Peripheral joint mobilization Made 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, Is alter positional relationships 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 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 JOINT MOTION: 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 In sellar 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.

Rolling Rolling, 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/Translation Slide/Translation Characteristics 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.

Closed-packed Position Open-packed Position Joint Closed-packed Position Open-packed Position Glenohumeral 90o ABD & Full ER combo 55o flexion w/ 20-30o HABD Elbow Humeroulnar Humeroradial Raduioulnar Full Extension 90o flex w/ mid-pronation Full pronation or supination 70o Flex w/ 10o supination Full ext w/ full supination 70o flex w/ 35o supination Distal Radiocarpal Joint Full extension & radial deviation or full flex Neutral position MCP joints 2-5 1 Full flexion Full opposition 20o flexion IP joints 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 1 MTP = 20o DF 2-5 MTP = 20o PF IP’s = 20o PF

10 simple steps Evaluation and Assessment Determine grades and dosage Patient position Joint position Stabilization Treatment force Direction of movement Speed and rhythm Initiation of treatment 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 JOINT MOBILIZATION 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

CONTRAINDICATIONS AND PRECAUTIONS Hypermobility Joint Effusion Inflammation

Conditions Requiring Special Precautions 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