been described in detail by Evjenth and Hamberg (8, which includes automobilization, autostretching, muscle
9). strengthening, coordination exercises and autotraction.
VII. Sequencing of Treatment Techniques: The use of Along with these self-care techniques, equipment for
multiple treatment techniques, often in one treatment home treatment has been developed.

REFERENCES
1. Mennell J: The science and art of joint manipulation. Vol. 6. Kaltenborn FM, Evjenth, 0: Manual mobilization of the
1, London: Churchill Ltd., 1949. extremity joints. Minneapolis, MN: OPTP, 1989.
2. Cyriax J: Textbook of Orthopaedic medicine. Vol. 1, 8th 7. Kaltenborn FM, Evjenth 0, Kaltenbom TB, Vollowitz E:
ed. London: Bailliere Tindall, 1983. The spine: basic evaluation and mobilization techniques.
3. Cyriax J: Textbook of Orthopaedic medicine. Vol. 2, 8th Minneapolis, MN: OPTP, 1993.
ed. London: Bailliere Tindall, 1974. 8. Evjenth 0, Hamberg J: Muscle stretching in manual ther-
4. Stoddard A: Manual of osteopathic technique. 2nd ed. Lon- apy, the extremities. Sweden: Alfta Rehab Forlag, 1985.
don: Hutchinson, 1966. 9. Evjenth 0, Hamberg J: Muscle stretching in manual ther-
5. Stoddard A: Manual of osteopathic practice. London: apy, the spinal column and the TMJ. Sweden: Alfta Rehab
Hutchinson, 1969. Forlag, 1985.

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