Peripheral joint mobilization

Physiotherapy

1. Peripheral Joint Mobilization/Manipulation

2. Joint mobilization, also known as manipulation, refers to manual therapy techniques that are used to modulate pain and treat joint impairments that limit range of motion (ROM) by specifically addressing the altered mechanics of the joint. The altered joint mechanics may be due to pain and muscle guarding, joint effusion, contractures or adhesions in the joint capsules or supporting ligaments, or aberrant joint motion.

3. High-velocity thrust techniques, typically called manipulation. The terms “mobilization” and “manipulation” will be used interchangeably, with the distinction made between non-thrust and thrust technique.

4. Mobilization/Manipulation 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.

5. Thrust manipulation/high-velocity thrust (HVT). Thrust refers to high-velocity, short-amplitude techniques. The thrust 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.

6. 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. Mobilization with Movement 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. Physiological Movements Physiological movements are movements the patient can do voluntarily (e.g., the classic or traditional movements, such as flexion, abduction, and rotation). The term osteokinematics is used when these motions of the bones are described.

9. 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. Terms that relate to accessory movements are component motions and joint play.

10. Component motions These are motions that accompany active motion but are not under voluntary control. The term is often used synonymously with accessory movement. 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.

11. 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 are necessary for normal joint functioning through the ROM and can be demonstrated passively, but they cannot be performed actively by the patient. The movements include distraction, sliding, compression, rolling, and spinning of the joint surfaces. The term arthrokinematics is used when these motions of the bone surfaces within the joint are described.

12. Manipulation Under Anesthesia Manipulation under anesthesia is a 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. Therapists may assist surgeons in the application of these skilled techniques in the operating room and continue with follow-up care.

13. Muscle Energy Techniques 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 technique requires the therapist to provide stabilization to the segment on which the distal aspect of the muscle attaches. A command for an isometric contraction of the muscle is given that causes accessory movement of the joint

14. Basic Concepts of Joint Motion: Arthrokinematics Joint Shapes In ovoid joints one surface is convex, and the other is concave. ■ In sellar (saddle) 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.

15. Types of Motion As a bony lever moves about an axis of motion, there is also movement of the bone surface on the opposing bone surface in the joint. ■ The movement of the bony lever is called swing and is classically described as flexion, extension, abduction, adduction, and rotation. 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. These accessory motions allow greater angulation of the bone as it swings. For the rolling, sliding, or spinning to occur, there must be adequate capsule laxity or joint play.

16. ROLL 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.

17. Rolling, if it occurs alone, causes compression of the surfaces on the side to which the bone is swinging and separation on the other side. Passive stretching using bone angulation 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.

18. Slide/Translation 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. ■ 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.

19. Combined Roll-Sliding in a Joint ■ The more congruent the joint surfaces are, the more sliding there is of one bony partner on the other with movement. ■ The more incongruent the joint surfaces are, the more rolling there is of one bony partner on the other with movement. ■ When muscles actively contract to move a bone, some of the muscles may cause or control the sliding movement of the joint surfaces. For example, the caudal sliding motion of the humeral head during shoulder abduction is caused by the rotator cuff muscles, and the posterior sliding of the tibia during knee flexion is caused by the hamstring muscles.If this function is lost, the resulting abnormal joint mechanics may cause microtrauma and joint dysfunction.

20. The joint mobilization techniques described in this chapter use the sliding component of joint motion to restore joint play and reverse joint hypomobility . Rolling (passive angular stretching) is not used to stretch tight joint capsules, because it causes joint compression.

21. 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

22. Passive-Angular Stretching Versus Joint-Glide Stretching Passive-angular stretching procedures, as when the bony lever is used to stretch a tight joint capsule, may cause increased pain or joint trauma because: ■ The use of a lever magnifies the force at the joint. ■ The force causes compression of the joint surfaces in the direction of the rolling bone. The roll without a slide does not replicate normal joint mechanics.

23. Joint glide stretching procedures, as when the translatory slide component of the joint function is used to stretch a tight capsule, are safer and more selective because: ■ The force is applied close to the joint surface and controlled at an intensity compatible with the pathology. ■ The direction of the force replicates the sliding component of the joint mechanics and does not compress the cartilage. ■ The amplitude of the motion is small yet specific to the restricted or adherent portion of the capsule or ligaments. Thus, the forces are selectively applied to the desired tissue.

24. Effects of Joint Motion Joint motion stimulates biological activity by moving synovial fluid, which brings nutrients to the avascular articular cartilage of the joint surfaces and intra- articular fibrocartilage of the menisci. Atrophy of the articular cartilage begins soon after immobilization is imposed on joints.

25. Extensibility and tensile strength of the articular and periarticular tissues are maintained with joint motion. With immobilization there is fibrofatty proliferation, which causes intra- articular adhesions as well as biochemical changes in tendon, ligament, and joint capsule tissue, which in turn causes joint contractures and ligamentous weakening

26. Afferent nerve impulses from joint receptors transmit information to the central nervous system and, therefore, 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.

27. Joint motion provides sensory input relative to ■ Static position and sense of speed of movement (type I receptors found in the superficial joint capsule). ■ Change of speed of movement (type II receptors found in deep layers of the joint capsule and articular fat pads). Sense of direction of movement (type I and III receptors; type III found in joint ligaments). ■ Regulation of muscle tone (type I, II, and III receptors). ■ Nociceptive stimuli (type IV receptors found in the fibrous capsule, ligaments, articular fat pads, periosteum , and walls of blood vessels).

28. Indications for Use of Joint Mobilization/ Manipulation Pain, Muscle Guarding, and Spasm Neurophysiological Effects Mechanical Effects Reversible Joint Hypomobility Positional Faults/ Subluxations Progressive Limitation Functional Immobility

29. Non-Thrust Oscillation Techniques Dosage and Rate of Application Grade I. Small-amplitude rhythmic oscillations are performed at the beginning of the range. They are usually rapid oscillations , like manual vibrations. Grade II. Large-amplitude rhythmic oscillations are performed within the range, not reaching the limit. They are usually performed at 2 or 3 per second for 1 to 2 minutes. Grade III. Large-amplitude rhythmic oscillations are performed up to the limit of the available motion and are stressed into the tissue resistance. They are usually performed at 2 or 3 per second for 1 to 2 minutes. Grade IV. Small-amplitude rhythmic oscillations are performed at the limit of the available motion and stressed into tissue resistance. They are usually rapid oscillations, like manual vibrations.

30. Non-Thrust Sustained Joint-Play Techniques Dosages and Rate of Application Grade I (loosen). Small-amplitude distraction is applied when 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. Kaltenborn15 called this “taking up the slack.” 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.

31. Indications ■ Grade I distraction is used with all gliding motions and may be used for relief of pain. Apply intermittent distraction for 7 to 10 seconds with a few seconds of rest in between for several cycles. Note the response and either repeat or discontinue. ■ Grade II distraction is used for the initial treatment to determine the sensitivity of the joint. 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. 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.

32. Positioning and Stabilization ■ The patient and the extremity to be treated should be positioned so the patient can relax. To relax the muscles crossing the joint, techniques of inhibition may be used prior to or between mobilization techniques. ■ Examination of joint play and the first treatment are initially performed in the resting position for that joint, so the greatest capsule laxity is possible. In some cases, the position to use is the one in which the joint is least painful.

33. With progression of treatment, the joint is positioned at or near the end of the available range prior to application of the mobilization force. This places the restricting tissue in its most lengthened position where the stretch force can be more specific and effective. ■ Firmly and comfortably stabilize one joint partner, usually the proximal bone. A belt, one of the therapist’s hands, or an assistant holding the part may provide stabilization. Appropriate stabilization prevents unwanted stress to surrounding tissues and joints and makes the stretch force more specific and effective.