1- Mobilization.pptx

Mobilization is a technique generally given by physiotherapist for improving mobility in different segments of the body

1. Mobilization Rushi Gajjar 1

2. Joint mobilization refers to manual therapy techniques that are used to modulate pain and treat joint dysfunctions that limit range of motion (ROM) by specifically addressing the altered mechanics of the joint 2

3. Causes for alter joint mechanics Pain and muscle guarding, Joint effusion, Contractures or adhesions in the joint capsules or supporting ligaments, Malalignment or subluxation of the bony surfaces. 3

4. Terms Mobilization/Manipulation Self-Mobilization (Auto-mobilization ) Mobilization with Movement Physiological Movements Accessory Movements Thrust Manipulation Under Anaesthesia Muscle Energy 4

5. 5 PHYSIOLOGICAL LIMIT

6. Mobilization/ Manipulation Mobilization and manipulation 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. 6

7. Self-Mobilization (Auto-mobilization) Self-mobilization refers to self-stretching techniques that specifically use joint traction or glides that direct the stretch force to the joint capsule 7

8. Mobilization with Movement Brian Mulligan Mobilization with movement (MWM) is the concurrent application of sustained accessory mobilization applied by a therapist and an active physiological movement to end range applied by the patient Passive end-of-range overpressure, or stretching, is then delivered without pain as a barrier . The techniques are always applied in a pain-free direction and are described as correcting joint tracking from a positional fault 8

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10. Physiological Movements Physiological movements are movements the patient can do voluntarily The term osteo -kinematics is used when these motions of the bones are described. 10

11. Accessory Movements Accessory movements are movements in the joint and surrounding tissues that are necessary for normal ROM but that cannot be actively performed by the patient. 11

12. Component motions are those motions that accompany active motion but are not under voluntary control. For example, motions such as upward rotation of the scapula and rotation of the clavicle, which occur with shoulder flexion, and rotation of the fibula, which occurs with ankle motions, are component motions 12

13. Joint play Joint play describes the motions that occur between the joint surfaces and also the distensibility or “give” in the joint capsule, which allows the bones to move The movements include distraction, sliding, compression, rolling, and spinning of the joint surfaces. The term arthro -kinematics is used when these motions of the bone surfaces within the joint are described . 13

14. Thrust Thrust is a high-velocity, short-amplitude motion such that the patient cannot prevent the motion . The motion is performed at the end of the pathological limit of the joint and is intended to alter positional relationships, snap adhesions, or stimulate joint receptors Pathological limit means the end of the available ROM when there is restriction 14

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16. Manipulation Under Anaesthesia 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. 16

17. 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 . A command for an isometric contraction of the muscle is given that causes accessory movement of the joint 17

18. 18 OVOID SURFACE SELLAR SURFACE

19. ARTHROKINEMATICS Joint Shapes ovoid or S ellar 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, respectively; similar to a horseback rider being in complementary opposition to the shape of a saddle 19

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21. Types of Motion The movement of the bony lever is called swing The amount of movement can be measured in degrees with a goniometer and is called ROM . Motion of the bone surfaces in the joint is a variable combination of rolling and sliding, or spinning 21

22. Roll Representation of one surface rolling on another. 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 (Fig. 5.3A) or concave (Fig. 5.3B). 22

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24. Slide/Translation Representation of one surface sliding on another, whether (A) flat or (B) curved. The same point on one surface comes into contact with new points on the opposing surface . Sliding is in the opposite direction of the angular movement of the bone if the moving joint surface is convex (Fig. 5.5A). Sliding is in the same direction as the angular movement of the bone if the moving surface is concave ( convex-concave rule) 24

25. Convex-concave rule 25

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27. Spin Representation of spinning. 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 . combination with rolling and sliding . Example shoulder with flexion/extension, the hip with flexion/extension, and the radio-humeral joint with pronation/supination 27

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29. Other Accessory Motions that Affect the Joint Compression Compression is the decrease in the joint space between bony partners. Normal intermittent compressive loads help move synovial fluid and thus help maintain cartilage health. Abnormally high compression loads may lead to articular cartilage changes and deterioration. 29

30. Traction/Distraction Traction is a longitudinal pull. Distraction is a separation, or pulling apart . whenever there is pulling on the long axis of a bone, the term long-axis traction is used. Whenever the surfaces are to be pulled apart, the term distraction, joint traction, or joint separation is used . For joint mobilization techniques, distraction is used to control or relieve pain when applied gently or to stretch the capsule when applied with a stretch force. A slight distraction force is used when applying gliding techniques. 30

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32. Effects of Joint Motion Maintain extensibility and tensile strength of the articular and peri -articular tissues Provide awareness of position and motion With injury or joint degeneration, there is a potential decrease in an important source of proprioceptive feedback that may affect an individual’s balance response. Joint motion provides sensory input 32

33. INDICATIONS FOR JOINT MOBILIZATION Pain, Muscle Guarding, and Spasm Reversible Joint Hypo-mobility Positional Faults/Subluxations Progressive Limitation Functional Immobility 33

34. INDICATIONS FOR JOINT MOBILIZATION Pain, Muscle Guarding, and Spasm gentle joint-play techniques to stimulate neurophysiological and mechanical effects . Neurophysiological Effects may inhibit the transmission of nociceptive stimuli at the spinal cord or brain stem levels.2 Mechanical Effects synovial fluid motion, which is the vehicle for bringing nutrients to the avascular portions of the articular cartilage (and intra-articular fibrocartilage Gentle joint-play techniques help maintain nutrient exchange and thus prevent the painful and degenerating effects of stasis when a joint is swollen or painful and cannot move through the ROM. The small-amplitude joint The small-amplitude joint techniques used to treat pain, muscle guarding, or muscle spasm should not place stretch on the reactive tissues 34

35. Reversible Joint Hypo-mobility Reversible joint hypo-mobility can be treated with progressively vigorous joint-play stretching techniques to elongate hypo-mobile capsular and ligamentous connective tissue . Sustained or oscillatory stretch forces are used to distend the shortened tissue mechanically 35

36. Positional Faults/Subluxations Malposition of one bony partner with respect to its opposing surface may result in limited motion or pain . MWM techniques attempt to realign the bony partners while the person actively moves the joint through its ROM.21 Manipulations are used to reposition an obvious subluxation, such as a pulled elbow or capitate-lunate subluxation 36

37. Progressive Limitation Diseases that progressively limit movement can be treated with joint-play techniques to maintain available motion or retard progressive mechanical restrictions . 37

38. Functional Immobility When a patient cannot functionally move a joint for a period of time, the joint can be treated with non-stretch gliding or distraction techniques to maintain available joint play and prevent the degenerating and restricting effects of immobility. 38

39. LIMITATIONS OF JOINT MOBILIZATION TECHNIQUES Mobilization techniques cannot change the disease process of disorders such as rheumatoid arthritis or the inflammatory process of injury. In these cases, treatment is directed toward minimizing pain, maintaining available joint play, and reducing the effects of any mechanical limitation 39

40. CONTRAINDICATIONS Hypermobility Patients with painful hypermobile joints may benefit from gentle joint-play techniques if kept within the limits of motion 40

41. Joint Effusion There may be joint swelling (effusion) due to trauma or disease. Rapid swelling of a joint usually indicates bleeding in the joint and may occur with trauma or diseases such as hemophilia necrotizing effect on the articular cartilage. Slow swelling (more than 4 hours) usually indicates serous effusion (a buildup of excess synovial fluid) or edema in the joint due to mild trauma, irritation, or a disease such as arthritis . If the patient’s response to gentle techniques results in increased pain or joint irritability, the techniques were applied too vigorously or should not have been done with the current state of pathology 41

42. Inflammation Whenever inflammation is present, stretching increases pain and muscle guarding and results in greater tissue damage. Gentle oscillating or distraction motions may temporarily inhibit the pain response 42

43. PRECAUTIONS Malignancy Bone disease detectable on radiographs Unhealed fracture Excessive pain Hypermobility in associated joints Total joint replacements Newly formed or weakened connective tissue such as immediately after injury, surgery, or disuse or when the patient is taking certain medications such as corticosteroids Systemic connective tissue diseases such as rheumatoid arthritis, in which the disease weakens the connective tissue Elderly individuals with weakened connective tissue and diminished circulation 43

44. PROCEDURES FOR APPLYING PASSIVE JOINT MOBILIZATION TECHNIQUES 44

45. Quality of pain If pain is experienced before tissue limitation: muscle guarding after an acute injury or during the active stage of a disease If pain is experienced concurrently with tissue limitation: damaged tissue begins to heal If pain is experienced after tissue limitation: tight capsular or peri -articular tissue, the stiff joint 45

46. Capsular restriction Passive ROM is limited Firm capsular end feel Decrease joint play movement 46

47. Subluxation or dislocation Subluxation: Partial displacement of the articulating joint surfaces Dislocation: Total displacement of the articulating joint surfaces 47

48. Grades or dosages of movement 48

49. Grades and their usages 49 Grade I and II are primarily used for treating joints limited by pain . Grades III and IV are primarily used as stretching maneuvers ( Increase ROM ).

50. 50 Anterior Posterior

51. Kaltenborn’s Sustained Translatory Joint-Play Techniques 51

52. Grades and usages 52 Grade I distraction is used with all gliding motions and may be used for relief of pain. Grade II distraction is used for the initial treatment to determine how sensitive the joint is. Once the joint reaction is known, the treatment dosage is increased or decreased accordingly Gentle grade II distraction applied intermittently may be used to inhibit pain . Grade II glides may be used to maintain joint play when ROM is not allowed. Grade III distractions or glides are used to stretch the joint structures and thus increase joint play

53. 53 Glenoid cavity Humerus Capsule/ Ligaments Separating force

54. Positioning and Stabilization Patient in relax position the first treatment are initially performed in the resting position for that joint so the greatest capsule laxity is possible then end or available ROM Firmly and comfortably stabilize one joint partner, usually the proximal bone. 54

55. Treatment Force and Direction of Movement Either gentle or strong The plane is in the concave partner, so its position is determined by the position of the concave bone Distraction techniques are applied perpendicular to the treatment plane Gliding techniques are applied parallel to the treatment plane 55

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57. Speed, Rhythm, and Duration of Movements Grades II and III are smooth, regular oscillations at 2 or 3 per second for 1 to 2 minutes low amplitude and high speed to inhibit pain or slow speed to relax muscle guarding For painful joints, apply intermittent distraction for 7 to 10 seconds with a few seconds of rest in between for several cycles . For restricted joints, apply a minimum of a 6-second stretch force followed by partial release (to grade I or II), then repeat with slow, intermittent stretches at 3- to 4- second intervals. 57

58. MOBILIZATION WITH MOVEMENT: PRINCIPLES OF APPLICATION Brian Mulligan’s concept self-stretching exercises, to therapist-applied passive physiological movement, to passive accessory mobilization techniques pain-free accessory mobilization with active and/or passive physiological movement. Passive end-range overpressure or stretching is then applied without pain as a barrier 58

59. Principles of MWM in Clinical Practice Comparable signs: A comparable sign is a positive test sign that can be repeated after a therapeutic maneuver to determine the effectiveness of the maneuver A comparable sign may include loss of joint play movement, loss of ROM, or pain associated with movement during specific functional activities such as lateral elbow pain with resisted wrist extension, painful restriction of ankle dorsiflexion, or pain with overhead reaching. 59

60. A passive joint mobilization Various combinations of parallel or perpendicular accessory glides to find the pain-free direction and grade of accessory movement There should be increased ROM, and the motion should be free of the original pain. The previously restricted and/or painful motion or activity is repeated 6 to 10 times by the patient while the therapist continues to maintain the appropriate accessory mobilization 60

61. PERIPHERAL JOINT MOBILIZATION TECHNIQUES 61