lecture 5. joint mobilization

7/30/2019 Lecture 5. Joint Mobilization

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Joint Mobilization

Dr. Afaf A.M. Shaheen

Lecture 5

RHS 322

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Outlines

What is Joint Mobilization?

Terminology

Relationship Between Physiological & Accessory

Motion Basic concepts of joint motion : Arthrokinematics

Effects of Joint Mobilization

Contraindications for Mobilization Precautions

Techniques of joint mobilization

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What is Joint Mobilization?

Joint Mobs Manual therapy technique

Used to modulate pain

Used to increase ROM

Used to treat joint dysfunctions that limit ROM byspecifically addressing altered joint mechanics

Factors that may alter joint mechanics: Pain & Muscle guarding

Joint hypomobility Joint effusion

Contractures or adhesions in the joint capsules orsupporting ligaments

Malalignment or subluxation of bony surfaces02/02/1434 3RHS 322


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Pondering Thoughts

Would you perform joint mobilizations on

someone who has a hypermobile joint?

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Terminology

Mobilizationpassive joint movement forincreasing ROM or decreasing pain

Applied to joints & related soft tissues at varying speeds &

amplitudes using physiologic or accessory motions

Force is light enough that patients can stop the movement

Manipulationpassive joint movement for

increasing joint mobility Incorporates a sudden, forceful thrust that is beyond the

patients control

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Terminology

Self-Mobilization (Auto-mobilization)self-stretching techniques that specifically use jointtraction or glides that direct the stretch force to the

joint capsule

Mobilization with Movement (MWM)concurrent application of a sustained accessory

mobilization applied by a therapist & an activephysiologic movement to end range applied by thepatient Applied in a pain-free direction

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Terminology Physiologic Movements

Osteokinematicsmotions of the bones movements done voluntarily

traditional movements such as flexion, extension, abduction,rotation

Accessory Movementsmovements within the joint &surrounding tissues that are necessary for normal ROM, but can not be

actively performed by the patient

Component motionsmotions that accompany active motion,but are not under voluntary control

Ex: Upward rotation of scapula & rotation of clavicle that occur withshoulder flexion

Joint playmotions that occur within the joint Determined by joint capsules laxity

Can be demonstrated passively, but not performed actively

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Terminology Arthrokinematicsmotions of bone surfaces within the joint

5 motions - Roll, Slide, Spin, Compression, Distraction

Muscle energyuse an active contraction of deep musclesthat attach near the joint & whose line of pull can cause thedesired accessory motion

Therapist stabilizes segment on which the distal aspect of the muscleattaches; command for an isometric contraction of the muscle is given,which causes the accessory movement of the joint

Thrusthigh-velocity, short-amplitude motion that the patientcan not prevent

Performed at end of pathologic limit of the joint (snap adhesions,stimulate joint receptors)

Techniques that are beyond the scope of our practice!

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Terminology

Concavehollowed or rounded inward

Convexcurved or rounded outward

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Relationship Between Physiological &

Accessory Motion

Biomechanics of joint motion

Physiological motion

Result of concentric or eccentric active muscle contractions

Bones moving about an axis or through flexion, extension,abduction, adduction or rotation

Accessory Motion

Motion of articular surfaces relative to one another Generally associated with physiological movement

Necessary for full range of physiological motion to occur

Ligament & joint capsule involvement in motion

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Basic concepts of joint motion :

Arthrokinematics

1. Joint ShapesType of motion is influenced by the

shapes of the joint surfaces

Ovoidone surface is convex,other surface is concave

What is an example of an ovoidjoint?

Sellar (saddle)one surface isconcave in one direction & convexin the other, with the opposingsurface convex & concaverespectively

What is an example of a sellarjoint?

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Basic concepts of joint motion :

Arthrokinematics

2. Types of joint motion

5 types of joint arthrokinematics

Roll

Slide

Spin

Compression

Distraction

3 components of joint mobilization Roll, Spin, Slide

Joint motion usually often involves a combination of rolling,sliding & spinning

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Roll

A series of points on one articulating

surface come into contact with a series of

points on another surface Ball rolling on ground

Example: Femoral condyles rolling on tibial plateau

Roll occurs in direction of movement

Occurs on incongruent (unequal) surfaces

Usually occurs in combination with sliding or

spinning

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Spin

Occurs when one bone rotates around a

stationary longitudinal mechanical axis

Same point on the moving surface createsan arc of a circle as the bone spins

Example: Radial head at the humeroradial

joint during pronation/supination; shoulderflexion/extension; hip flexion/extension

Spin does not occur by itself during normal

joint motion

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Slide Specific point on one surface comes

into contact with a series of points onanother surface

Surfaces are congruent

When a passive mobilization techniqueis applied to produce a slide in the joint

referred to as a GLIDE.

Combined rolling-sliding in a joint The more congruent the surfaces are, the

more sliding there is

The more incongruent the joint surfacesare, the more rolling there is

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Compression

Decrease in space between two joint surfaces

Adds stability to a joint

Normal reaction of a joint to muscle contraction

Distraction -

Two surfaces are pulled apart

Often used in combination with joint

mobilizations to increase stretch of capsule.

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Convex-Concave & Concave-Convex Rule

Basic application of correct mobilizationtechniques - **need to understand this!

Relationship of articulating surfaces associated with

sliding/gliding

One joint surface is MOBILE & one is STABLE

Concave-convex rule: concave joint surfaces

slide in the SAME direction as the bonemovement (convex is STABLE)

If concave joint is moving on stationary convex

surfaceglide occurs in same direction as roll

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Convex-concave rule: convexjointsurfaces slide in the OPPOSITE

direction of the bone movement

(concave is STABLE)If convex surface in moving on

stationary concave surface

gliding occurs in opposite

direction to roll

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RULE OF CONCAVE-

CONVEX

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Effects of Joint Mobilization Neurophysiological effects

Stimulates mechanoreceptors to pain Affect muscle spasm & muscle guardingnociceptive stimulation

Increase in awareness of position & motion because of afferent nerveimpulses

Nutritional effects Distraction or small gliding movementscause synovial fluid movement Movement can improve nutrient exchange due to joint swelling &

immobilization

Mechanical effects

Improve mobility of hypomobile joints (adhesions & thickened CT fromimmobilizationloosens)

Maintains extensibility & tensile strength of articular tissues

Cracking noise may sometimes occur

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Contraindications for Mobilization

Should not be used haphazardly

Avoid the following:

Inflammatory arthritis

Malignancy Tuberculosis

Osteoporosis

Ligamentous rupture

Herniated disks with nerve

compression

Bone disease

Neurological involvement

Bone fracture Congenital bone

deformities

Vascular disorders

Joint effusion

May use I & II

mobilizations to relieve

pain

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Precautions

Osteoarthritis

Pregnancy

Flu

Total joint replacement

Severe scoliosis

Poor general health

Patients inability to relax

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10 simple steps

1. Evaluation and Assessment

2. Determine grades and dosage

3. Patient position

4. Joint position5. Stabilization

6. Treatment force

7. Direction of movement

8. Speed and rhythm9. Initiation of treatment

10. Reassessment

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Maitland Joint Mobilization


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Maitland Joint Mobilization

Grading Scale Grading based on amplitude of movement & where

within available ROM the force is applied.

Grade I Small amplitude rhythmic oscillating movement at the

beginning of range of movement Manage pain and spasm

Grade II Large amplitude rhythmic oscillating movement within

midrange of movement Manage pain and spasm

Grades I & IIoften used before & after treatment withgrades III & IV02/02/1434 27RHS 322


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Grade III Large amplitude rhythmic oscillating movement up to point

of limitation (PL) in range of movement

Used to gain motion within the joint Stretches capsule & CT structures

Grade IV Small amplitude rhythmic oscillating movement at very end

range of movement

Used to gain motion within the joint Used when resistance limits movement in absence of pain

Grade V(thrust technique) - Manipulation

Small amplitude, quick thrust at end of range Accompanied by popping sound (manipulation)

Velocity vs. force

Requires training

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Indications for Mobilization

Grades I and II - primarily used for pain

Pain must be treated prior to stiffness

Painful conditions can be treated daily

Small amplitude oscillations stimulatemechanoreceptors - limit pain perception

Grades III and IV - primarily used to increase

motion Stiff or hypomobile joints should be treated 3-4

times per weekalternate with active motion

exercises02/02/1434 29RHS 322


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ALWAYS Examine PRIOR

to Treatment

If limited or painful ROM,examine & decide whichtissues are limitingfunction

Determine whethertreatment will be directedprimarily toward relievingpain or stretching a jointor soft tissue limitation

Quality of pain whentesting ROM helpsdetermine stage ofrecovery & dosage oftechniques

1) If pain is experienced BEFORE tissuelimitation, gentle pain-inhibiting jointtechniques may be used

Stretching under these circumstancesis contraindicated

2) If pain is experiencedCONCURRENTLY with tissuelimitation (e.g. pain & limitation thatoccur when damaged tissue begins toheal) the limitation is treatedcautiouslygentle stretchingtechniques used

3) If pain is experienced AFTER tissuelimitation is met because of stretchingof tight capsular tissue, the joint canbe stretched aggressively

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J i t P iti


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Joint Positions Resting position

Maximum joint play - position in which joint capsule and ligaments aremost relaxed

Evaluation and treatment position utilized with hypomobile joints

Loose-packed position Articulating surfaces are maximally separated

Joint will exhibit greatest amount of joint play

Position used for both traction and joint mobilization

Close-packed position Joint surfaces are in maximal contact to each other

General rule: Extremes of joint motion are close-packed, &midrange positions are loose-packed.

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Joint Mobilization Application

All joint mobilizations follow the convex-concave rule

Patient should be relaxed

Explain purpose of treatment & sensations to expect to

patient

Evaluate BEFORE & AFTER treatment

Stop the treatment if it is too painful for the patient

Use proper body mechanics

Use gravity to assist the mobilization technique ifpossible

Begin & end treatments with Grade I or II oscillations

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Positioning & Stabilization Patient & extremity should be positioned so that the

patient can RELAX

Initial mobilization is performed in a loose-packed

position

In some cases, the position to use is the one in which the jointis least painful

Firmly & comfortably stabilize one joint segment,

usually the proximal bone Hand, belt, assistant

Prevents unwanted stress & makes the stretch force more

specific & effective

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Treatment Force & Direction of

Movement

Treatment force is applied as close to theopposing joint surface as possible

The larger the contact surface is, the more comfortable the

procedure will be (use flat surface of hand vs. thumb)

Direction of movement during treatment is

either PARALLEL or PERENDICULAR to the

treatment plane

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Treatment plane lies on theconcave articulating surface,perpendicular to a line from thecenter of the convex articulatingsurface (Kisner & Colby, p. 226 Fig. 6-11)

Joint traction techniques areapplied perpendicular to thetreatment plane

Entire bone is moved so that thejoint surfaces are separated

Treatment Direction

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Gliding techniques are applied parallel to the treatmentplane

Glide in the direction in which the slide would normally occur for thedesired motion

Direction of sliding is easily determined by using the convex-concaverule

The entire bone is moved so that there is gliding of one joint surface onthe other

When using grade III gliding techniques, a grade I distraction should beused

If gliding in the restricted direction is too painful, begin glidingmobilizations in the painless direction then progress to gliding inrestricted direction when not as painful

Reevaluate the joint response the next day or have the

patient report at the next visit If increased pain, reduce amplitude of oscillations If joint is the same or better, perform either of the following:

Repeat the same maneuver if goal is to maintain joint play

Progress to sustained grade III traction or glides if the goal is to increase jointplay

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Speed, Rhythm, & Duration of

Movements

Joint mobilization sessionsusually involve:

3-6 sets of oscillations

Perform 2-3 oscillations persecond

Lasting 20-60 seconds fortightness

Lasting 1-2 minutes for pain2-3 oscillations per second

Apply smooth, regularoscillations

Vary speed of oscillationsfor different effects

For painful joints, applyintermittent distraction for 7-

10 seconds with a fewseconds of rest in betweenfor several cycles

For restricted joints, apply aminimum of a 6-second

stretch force, followed bypartial release then repeatwith slow, intermittentstretches at 3-4 secondintervals

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Patient Response

May cause soreness

Perform joint mobilizations on alternate days to

allow soreness to decrease & tissue healing tooccur

Patient should perform ROM techniques

Patients joint & ROM should be reassessed after

treatment, & again before the next treatment

Pain is always the guide

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Joint Traction Techniques

Technique involving pulling one articulating surface

away from anothercreating separation

Performed perpendicular to treatment plane Used to decrease pain or reduce joint hypomobility

Kaltenborn classification system

Combines traction and mobilization

Joint looseness = slack

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References

Houglum, P.A. (2005). Therapeutic exercise formusculoskeletal injuries, 2nd ed. Human Kinetics:Champaign, IL

Kisner, C. & Colby, L.A. (2002). Therapeuticexercise: Foundations and techniques, 4th ed. F.A.Davis: Philadelphia.

http://www.pt.ntu.edu.tw/hmchai/Kinesiology/KINmotion/JointStructionAndFunciton.htm

www.google.com (images)

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