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11/26/2008
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B.ARUNB.ARUNB.ARUNB.ARUN.,MPT,CMPT,COHS.,MPT,CMPT,COHS.,MPT,CMPT,COHS.,MPT,CMPT,COHS
ORTHOPEDIC PHYSIOTHERAPYORTHOPEDIC PHYSIOTHERAPYORTHOPEDIC PHYSIOTHERAPYORTHOPEDIC PHYSIOTHERAPY
DEFINITION
• Mobilizations: these are passive movements
performed by therapist at a slow speed enough
that the patient can stop the movement.
• Manipulations: these are sudden movements
performed with a high velocity, short amplitude
motion such that the patient cannot prevent the
motion.
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Terminology
• Mobilization – passive joint movement for
increasing ROM or decreasing pain
– Applied to joints & related soft tissues at varying
speeds & amplitudes using physiologic or accessory motions
– Force is light enough that patient’s can stop the movement
• Manipulation – passive joint movement for
increasing joint mobility
– Incorporates a sudden, forceful thrust that is beyond the patient’s control
Terminology
• Self-Mobilization (Automobilization) –self-stretching techniques that specifically use joint traction 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 clinician & an active physiologic movement to end range applied by the patient– Applied in a pain-free direction
Terminology• Physiologic Movements – movements done
voluntarily
– Osteokinematics – motions of the bones
• Accessory Movements – movements within the
joint & surrounding tissues that are necessary for
normal ROM, but can not be voluntarily performed
– Component motions – motions that accompany active
motion, but are not under voluntary control
• Ex: Upward rotation of scapula & rotation of clavicle that occur with shoulder flexion
– Joint play – motions that occur within the joint
• Determined by joint capsule’s laxity
• Can be demonstrated passively, but not performed actively
Terminology• Arthrokinematics – motions of bone surfaces within the
joint– 5 motions - Roll, Slide, Spin, Compression, Distraction
• Muscle energy – use an active contraction of deep muscles that attach near the joint & whose line of pull can cause the desired accessory motion– Clinician stabilizes segment on which the distal aspect of the
muscle attaches; command for an isometric contraction of the muscle is given, which causes the accessory movement of the joint
• Thrust – high-velocity, short-amplitude motion that the patient can 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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Joint Surfaces of Ovoid
and Sellar Joints KINEMATICS • Physiological Movements & Accessory
movements.
• Also called as
• Osteokinematics (Physiological
movements)
• Arthrokinematics. (Accessory movements
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Osteokinematics
• Deals about the movement present in the joint
• Helps to find out the amount of Motion
available in particular joint
• Can be visualized
• Can be measured
• Also called as Physiological movements
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ARTHROKINEMATICS
• Also termed as Accessory movements
• Movements occurs inside the joint.
• Responsible for improving Physiological
movements.
• Restriction in accessory motion results in
decrease of physiological movements.
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Arthrokinematics
• Roll
• Glide / Slide
• Spin
• Compression
• Distraction26-11-2008 11
Roll
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Slide Spin
Compression Distraction
CONCAVE AND CONVEX
RULE
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Grades of Movement in a
Normal and a Restricted Joint
Adapted by permission from G. Maitland 1991.
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 & II – often used before & after treatment with grades III & IV
• 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
OSCILLATION MOBILIZATION
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Beginning range of
movement
Pathological limit of
movement
Normallimit of
movement
Kaltenborn Traction
Grading• Grade I (loosen)
– Neutralizes pressure in joint without actual surface
separation
– Produce pain relief by reducing compressive forces
• Grade II (tighten or take up slack)
– Separates articulating surfaces, taking up slack or eliminating play within joint capsule
– Used initially to determine joint sensitivity
• Grade III (stretch)
– Involves stretching of soft tissue surrounding joint
– Increase mobility in hypomobile joint
SUSTAINED MOBILIZATION
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INDICATIONS
• Pain
• Muscle spasm
• Decreased ROM
• Hypomobile Joints
• Reduce Functionally Mobility.
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CONTRAINDICATION • Inflammatory arthritis ( RA, AKS)
• Malignancy
• Bone disease
• Bone Fracture
• Vascular disorder
• Unskilled manipulator
• Joint effusion26
• Pregnancy
• TKR, THR
• Closed pack position
• Cauda equina lesion.
• Undiagnosed pain
• Protective muscle
spasm
• Inability of the patient
to relax.
• Rubbery end feel of the
joint.
• Evidence of involvement
of 2 adjacent nerve root
in lumbar spine
• Lower limb neurological
symptoms due to
cervical or thoracic
dysfunction.27
CAUSES FOR COMPLICATIONS
• Practioner — Related complications
� Diagnostic error
� Lack of skill
� Lack of interprofessional consultation
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Patient — Related complications
� Patient with psychological intolerance of pain.
� Patient involved in litigation
� Patient recently undergone treatment to any
practioners.
� Patient develop psychological dependence on
manipulation.
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• Patient in whom uncomplicated sciatica
becomes a unilateral radiculopathy with distal
paralysis of limb, sensory loss.
• These patients usually doesn’t respond to
manipulation & should be considered as
surgical emergency.
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JOINT POSITIONSJOINT PLAY
• Each joint in the body has positioned to
make maximum amount of motion.
• Joint should be positioned in a Relaxed
position.
RESISTING POSITION:
• The position in which the joint capsule &
ligaments are relaxed.
• Helps in evaluation of the joint
• Treatment done for hypomobile joints
• Placing the joint in resting position allows the
joint to assumes a Loose pack position
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Closed pack position:
• Here maximal contact of articular surface of
bones with capsule & ligaments are tense or
tight.
• No movement is seen.
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TREATMENT PLANES
• Direction of movement is either parallel or
Perpendicular to the treatment planes.
• Joint traction – Perpendicular to the
treatment plane
• Glides — Parallel to the
treatment planes.
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TREATMENT FORCE
• It should be close to the opposing joint surface,
• Either Gentle or Strong.
• Large contact area will be more comfortable than
small surfaces..
• Like use of Hand is advised than Thumb for
mobilizing larger joint or Surface.
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SPEEDOSCILLATIONS:
• Grade I & IV are usually rapid oscillations
• Grades II & III are smooth, regular oscillations at
two or three per second for 1 to 2 minutes.
• Vary the speed of oscillation for different effects
such as low amplitude and high speed to inhibit
pain or slow speed to relax muscle guarding.
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Sustained:
• Painful joints : Apply intermittent distraction 7—10 sec
• Few seconds of Rest in-between.
• If no response Repeat correctly or Discontinue.
• Resisted Joints :
• Apply for 6 sec stretch force
• Followed by partial release
• Repeat with intermittent stretches for 3—4 sec intervals.
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LIMITATION
1. Can’t change the disease process of Disorders.
2. Like OA,RA manual therapy helps in Reducing
pain & mobilize joints.
3. Skill of therapist affects outcome.
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PRINCIPLES OF MANUAL THERAPY
• The principles are summarize by clinicians such as
Grieves, Maitland, Cyriax ect..
1. Remember the contraindications & conditions
require extra care.
2. Don’t harm the patient or yourself
3. A through examination is necessary
4. Make an accurate diagnosis as possible based on
solid knowledge of anatomy. 39
5. All pain arise from lesion, so treatment should
focus on the lesion.
6. Constant reassess to determine the effect of the
technique being used.
7. Progress is governed by the response to previous
treatment.
8. Discontinue technique that are not productive
9. Make the patient to relax, reduce anxiety & fear.
10.Don’t force the protective muscle spasm.40
11. A slight alteration of joint position or angle of
thrust often allows a technique much more
effective.
12. Warm up patients of the potential for post
treatment soreness.
13.Don’t over treat.
14.Aim for restoration of normal , painless
technique.
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Causes of Limited Range of
Motion
• Loss of Extensibility of periarticular connective
tissue structures, ligaments, capsule & fascia.
• Deposition of Fibrofatty infiltrates acting as
intraarticular “Glue”.
• Adaptive shortening of Muscles.
• Breakdown of articular cartilages.
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EFFECTS
• Mobilization showed that it helps in break down of
Muscle shortening and reduce the fibroblastic
proliferations inside the joints.
• Forceful passive movements has shown to
rupture of intra-articular adhesion that forms
during immobilization.
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Pain & Muscle guarding
• Wyke’s explained that Receptors nerve
endings present in various periarticular
structures.
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• Type I (postural) & Type II (dynamic)
mechanoreceptors are located in joint capsule.
• They have low threshold and excited by repetitive
movements including oscillations.
• Type III mechanoreceptors are found in joint
capsules and extracapsular ligaments.
• They are excited in stretching & thrust
maneuvers.
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• Type IV, (Pain receptors), are found in capsule,
ligaments, Fat pads and Blood vessel walls.
• These receptors are fired by noxious stimuli as
in trauma and have a relatively high threshold.
• Type IV are Slow conducting fibers,
• Type I & II are Fast conducting fibers.
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EFFECT OF MANUAL
THERAPY PAIN REDUCTION
• During Oscillatory glides, faster impulses
overwhelm the slower impulses.
• It helps in closing of gate at spinal level.
• Release of Endorphins from CNS.
Melzack R, Torgerson WS: On the language of pain, Anesthesiology, 1971
Wyke B: Articular neurology—a review, physiotherapy, 1958
EFFECTS OF MANUAL
THERAPY
Pain Reduction
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Small amplitude distraction,
Oscillatory
movement
Stimulate mechanorece
ptors
Inhibit
Transmission of Nociceptive
stimuli
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Brings nutrition to Avascular
Articular cartilage
Small Amplitude
Distractions
& Glides
Stimulates Synovial
Fluid motion
Gentle Joint play helps in
maintain Nutrient
exchange
Prevent Painful
Degeneration
Muscle Relaxation
• Type III receptors in joint & golgi tendon organ
fire by stretching or thrusting of a joint result in
temporary inhibition or relaxation of muscle.
• This itself cause an increase Range of motion
and helps prepare the joint for further
stretching & mobilization.
Paris SV: extremity dysfunction and mobilization . Institute Press, Atlanta 1980
Wyke B: Articular neurology—a review, physiotherapy, 1958
IMPORTANT RULES FOR
MOBILIZATION
Described by Stanley. V. Paris.
1. Identify the location and direction of the
limitation. for e.g Ankle stiffness, posterior glide
of talus is restricted.
2. Prepare the soft tissue, (i.e) first reduce the
swelling, pain, muscle guarding or tightness.
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3) Protect neighboring hypermobilities. If patient
is having shoulder dislocation, following a
anterior laxity, mobilization focused on
improving abduction and rotation.
4) Communicate with the surgeon, find out which
tissue have been cut or scarified, and what
motions should be avoided initially.
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WHAT IS THE NAME OF A
CROSS BREED BETWEEN THIS
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