PERIPHERAL JOINT MOBILIZATION

COURSE LEARNING OUTCOMES

At the end of this lesson, student should be able to :

Define terms used in peripheral joint mobilization techniques.

Explain basic concept of joint motion and position.

Explain the effects of joint mobilization.

Identify and list indication, contraindication, precautions and the limitation of joint

mobilization techniques.

Explain the concept of joint mobilization grading scale.

OVERVIEW (PART 1)Introduction

Definition of terms

Basic Concept of Joint Motion (Arthrokinematics)

Effects of Mobilization

Indication and Contraindication

Limitation of Joint Mobilization

Closed and Loose Packed Joint Position

Grading Scales

Introduction

Joint mobilization : Manual therapy techniques that are used to

modulate pain and treat joint dysfunctions that limit range of

motion and specifically altered mechanics of joint.(Kisner,C.& Colby, L.(2007) Therapeutic Exercise; Foundation and techniques,5th ed,F.A

Davis)

Define the terms used in Joint Mobilization•passive, skilled manual therapy techniques

•applied at joint and related soft tissues

• varying speed and amplitude

•using physiological or accessory motion

Mobilization

•self stretching technique that specifically use joint traction/glides that direct the stretch force to the joint capsule. Self-mobilization

•concurrent application of sustained accessory mobilization applied by a therapist and an active physiological movement to ER applied by the patient.

Mobilization with movement (MWM)

•movement that patient can do voluntarilyPhysiological movement

•movement in the joint & surrounding soft tissues that are necessary for normal ROM, BUT not actively performed by patient.Accessory movement

• motion that accompany active movement but not voluntarily control (scapula movt).

Component motion

• motion that occur between joint surface.Joint Play

• high velocity, short amplitude motion

• - end of pathological limit of the joint

• - alter positional relationship, snap, adhesions or stimulate joint receptor

Thrust

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

x

Y

Z

Joint Shapes & Arthrokinematics Ovoid – one surface is convex, other surface

is concave What is an example of an ovoid joint?

Sellar (saddle) – one surface is concave in one direction & convex in the other, with the opposing surface convex & concave respectively What is an example of a sellar joint?

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

Roll

A series of points on one articulating surface come into

contact with a series of points on another surface Rocking chair analogy; 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

Spin

Occurs when one bone rotates around a stationary longitudinal mechanical axis Same point on the moving surface creates an arc of a circle as the bone spins

Example: Radial head at the humeroradial joint during pronation/supination; shoulder

flexion/extension; hip flexion/extension

Spin does not occur by itself during normal joint motion

Slide Specific point on one surface comes into contact

with a series of points on another surface

Surfaces are congruent

When a passive mobilization technique is 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 surfaces are, the more

rolling there is

Compression

Decrease in space between two joint surfaces

Adds stability to a joint

Normal reaction of a joint to muscle contraction

Normal compression occurs in spine and extremities during weight bearing.

Normal intermittent compressive load helps move synovial fluid and thus maintain cartilage health.

Abnormal high compression loads may lead to articular cartilage changes and deterioration.

Distraction

Two surfaces are pulled apart

Often used in combination with joint mobilizations to increase stretch of capsule.

Long axis traction is different form distraction.

Convex-Concave & Concave-Convex Rule

Basic application of correct mobilization techniques -

**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 bone movement (convex is

STABLE)

If concave joint is moving on stationary convex surface – glide

occurs in same direction as roll

Convex-concave rule: convex joint surfaces 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

The shape of the joint surface influences the direction of the accessory movement

If surface of moving bone is convex, sliding is in the opposite direction of the

bone’s physiological movement

If the surface of the moving bone is concave, sliding is in the same direction as the

physiological movement of the bone

EFFECTS

Moving synovial fluid.

Retard cartilage atrophy

Maintain extensibility/tensile strength

Stimulate afferent nerve impulse

Indications

Pain - small amplitude oscillations to treat

Muscle spasm/guarding - gentle oscillations

and sustained stretch to maintain joint play

Joint hypomobility/stiffness - oscillatory

forces used to stretch joint capsule

Goals: stimulate neurophysiological and

mechanical effects.

- Positional faults/subluxations – after prolonged

immobilized, faulty tracking of the joint surface

- Progressive limitation- mechanical restrictions

- Functional immobility – maintain available joint play and

prevent degenerating and restricting effect.

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

Limitation

Techniques cannot change a disease process Be careful with unexplained pain syndromes

Therapist skill will affect the outcome

Precautions

Malignancy

Total joint replacement

Healed tissue

Systemic connective tissue disease

Elderly

Position of the joints

Closed packed position (tightly packed

position)

- maximal contact of the articular surface

- extreme end of the ROM

- avoid position for joint mobilization

Loosed packed position (resting position)

- joint structures are most relaxed

- contacts between joint surface are lesser

Grading scale

2 systems of grading:

Graded oscillation techniques. (Maitland)

Sustained translatory joint play techniques. (Kalterborn)

Grades of Oscillations (Maitland)

Dosages:

Grade I - small amplitude rhythmic oscillations at the beginning of the range (pain and spasm)

Grade II - large amplitude rhythmic oscillations within the midrange of the movement, not reaching the limit (pain and spasm)

Grade III - large amplitude rhythmic oscillations up to the limit of available motion and stressed into tissue resistance (into restriction)

Grade IV - small amplitude rhythmic oscillations to the limit of available motion and stress into the tissue resistance (not pain)

Grade V - small amplitude, high velocity(quick) thrust manipulation at end range- required advanced training!

Grades of Oscillations (Maitland)

GRADED OSCILLATION TECHNIQUES

Uses

Grades I and II

for joints limited by pain

Grades III and IV

stretching maneuvers

Sustained Translatory Joint-Play Techniques

Dosages:

Grade I (loosen)- small amplitude distraction is applied

where no stress is placed on the capsule. It equalizes cohesive

forces, muscle tension, and atmospheric pressure acting on the

joint.

Grade II (tighten) – enough distraction or glide is applied

to tighten the tissues around the joint.

Grade III (stretch) – a distraction or glide is applied with an

amplitude large enough to place stretch on the joint capsule

and surrounding periarticular structures.

SUSTAINED TRANSLATORY JOINT-PLAY TECHNIQUES

Uses

Grade I distraction

Used with all the gliding motions

For relief of pain

SUSTAINED TRANSLATORY JOINT-PLAY TECHNIQUES

Grade II distraction

For INITIAL TREATMENT

May be used to inhibit pain when applied

intermittently

SUSTAINED TRANSLATORY JOINT-PLAY TECHNIQUES

Grade II glides

May be used to maintain joint play when ROM

is not allowed

SUSTAINED TRANSLATORY JOINT-PLAY TECHNIQUES

Grade III distraction or glides

Used to stretch the joint structures and thus

increase joint play

REFERENCE:

Kisner, C. & Colby, L.A. (2007). Therapeutic Exercise Foundations and

Techniques, 5th ed. Chapter 5.

Lakshmi,S.N. (2005). Textbook Therapeutic Exercises,1st ed. Chapter 10.

http//www.podcaster.tv-episodes-joint traction versus bone traction in shoulder

joint 5782985.html

BRAIN CHALLENGE

What are the different between

mobilization and manipulation?

PRACTICAL SESSIONS (3 hours)

1) Find out the human joint shape for:

- UL (shoulder complex, elbow, radioulnar, carpometacarpal)

- LL (hip, knee, ankle, metatarsophalangeal)

2) Find out the closed and loosed packed position for joint:

- UL (shoulder complex, elbow, radioulnar, carpometacarpal)

- LL (hip, knee, ankle, metatarsophalangeal)

THANK YOU