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Peripheral joint mobilizationMade by Sajida Mazhar
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Joint mobilization
•Joint mobilization refers to manual therapy techniques that are used to ▫modulate pain and ▫treat joint dysfunctions ▫regain range of motion (ROM) ▫addressing the altered mechanics of the
joint.
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•The altered joint mechanics may be due to ▫pain▫muscle guarding ▫joint effusion▫Contractures ▫adhesions in the joint capsules ▫Adhesions in supporting ligaments ▫Malalignment ▫subluxation of the bony surfaces
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Joint mobilization• It differ from stretching in that they
▫ specifically address restricted capsular tissue by replicating normal joint mechanics
▫ minimizing abnormal compressive stresses on the articular cartilage in the joint.
• practitioner must know ▫ anatomy▫ arthrokinematics and ▫ pathology of the neuromusculoskeletal system ▫ recognize when the techniques are indicated ▫ when other techniques would be more effective for regaining
lost motion.
▫False use of may lead to potential harm to the patient’s joints.
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Mobilization/Manipulation
•They are passive skilled manual therapy techniques▫applied to joints and related soft tissues ▫at varying speeds and amplitudes using
physiological or accessory motions for therapeutic purposes.
• speeds and amplitudes could range from ▫a small-amplitude force applied at high
velocity ▫to a large-amplitude force applied at slow
velocity
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Self-Mobilization (Auto-mobilization)•Self-mobilization refers to self-stretching
techniques▫specifically use joint traction or glides that
direct▫ the stretch force to the joint capsule.
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Mobilization with Movement•Mobilization with movement (MWM) is
▫accessory mobilization Applied by a therapist
▫ an active physiological movement to end range applied by the patient
The techniques are always applied in▫a pain-free direction and ▫described as correcting joint tracking from
a positional fault
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Physiological Movements
•Physiological movements are movements the patient can do voluntarily
•(e.g., the classic or traditional movements,
•such as flexion, abduction, and rotation)
•term osteokinematics is used for these
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Accessory Movements• Accessory movements are movements in the
joint and surrounding tissues ▫ that are necessary for normal ROM▫cannot be actively performed by the patient.
• Component motions ▫Accompany active motion ▫but are not under voluntary control. ▫E.g. motions such as upward rotation of the
scapula and rotation of the clavicle, which occur with shoulder flexion, ext rotation of the tibia in knee extension.
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Accessory Movements• joint play.
▫ the motions that occur between the joint surfaces ▫ the distensibility or “give” in the joint capsule▫ necessary for normal joint functioning through the ROM ▫ Demonstrated passively ▫ but they cannot be performed actively ▫ The movements include
distraction, Sliding, compression, rolling, spinning of the joint surfaces.
• The term arthrokinematics is used for these motions
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Thrust
•Thrust is a high-velocity, ▫short-amplitude motion ▫that the patient cannot prevent the motion.▫The motion is performed at the end of the
pathological limit (end of the available ROM when there is restriction.)
•Is alter positional relationships▫ snap adhesions, ▫stimulate joint receptors.
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Manipulation Under Anesthesia•Manipulation under anesthesia
▫is a medical procedure▫used to restore full ROM ▫by breaking adhesions around a joint ▫while the patient is anesthetized. ▫The technique may be a rapid thrust or a
passive stretch ▫using physiological or accessory
movements
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Muscle Energy
•Muscle energy techniques use ▫active contraction of deep muscles that
attach near the joint and ▫whose line of pull can cause the desired
accessory motion. ▫The therapist stabilize the segment on
which the distal aspect of the muscle attaches.
▫A command for an isometric contraction of the muscle, that causes accessory movement of the joint
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BASIC CONCEPTS OF JOINTMOTION: ARTHROKINEMATICS
•Joint Shapes▫The type of motion occurring between bony
partners in a joint ▫is influenced by the shape of the joint
surfaces.
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Joint Shapes• In ovoid joints
▫ one surface is convex, the ▫ other is concave
• In sellar joints, ▫ one surface is concave in
one direction▫ and convex in the other, ▫ with the opposing surface
convex and concave
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Types of Motion• As a bony lever moves about an axis of motion, • also movement of the bone surface on the opposing
bone surface in the joint.• The movement of the bony lever is called swing
▫ as flexion, extension, abduction, adduction, and rotation. ▫ measured in degrees with a goniometer and is called
ROM.• Motion of the bone surfaces in the joint is a
combination of rolling and sliding, or spinning.▫ These accessory motions allow greater angulations of
the bone as it swings. ▫ For the rolling, sliding, or spinning▫ There must adequate capsule laxity or joint play.
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Types of Motion• Roll• Characteristics of one bone
rolling on another are as follows.
• The surfaces are incongruent.
• New points on one surface meet new points on the opposing surface.
• Rolling results in angular motion of the bone (swing).
• Rolling is always in the same direction as the swinging bone motion whether the surface is convex or concave.
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RollingRolling, if it occurs alone,
causes ▫ compression of the surfaces
on the side to which the bone is swinging
▫ separation on the other side. ▫ Passive stretching using▫ bone angulations alone may
cause stressful compressive forces to portions of the joint surface,
▫ potentially leading to joint damage.
• In normally functioning joints, pure rolling does not occur alone but in combination with joint sliding and spinning
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Slide/TranslationSlide/TranslationCharacteristics of one bone
sliding (translating) across another include the following.
• For a pure slide, the surfaces must be congruent, either
• Flat or curved
• The same point on one surface comes into contact with
• the new points on the opposing surface.
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Slide/Translation• Pure sliding does not occur in
joints • because the surfaces are not
completely congruent.• The direction in which sliding
occurs depends on• whether the moving surface
is concave or convex.• Sliding is in the opposite
direction of the angular movement of the bone if the moving joint surface is convex.
• Sliding is in the same direction
• as the angular movement of the bone
• if the moving surface is concave.
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Combined Roll-Sliding in a Joint•The more congruent the joint surfaces
are, the more sliding
•The more incongruent the joint surfaces are, the more rolling
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• Spin• There is rotation of a
segment about a stationary mechanical axis
• The same point on the moving surface creates an arc of a circle as the bone spins
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• Spinning rarely occurs alone in joints but
• in combination• with rolling and sliding.• Three examples of spin
occurring in joints of the body
• are the shoulder with flexion/extension, the hip with
• flexion/extension, and the radiohumeral joint with
• pronation/supination
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Other Accessory Motions• Compression• Compression is the decrease in
the joint space between• bony partners.
▫ weight bearing jts▫ With muscle contration
(stabilization)▫ With rolling
• help move synovial fluid and thus help maintain cartilage health.
• Abnormally high loads may lead• articular cartilage changes and
deterioration
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• Traction/Distraction• Traction isa longitudinal
pull.• Distraction is a
separation, or pulling apart
• if traction is applied• to the shaft of the
humerus, it results in a glide of the joint surface Distraction of the glenohumeral
• joint requires a pull at right angles to the glenoid fossa
• whenever there is pulling on the long axis of a bone, the term long-axis traction
• the surfaces are to be pulled apart, the term distraction, joint traction, or joint separation is used.
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Open and close pack position
Position patient in a relaxed, distracted, supported position so the joint capsule is lax (loose(open)-packed position).
Close-packed position is one in which there is maximal contact of the articulating surfaces.
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Joint Closed-packed Position
Open-packed Position
Glenohumeral 90o ABD & Full ER combo
55o flexion w/ 20-30o HABD
Elbow Humeroulnar Humeroradial Raduioulnar
Full Extension90o flex w/ mid-pronationFull pronation or supination
70o Flex w/ 10o supinationFull ext w/ full supination70o flex w/ 35o supination
Distal Radiocarpal Joint Full extension & radial deviation or full flex
Neutral position
MCP joints2-51
Full flexionFull opposition
20o flexion20o flexion
IP joints Full Extension 20o flexion
Hip Full IR, Ext & ABD 55o flex w20-30o HABD
Knee (tibiofemoral) Full Ext & ER 20-25o flexion
Ankle Mortise Full DF 10o PF
Subtalor Full EV or INV Midrange PF & DF
Forefoot Full DF 1 MTP = 20o DF2-5 MTP = 20o PFIP’s = 20o PF
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10 simple steps1. Evaluation and Assessment2. Determine grades and dosage3. Patient position4. Joint position5. Stabilization6. Treatment force7. Direction of movement8. Speed and rhythm9. Initiation of treatment10. Reassessment
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Grades of Oscillations (Maitland)
•Grade I - small amplitude movement at the beginning of the range (pain and spasm)
•Grade II - large amplitude movement within the midrange of the movement (pain and spasm)
•Grade III - large amplitude movement at the end of the range (into restriction)
•Grade IV - small amplitude movement at end range when tissue resistance (not pain) is limiting
•Grade V - small amplitude, quick thrust manipulation at end range-
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Normal motion
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Grades of Oscillations (Maitland)
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INDICATIONS FOR JOINTMOBILIZATION•Pain, Muscle Guarding, and Spasm
▫Painful joints, reflex muscle guarding, and muscle spasm treated gentle joint-play techniques to stimulate neurophysiological and mechanical effects
•neurophysiological and mechanical effects▫stimulate the mechanoreceptors▫Inhibit nociceptive stimuli
•mechanical effects▫Synovial fluid motion provide neutrients to
jts
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•The small-amplitude joint techniques used to
•treat pain, muscle guarding, or muscle spasm should not
•place stretch on the reactive tissues
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•Reversible Joint Hypomobility▫joint-play stretching techniques to elongate▫hypomobile capsular and ligamentous
connective tissue•Positional Faults/Subluxations
▫Malposition / regain ROM▫realign the bony partners
•Progressive Limitation▫Diseases that progressively limit movement
can be treated with joint-play•Functional Immobility
▫Patient functionaly imobile
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CONTRAINDICATIONSAND PRECAUTIONS•Hypermobility•Joint Effusion•Inflammation
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Conditions Requiring SpecialPrecautions for Stretching• Malignancy• Bone disease detectable on radiographs• Unhealed fracture • Excessive pain • Hypermobility in associated joints • Total joint replacements • Newly formed or weakened connective tissue• Systemic connective tissue diseases such as
rheumatoid• Elderly individuals