Peripheral joint mobilizationMade by Sajida Mazhar

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.

•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

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.

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

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.

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

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

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.

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

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.

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

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

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.

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

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.

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.

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

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.

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.

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

• 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

• 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

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

• 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.

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.

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

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

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-

Normal motion

Grades of Oscillations (Maitland)

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

•The small-amplitude joint techniques used to

•treat pain, muscle guarding, or muscle spasm should not

•place stretch on the reactive tissues

•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

CONTRAINDICATIONSAND PRECAUTIONS•Hypermobility•Joint Effusion•Inflammation

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