1. Flexibility Definition The ROM available in a jt. or group of jts. The ability of a m. to relax & yield to a stretching force. The freedom or ability to move part or parts of body in a wide R of purposeful movs at the required speed. The ability to move a jt. Through a normal ROM with undue stress to musculo-tendinous unit.

2. Flexibility Flexibility Extensibility of periarticular tissues to allow normal motion of a joint. or a limb. Extensibility of periarticular tissues to allow normal motion of a joint. or a limb. * Hypermobility * Hypermobility The ROM in excess of the accepted normal in most of joints. The ROM in excess of the accepted normal in most of joints. (may be normal) * Laxity * Laxity Excessive jt. instability & abnormal motion of a given joint. Excessive jt. instability & abnormal motion of a given joint. (pathological)

3. Types of Flexibility Ballistic Flexibility: Ballistic Flexibility: Normal ROM associated with bouncing & rhythmic movements. Normal ROM associated with bouncing & rhythmic movements. Dynamic Functional Flexibility: Dynamic Functional Flexibility: Activities that need certain angle to certain joints. & particular patterns (usual activities). Activities that need certain angle to certain joints. & particular patterns (usual activities).

4. Factors Affecting Flexibility 1. Wrong habits: ↓ flexibility sitting for a long period (in school, watching TV, computer work, sedentary games) 2. Good habits: → ↑ flexibility. 3. Genetic factors: females > males. 4. Hormonal factors: females > males. 5. Body build proportion & ↑ height → ↑ flexibility. 6. Body wt. ↑ → ↓ flexibility 7. Age: flexibility changes during a certain age ↑ 2 - 6 y ↓ 6 - 12 y ↑ 18 - 22 y ↓ 35 - up 8. Skills & sport activities → ↑ flexibility.

5. Contractile & Non-contractile Tissue Contractile 1. Ms Non-contractile Non-contractile 1. Skin 2. CT 3. Ligaments 4. Tendons 5. Capsules 6. Synovial Membrane

6. * * N.B. Soft tissues that can restrict joint motion are : Soft tissues that can restrict joint motion are : 1. Skin 2. CT, tendons, ligaments 3. Ms Each one has unique qualities affecting its extensibility (ability to elongate). Each one has unique qualities affecting its extensibility (ability to elongate). Factors affecting soft tissues lengthening : Factors affecting soft tissues lengthening : 1. Velocity of stretch force 2. Intensity of stretch force 3. Duration of stretch force 4. Mechanical properties of contractile & non-contractile tissues 5. Neuro-physiological properties of contractile tissues

7. When soft tissue is stretched, either elastic or plastic changes occur Elasticity Elasticity Ability of soft tissue to return to its resting length after passive stretching. Ability of soft tissue to return to its resting length after passive stretching. Plasticity Plasticity Tendency of soft tissue to assume new & greater length after the stretch force has been removed. Tendency of soft tissue to assume new & greater length after the stretch force has been removed. Both contractile & non-contractile tissues have elastic & plastic properties. Both contractile & non-contractile tissues have elastic & plastic properties.

8. Degrees of Deformity 1 st degree can be corrected actively (shortness). 1 st degree (grade I): can be corrected actively (shortness). 2 nd degree can be corrected passively (shortness). 2 nd degree (grade II): can be corrected passively (shortness). 3 rd degree can’t be corrected neither activelypassively 3 rd degree (grade III): can’t be corrected neither actively nor passively (contractures).

9. Indications of Stretching 1. Limited ROM due to adhesions & scar tissues formation leading to shortening of Muscles, CT & Skin. 2. Prevention of structural ( neglected soft tissue → shortening → structural limitations → deformities 2. Prevention of structural ( neglected soft tissue → shortening → structural limitations → skeletal deformities (prophylactic intervention) 3. When contractures interfere with every day functional activities or nursing care. 3. When there’s muscle weakness & opposing tissue tightness. * Tight muscle must be elongated before weak m. can be effectively strengthened. * Tight muscle must be elongated before weak m. can be effectively strengthened.

10. Goals of Stretching 1. To regain or re-establish normal joint. ROM & mobility of soft tissue surrounding a jt.. 2. To prevent irreversible contractures. 3. To ↑ general flexibility of a part of the body prior to vigorous strengthening excerises. 4. To prevent or minimize risk of musculo-tendinous injuries related to specific physical activities & sports.

11. Precautions to Stretching 1. Don’t passively stretch (force) a joint beyond its normal ROM (Remember that normal ROM varies among normal individuals). (Remember that normal ROM varies among normal individuals). 2. Newly united # should be protected by stabilization between # site & the joint where motion takes place. 3. Extra caution in pts. with known or suspected osteoporosis due to: a. Disease b. Prolonged bed rest c. Aging d. Prolonged use of steroids (cortisone) 4. Avoid vigorous stretching of muscles & CT that have been immobilized over a long period of time. CT lose their tensile strength after prolonged immobilization. 4. Avoid vigorous stretching of muscles & CT that have been immobilized over a long period of time. CT (tendons & ligaments) lose their tensile strength after prolonged immobilization.

12. Precautions to Stretching → traumas → soft tissue weakness a. High intensity, short duration procedures → traumas → soft tissue weakness b. Stretching should be low intensity for long duration stretch. c. Strengthening excerises should be added to stretching program at some point, so patient will be able to develop appropriate balance between flexibility & strength.

13. Contraindications to Stretching 1. Acute infections. 2. Signs of inflammation. 3. Pain at the site to be stretched. 4. Osteomyelites ( acute stage ). 5. Bone tumors. 6. Advanced osteoporosis. 7. Severe spasticity. 8. Pain that isn’t yet evaluated by the PT or physician. 9. Joint laxity (hypermobility). 10. Joint subluxation. 11. Joint dislocation. 12. Joint fusion. 13. Joint deformity. 14. Tissue adhesions (contractures ). 15. Acute Traumas

14. Principles of Stretching 1. Consider the best stretching type to ↑ ROM. 2. Explain goals of stretching to the pt. 3. Position the pt. in a comfortable relaxed pos. → allow the best plane of motion to conduct stretching. 4. Free the area from restrictive clothing, bandage, splints. 5. Apply superficial heating to the soft tissues to be stretched. 6. It will ↓ possibility of injury. 7. Stretch direction is done opposite to tightness. 7. The pt. must be completely relaxed throughout stretching,employ relaxation techniques before stretching.

15. 8. Stretching movs. or exs. are performed at least 3 times/week to maintain flexibility. Progress to daily stretching routines. 9. 1-3 repetitions of each stretch must be done. The No. of repetitions can be ↑ if the goal is to ↑ ROM. 10. Degree of stretch can be ↑ or ↓ depending on time of stretch & external force applied. 11. Tension produced shouldn’t cause pain, the pt should only feel a slight tension, which ↓ with stretching. (due to adaptation) 12. Stretch ↑ gradually, building to a max. as the tissues release. 13. Stretch should be removed gradually to prevent rebouncing or tightening of the ms.

16. Stretching depends on: 1. Type of stretching force. 2. Intensity. 3. Duration 4. Velocity.

17. Types: A. Passive Stretching PT applies an external force & controls stretch 1 direction, 2 speed, 3 intensity & 4 duration to the tight m.. Don’t confuse between: Don’t confuse between: 1. Passive stretching → elongation of soft tissues 1. Passive stretching → elongation of soft tissues beyond full R of restriction. 2. Passive ROM exs. → applied (available) 2. Passive ROM exs. → applied within the unrestricted (available) ROM. Pt. must be completely relaxed during passive stretching. Pt. must be completely relaxed during passive stretching. Time of stretch force is usually 15 : 30 sec & repeated several times during ex. session. Time of stretch force is usually 15 : 30 sec & repeated several times during ex. session.

18. 1. Manual Passive Stretching Usually considered a short-duration stretch. Usually considered a short-duration stretch. No specific No. of secs. are determined to be the most effective duration. No specific No. of secs. are determined to be the most effective duration. In a study to stretch hip abd. of healthy subjects 15, 45 sec & 2 min at the same speed → no difference. In a study to stretch hip abd. of healthy subjects 15, 45 sec & 2 min at the same speed → no difference. Intensity & duration of stretch depend on: Intensity & duration of stretch depend on: 1. Pt’s tolerance 2. PT strength & endurance  Low intensity, long duration manual stretch is more comfortable & tolerated by pt.

19. Maintained versus Ballistic Stretch MANUAL PASSIVE STRETCH HIGH INTENSITY STRETCH MAINTAINED, GENTLE PROLONGED 15-30 SEC OR MORE VERY SLOW QUICK LENGTHENING VERY SHORT DURATION BOUNCING Inhibit stretch reflex & ↓ Muscle tension Facilitate muscle contraction & ↑ tension

20. 2. Prolonged Mechanical Stretch Low intensity external force (5-15 lb) (2: 6 kg) applied to shortened tissues over a prolonged period by mech. equipments. Low intensity external force (5-15 lb) (2: 6 kg) applied to shortened tissues over a prolonged period by mech. equipments. Stretch force is applied through positioning with weighted traction, pulley system, dynamic splint & serial casts. Stretch force is applied through positioning with weighted traction, pulley system, dynamic splint & serial casts. Prolonged stretch may be maintained for 20-30 min. or longer → effective stretch & ↑ ROM Prolonged stretch may be maintained for 20-30 min. or longer → effective stretch & ↑ ROM (low intensity mechanical stretch). (low intensity mechanical stretch). Comparing long-duration mech. stretch & manual passive stretch ( the latter is rather short there’s transient Comparing long-duration mech. stretch & manual passive stretch ( the latter is rather short & there’s transient & temporary achievement of ROM).

21. Examples 1. Bohannon evaluated the effectiveness of an 8 min mechanical hamstring stretch compared to a 20 min or longer using overhead pulley system. The 8 min stretch resulted in a small ↑ in hamstring flexibility, which was lost in 24 hrs. It was suggested that 20 min or longer stretch is more effective to ↑ ROM & has a more permanent basis. 2. Use of tilt table-wedge board standing for 30 min/daily → ↑ dorsiflexion in neurological pts. 3. Dynasplint (dynamic splint) → prolonged low intensity stretch of elbow, wrist, knee & ankle → ↑ ROM. 4. Low intensity prolonged stretch of 5-12 lb applied for 1 hr/daily has been found to be more effective than manual passive stretch over a 4-week period with pt’s with bilateral knee flexion contractures. It is more comfortable

22. Permanent lengthening ( Plastic changes in contractile & non-contractile tissues ) has been reported with long duration stretch. The term “Permanent lengthening” means that the length is maintained after the stretching force is removed. The term “Permanent lengthening” means that the length is maintained after the stretching force is removed.

23. 3. Cyclic Mechanical Stretching It is passive stretching using a mechanical devices as an Autorange using a 20-sec high intensity It is passive stretching using a mechanical devices as an Autorange using a 20-sec high intensity (up to the patient’s pain tolerance). 1. Intensity of stretch, 2. Length of each cycle, 3. No. of stretch cycles/min Can be adjusted with the unit. It is similar & may be used as a useful alternative to manual passive stretching. It is similar & may be used as a useful alternative to manual passive stretching.

24. B. Active Inhibition Is a tech. in which the patient reflexively relaxes muscles to be elongated prior to stretching maneuver. When the patyent is relaxed → minimal R to elongate the m. It relaxes only the: - Contractile structures, - Not the CT. The m. must be: Normally innervated and Under voluntary control. It Can ’ t be used with pts having: 1. Weakness, 2. Spasticity 3. Paralysis (From a neuromuscular disease). It Can be used in: Post-operative patient. (to avoid tightness).

25. Active Inhibition Techniques. 1. Contract-relax 1. Contract-relax (hold-relax): Pt performs an isometric contraction of tight muscle before it is Pt performs an isometric contraction of tight muscle before it is passively stretched (lengthened). passively stretched (lengthened). M. will relax as a result of ”autogenic inhibition” (Golgi tendon organ may fire at ↓ tension). M. will relax as a result of ”autogenic inhibition” (Golgi tendon organ may fire at ↓ tension). 2. Contract-relax-contract 2. Contract-relax-contract (hold-relax-contract). a. 1 st a contraction of tight muscle. b. 2 nd relaxation of tight muscle. (autogenic inhibition). c. 3 rd concentric contraction of opposite muscle (reciprocal inhibition of tight m.). inhibition of tight m.). In a study, the contract-relax-contract produced a greater ↑ in ankle dorsiflexion > contract-relax tech. (in short calf m ). * Both techs produce ↑ ROM > manual stretching. * Both techs produce ↑ ROM > manual stretching.

26. 3. Agonist Contraction Agonist = muscle opposite to the tight muscle. Agonist = muscle opposite to the tight muscle. Antagonist = Tight muscle. Antagonist = Tight muscle. Patient dynamically contracts the muscle opposite to the tight muscle against resistance → reciprocal inhibition of tight muscle. Patient dynamically contracts (shortens) the muscle opposite to the tight muscle against resistance → reciprocal inhibition of tight muscle.

27. C. C. Self-Stretching Is a type of flexibility excerises. the patient carries out by himself. Is a type of flexibility excerises. the patient carries out by himself. Pt. may passively stretch his tightness by: Pt. may passively stretch his tightness by: 1. His/her own body weight. (& gravity) 2. Active inhibition. 3. Manual passive stretch (using sound limb)

30. Peripheral joint mobilization Peripheral joint mobilization Definition: Peripheral joint mobilization (PJM) is the use of skilled graded forces to mobilize joints: to improve motion & normalize joint function. Peripheral joint mobilization (PJM) is the use of skilled graded forces to mobilize joints: to improve motion & normalize joint function.

31. Mobilization Techniques are used to 1. Improve jt. nutrition. 2. Improve m. spasm & tension 3. Reduce pain. 4. Reverse jt. hypomobility. 5. Improve or restore motion. 6. Treat jt. dysfunction as stiffness.

32. The PT should recognize When the mobilizing techniques are indicated (at any ROM), or When the mobilizing techniques are indicated (at any ROM), or If other stretching techniques are more effective (stretching, stretching ex’s or CTM) If other stretching techniques are more effective (stretching, stretching ex’s or CTM) To regain the lost motion To regain the lost motion

33. A. Joint Mobilization Is a type of passive mov performed by the PT at a speed slow enough that the pt. can stop the mov. Is a type of passive mov performed by the PT at a speed slow enough that the pt. can stop the mov. The tech. may be applied with: 1. Oscillatory motion or The tech. may be applied with: 1. Oscillatory motion or 2. Sustained stretch 2. Sustained stretch to to 1. ↓ Pain or 2. ↑mobility. The tech. may use: The tech. may use: 1. Physiologic or 2. Accessory movs.

34. Mobilization Techniques Physiologic movements Physiologic movements 1. Movs. that the pt can perform voluntarily as flex, ext, abd, add rot. 1. Movs. that the pt can perform voluntarily as flex, ext, abd, add & rot. 2. Described as (Osteokinematic). i.e. mov of bones in relation to each others Accessory movements Accessory movements 1. Movs within the jt surrounding tissues that are necessary for normal ROM, can’t be done by pt. 1. Movs within the jt & surrounding tissues that are necessary for normal ROM, can’t be done by pt. 2. Described as a. Component motions b. joint play.

35. Accessory motions Accessory motions Accessory motions Motions that accompany active mov, but Motions that accompany active mov, but Aren’t under voluntary control Aren’t under voluntary control Component mov is the often used term with accessory mov. Component mov is the often used term with accessory mov. As: upward rot. of scapula & clavicle occurring in sh. flex. As: upward rot. of scapula & clavicle occurring in sh. flex. B. Joint Play B. Joint Play Motions that occur in jts & distensibility or give in of the jt capsule, which allow bones to move. Motions that occur in jts & distensibility or give in of the jt capsule, which allow bones to move. Are necessary for normal functioning through the ROM. Are necessary for normal functioning through the ROM. Can be demonstrated passively, Can be demonstrated passively, Can’t be performed actively by the pt. Can’t be performed actively by the pt. Include: Include: distraction, sliding, compression, rolling, spinning of the jt surfaces. Arthrokinematic is used to describe these motions of bone surfaces within the jt.

36. B. Manipulation Is a passive mov using physiologic or accessory motions. It may be applied: 1. With a thrust, (cyropractic) or 2. Under anesthesia Is a passive mov using physiologic or accessory motions. It may be applied: 1. With a thrust, (cyropractic) or 2. Under anesthesia

37. B. Manipulation THRUST A sudden mov performed with a high velocity. A sudden mov performed with a high velocity. Without anaesthesia. Without anaesthesia. Short amplitude motion, can’t be prevented by the pt. Short amplitude motion, can’t be prevented by the pt. Performed At end of pathologic limit (end of available ROM, when there’s restriction). Performed At end of pathologic limit (end of available ROM, when there’s restriction). Using: 1. Physiologic, or 2. Accessory movs. Using: 1. Physiologic, or 2. Accessory movs. Effects: Effects: 1. Snaps adhesions. 2. Stimulates jt receptors. MANIPULATION UNDER ANAESTHESIA Medical procedure used to restore full ROM by breaking adhesions surrounding jt. Medical procedure used to restore full ROM by breaking adhesions surrounding jt. With anaesthesia. With anaesthesia. Performed through: 1. Rapid thrust, or 2. Passive stretch. Performed through: 1. Rapid thrust, or 2. Passive stretch. Using: 1. Physiologic, or 2. Accessory movs. Using: 1. Physiologic, or 2. Accessory movs.

38. Factors Affecting Jt. Motion A. Jt. shape. B. Types of Motion. B. Types of Motion. C. Other Accessory motions. C. Other Accessory motions.

39. Factors Affecting Joint motion A. Joint Shape The type of motion is influenced by jt. shape. The type of motion is influenced by jt. shape. Ovoid : one convex surface & one concave (as A). Ovoid : one convex surface & one concave (as A). Sellar (Saddle): one surface is concave in one direction & convex in the other, with the opposing surface convex & concave ( as a horse back rider) (as B). Sellar (Saddle): one surface is concave in one direction & convex in the other, with the opposing surface convex & concave ( as a horse back rider) (as B).

40. B. Types of Motion When a bony lever (bone) moves about an axis of motion → mov of bony surfaces on the opposing bone surface within the jt. When a bony lever (bone) moves about an axis of motion → mov of bony surfaces on the opposing bone surface within the jt. i.e. i.e. 1. Movement of bony lever - Called swing as (flex, ext, add, abd & rot.) - Measured in degrees. - Called ROM. - Measured in degrees. - Called ROM. 2. Motion of the bony surfaces - Within jt is a combination of rolling, sliding & spinning. 2. Motion of the bony surfaces - Within jt is a combination of rolling, sliding & spinning. - These accessory motions allow greater angulation of bone as it swings. - These accessory motions allow greater angulation of bone as it swings. - This needs adequate capsule laxity or jt. play. - This needs adequate capsule laxity or jt. play.

41. a. Roll One bone rolls on another. The surfaces are incongruent. One bone rolls on another. The surfaces are incongruent. New points on one surface meet new points on the opposing surface. New points on one surface meet new points on the opposing surface. Results in angular motion. Results in angular motion. Always rolling occur in the same direction of the mov., whether the surface is convex or concave. Always rolling occur in the same direction of the mov., whether the surface is convex or concave. There’s compression of the surface on the side to which the bone is angulating & separation on the other side. There’s compression of the surface on the side to which the bone is angulating & separation on the other side. In normal functioning jts, pure rolling doesn’t occur alone, but in combination with sliding & spinning. In normal functioning jts, pure rolling doesn’t occur alone, but in combination with sliding & spinning.

42. b. Slide One bone slides across another. One bone slides across another. For pure slide, the surface must be congruent either flat or curved. For pure slide, the surface must be congruent either flat or curved. There’s no pure slide as jt surfaces aren’t completely congruent. There’s no pure slide as jt surfaces aren’t completely congruent. Same point on one surface comes into contact with new points on the opposing surface. Same point on one surface comes into contact with new points on the opposing surface. Direction of slides depends on whether the surface is convex or concave. Direction of slides depends on whether the surface is convex or concave.

43. If the moving surface is convex → Sliding is in the opposite direction of angular mov. If the moving surface is convex → Sliding is in the opposite direction of angular mov. If the moving surface is concave → Sliding is in the same direction as the angular mov. If the moving surface is concave → Sliding is in the same direction as the angular mov. This mechanical relationship is known as convex-concave rule. It determines the direction of the mobilization force, when jt mobilization gliding techniques are used. This mechanical relationship is known as convex-concave rule. It determines the direction of the mobilization force, when jt mobilization gliding techniques are used.

44. c. Combined roll-sliding in a joint The more congruent the jt surface → the more sliding of one bony partner on the other with movs. (e.g. metatarsals & metacarpals) The more incongruent the jt surface → the more rolling movs. (e.g. hip & sh)

45. For Joint Mobilization Techniques Sliding Sliding Is used to Is used to ↓ 1. Restore jt. play 2. Reverse jt. Hypomobility Rolling Rolling Is not used, as Is not used, as ↓ 1. Jt. Compression E.g. hip abd add E.g. hip abd & add sh abd add sh abd & add

46. When PT passively moves the articulating surface in the direction in which the slide normally occurs → When PT passively moves the articulating surface in the direction in which the slide normally occurs → Translatory glide (glide) ↓ used to used to 1. Control pain or 2. Stretch capsule 1. Control pain or 2. Stretch capsule If applied gently If with stretch force If applied gently If with stretch force

47. d. Spin Rotation of one bony segment about a stationary mechanical axis. Rotation of one bony segment about a stationary mechanical axis. Spinning rarely occurs alone, but in combination with rolling & sliding. Spinning rarely occurs alone, but in combination with rolling & sliding. 3 examples of spinning in the body jts: 3 examples of spinning in the body jts: 1. Sh.: with flex/ext. 2. Hip: with flex/ext. 3. Radio-humeral: with sup./pron. 4. **Knee ext either by closed or open chain

48. C. Other Accessory Motions that affect the Joint e. Compression. f. Traction (A&B).

49. e. Compression Is the ↓ in jt space. Is the ↓ in jt space. Occurs in LL & spinal jts with wt. bearing. Occurs in LL & spinal jts with wt. bearing. Some compression occurs as m. cont → provide stability to jt. Some compression occurs as m. cont → provide stability to jt. As one bone rolls on the other, some compression occurs on the side to which the bone is angulating. As one bone rolls on the other, some compression occurs on the side to which the bone is angulating. Normal intermittent compression loads → help in moving synovial fluid so → maintain cartilage health. Normal intermittent compression loads → help in moving synovial fluid so → maintain cartilage health. Abnormal high compression loads → (friction → erosion & OA) Abnormal high compression loads → articular cartilage changes & deterioration. (friction → erosion & OA)

50. f. Traction Distraction or separation of jt surfaces. Distraction or separation of jt surfaces. For distraction to occur, the surfaces must be pulled apart. The mov isn’t always the same. For distraction to occur, the surfaces must be pulled apart. The mov isn’t always the same. Pulling on the long axis of one bone (as pulling the shaft of humerus → glide jt surface) (long axis traction). Pulling on the long axis of one bone (as pulling the shaft of humerus → glide jt surface) (long axis traction). Distraction of gleno-humeral jt requires Distraction of gleno-humeral jt requires a pull at a 90° to the glenoid fossa → distraction & jt traction or jt separation. Distraction is used to: Distraction is used to: 1. Control or relieve pain: If applied gently. 2. Stretch the capsules: If applied with stretching force.

51. Effects of Joint Motion 1. Skim. biologic activity by moving synovial fluid → brings nutrients to the avascular articular cartilage of jt surfaces & intra-articular fibrocartilage of the menisci. 2. Maintains extensibility & strength of: articular & periarticular tissues (ligs, ms, tendons & capsules).  With immobilization → fibrofatty prolifiration → intra-articular adhesions & biochemical changes in [tendons, ligs & jt capsule] → m. contractures, jt stiffness & lig. weakening. 3. Provide proprioceptive feedback (awareness of pos. & mov. sense) a. Static pos. & sense of speed of mov. b. Change of speed of mov. c. Sense of direction of mov. d. Regulation of m. tone.

52. Indications of Joint Mobilization 1. Pain, m. guarding & spasm All can be treated with gentle jt play tech to stim. neurophysiological & mechanical effects. All can be treated with gentle jt play tech to stim. neurophysiological & mechanical effects. a. Neurophysiological effect: Small amplitude oscillatory mov → stim mechanoreceptors → ↓ transmission of nociceptive stimuli at spinal cord & brain stem levels. b. Mechanical effects:  Small-amplitude distraction or gliding mov →  Small-amplitude distraction or gliding mov → synovial fluid motion → bring nutrients to the avascular portions of articular cartilage. ( ↓ pain of ischemia)  Gentle jt-play → maintain nutrient exchange → prevent painful effects of stasis when a jt is painful or swollen & can’t move through a ROM. (but not in acute or massive swelling)

53. Reversible Jt. Hypomobility Can be treated with: 1. Progressive vigorous jt. play stretching techs. → elongate hypomobile structures. 1. Progressive vigorous jt. play stretching techs. → elongate hypomobile structures. 2. Sustained or oscillatory stretch forces → mechanically distend shortened tissues. 2. Sustained or oscillatory stretch forces → mechanically distend shortened tissues.

54. Progressive Limitations Diseases that progressively limit movement can be treated by jt. play techs to: Diseases that progressively limit movement can be treated by jt. play techs to: 1. Maintain available motion. 2. Retard progressive mechanical restrictions. 4. Functional Immobility (obligatory bedriddeness) In this case the aim is to: In this case the aim is to: 1. Maintain available jt. play. 2. Prevent degenerating. 3. Delay or reduce the effects of immobility.

55. N.B. Mobilization techniques  Can’t change the disease process of disorders as: 1. Rheumatoid arthritis. 2. Inflammation.  It only can: 1. Minimizes pain. 2. Maintain available jt. Play. 3. Reduces effects of mech. limitations.

56. Contra-indications 1. Hypermobility: AS PJM → Potential necrosis of ligs. or capsules. Potential necrosis of ligs. or capsules. (Hypermobile pts may benefit from jt. play tech. if kept within the limits of motion ).

57. 2. Joint Effusion Never mobilize or stretch a swollen jt with: 1. mobilization or 2. passive stretching. The capsule is already stretched by the extra fluid. Extra fluid & m. response to pain (spasm) → limited motion. Never mobilize or stretch a swollen jt with: 1. mobilization or 2. passive stretching. The capsule is already stretched by the extra fluid. Extra fluid & m. response to pain (spasm) → limited motion. Gentle oscillating motions that don’t stretch capsule or stress it →: Gentle oscillating motions that don’t stretch capsule or stress it →: 1. Improve fluid flow. 2. ↓ pain. 3. Maintains available jt play. If pt response to jt play is ↑ pain or jt. Irritability: The techs. were either: If pt response to jt play is ↑ pain or jt. Irritability: The techs. were either: 1. Too vigorous, or 2. Don’t suit the current state of pathology.

58. 3. Inflammation 3. Inflammation Stretching in presence of inflammation → Stretching in presence of inflammation → 1. ↑ Pain. 2. ↑ muscle guarding. 3. Greater tissue damage. 4. Spreading the inflam. process & infection.

59. Precautions In most cases jt mobilization is safer than passive angular stretching. In most cases jt mobilization is safer than passive angular stretching. But But Sometimes Jt mobilization can be used with extreme care in: Sometimes Jt mobilization can be used with extreme care in: 1. Malignancy - » spread & growth. 2. Excessive pain - » m. guarding, prevent mov. 3. Total jt. replacement - » disl. or loosen int. fixation. 4. Bone disease (Osteoporosis, TB, Rickets). 5. Unhealed # (site & stabilization) - » re-fracture. 6. Hypomobility ( in associated jts & m. weak) - » ↑ capsule laxity, lig. Weakness & jtdisl. 6. Hypomobility ( in associated jts & m. weak) - » ↑ capsule laxity, lig. Weakness & jt disl.

60. Procedure for Applying Jt Mobilization Techniques A.Evaluation & Assessment if 1. limited, or 2. painful mov. Evaluate 1.Tissue limiting fun 2.State of pathology Determine ttt direction 1.Relieving pain 2.Stretching a jt 3.Soft tissue limit Determine Pain quality 1.Recovery Stage 2.Treatment Dose

61. 3 Possibilities for pain !!!! While moving or mobilizing & found!!!! 1. B efore tissue limitation (after acute injury or active stage of a disease), use p ain inhibiting jt. tech to relieve pain & maintain jt. play. 2. With tissue limitation (as damaged tissue begins to heal) (subacute), use gradual g entle stretching tech to tight tissue, but Don’t exacerbate pain by injuring the tissues. 3. After tissue limitations (as stretching a tight capsule or a peri-articular tissue of ch. stiff jts), use ↓ force of the stretching techniques.

62. If the capsule is limiting the motion, there’s:

63. B. Grades of mov. (Dosage, Amplitude) 2 systems of techniques: 1. Graded oscillation. 2. Sustained translatory jt. Play.

64. 1. Graded Oscillation Tech. Dosage Grade I Small amplitude rhythmic oscillations at the beginning of ROM. Grade II Large amplitude rhythmic oscillations within the ROM, but not reaching the limitation. Grade III Large amplitude rhythmic oscillations up to the limit of available motion & stressed into tissue resistance. Grade IV Small amplitude rhythmic oscillations, up to the limit of the available motion & stressed into tissue resistance. Grade V Small amplitude, high velocity, thrust tech.. Performed to break adhesions at the level of available motion (Stretch) Small amplitude, high velocity, thrust tech.. Performed to break adhesions at the level of available motion ( manipulation or chiropractic ). (Stretch)

65. Graded oscillation technique

66. Techniques Oscillations may be done using: Oscillations may be done using: 1- Physiologic (osteokinematic) motions. 1- Physiologic (osteokinematic) motions. 2- Jt. play (arthrokinematic) techs. 2- Jt. play (arthrokinematic) techs.

67. Sustained Translatory jt. Play Technique Grade I (Loosen): Grade I (Loosen): Small amplitude distraction, applied where no stress is placed on the capsule. Small amplitude distraction, applied where no stress is placed on the capsule. 1. Equalizes cohesive force, 2. 2. M. tension 3. 3. Atmospheric pressure acting on the jt. Grade II ( Till tightness): Grade II ( Till tightness): Distraction or glide applied to tightend tissues around jt. Distraction or glide applied to tightend tissues around jt. Grade III: Grade III: Distraction or glide with large enough amplitude to place Distraction or glide with large enough amplitude to place a stretch on jt. capsule & surrounding peri-articular structures. a stretch on jt. capsule & surrounding peri-articular structures.

68. Sustained translatory joint-play technique

69. Uses Grade I: Used with gliding motions to relieve pain. Grade I: Used with gliding motions to relieve pain. Grade II: Used to determine how sensitive the jt is. Grade II: Used to determine how sensitive the jt is. Grade III: Used to stretch jt. structures & ↑ jt play. Grade III: Used to stretch jt. structures & ↑ jt play. Technique: Technique: This grading system describes jt. play techniques that separate or glide (slide) jt surfaces. This grading system describes jt. play techniques that separate or glide (slide) jt surfaces.

70. N.B. The consistency between the dosage of the two grading systems is grade I (no tension on the jt capsule or surroundings). The consistency between the dosage of the two grading systems is grade I (no tension on the jt capsule or surroundings). Grade III (sustained stretch) & IV (oscillation) are similar in dosage as they are applied with a stretch force at the limit of the motion. Grade III (sustained stretch) & IV (oscillation) are similar in dosage as they are applied with a stretch force at the limit of the motion. Using oscillating or sustained tech., depends on the pt’s response. Using oscillating or sustained tech., depends on the pt’s response. Pain management: use oscillating tech. Pain management: use oscillating tech. Loss of jt. play & ↓ function: use sustained stretch. Loss of jt. play & ↓ function: use sustained stretch. To maintain available R.: Use either grade II! oscillating or II sustained technique. To maintain available R.: Use either grade II! oscillating or II sustained technique.

71. C. Patient Position 1. C. Patient Position The pt. & treated extremity should be carefully positioned & relaxed. 2. The jt. is positioned so that the capsule has greatest laxity.

72. D. Stabilization Firm & comfortable stabilization for proximal parts by using: Firm & comfortable stabilization for proximal parts by using: 1. Belt. 2. PT hand. 3. External assistance.

73. E. Force Treatment force is applied as close to the opposing jt. surfaces as possible. Treatment force (gentle or strong) is applied as close to the opposing jt. surfaces as possible. The larger the contact surface of PT hand The larger the contact surface of PT hand → the more comfortable procedure will be. → the more comfortable procedure will be. e.g. use flat surface of the hand instead of forcing with the thumb. e.g. use flat surface of the hand instead of forcing with the thumb.

74. F. Direction of Movement Either parallel to, or perpendicular to ttt plane. Either parallel to, or perpendicular to ttt plane. Jt. traction: Perpendicular to ttt plane. Jt. traction: Perpendicular to ttt plane. The entire bone is moved → jt surfaces are separated. The entire bone is moved → jt surfaces are separated. Gliding tech. : Parallel to the ttt plane. Gliding tech. : Parallel to the ttt plane. This is determined by using the convex-concave rule. This is determined by using the convex-concave rule. - If the surface of moving bone is convex -→ opposite direction glide. - If the surface of moving bone is convex -→ opposite direction glide. - If the surface of moving bone is concave → glide in the same direction. The entire bone is moved, so there’s gliding of one jt. surface on the other. The entire bone is moved, so there’s gliding of one jt. surface on the other. No swing of the bone that causes rolling & compression of the jt. surfaces No swing of the bone that causes rolling & compression of the jt. surfaces