APPLICATION OF JOINT MOBILIZATION

 

APPLICATION OF JOINT MOBILIZATION
INTRODUCTION;
Skilled passive movement of the articular surfaces performed by a physical therapist to decrease pain or increase joint mobility
DETERMINATION OF JOINT MOBILITY FOR APPLICATION
The mobilization technique evolved as a result of observation conducted by physicians
 See and measure decreased active movement of limb
 Feel restricted joint play in associated joints
 Passive movements increase active movements, increase in joint play and decrease pain.
TECHNIQUES OF JOINT MOBILIZATION
 Pain-relief mobilization
 Relaxation mobilization
 Stretch mobilization
 Manipulation
ARTHOKINEMATIC RULES OF MOTION
JOINT MORPHOLOGY
Joint surfaces are defined as
 CONVEX; rounded or arched
 CONCAVE; hollowed or shallow
Joint morphology
 OVOID; concave and convex articular partner surface
 SELLER; saddle shape with each articular surface having a concave and convex component in a specific direction
CONCAVE and CONVEX CHARACTEISTICS
 Convex surfaces have more cartilage at the center
 Concave surfaces have more cartilage on the periphery
 Where surfaces appear flat the larger articular surface is considered convex
RULE OF MOTION
Concave rule motion;
• convex surface is stationary and concave surface moves
• osteo and arthrokinematic motion is in the same direction
• arthrokinematic mobilization gliding force is in the same direction as osteokinematic bony movement

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Convex motion rule;
• concave surface is stationary and convex surface moves
• osteo and arthrokinematic motion is in the opposite direction
• arthrokinematic mobilization gliding force is in the opposite direction as osteokinematic bony movement

Arthokinematic roll always occurs in the same direction as bone movement regardless of whether the joint surface is convex or concave in shape

FUNCTIONAL ROLL AND GLIDE ANALOGY
 The more congruent; the more glide
 The more incongruent; the more roll
OBLIGATE TRANSLATION
 During ARPM translation direction is influenced by the capsuloligamentous complex
 Passive restraints act not only to restrict movement but also to reverse articular movements at the end range of motion
 At end range, asymmetrical capsular mobility causes obligate translation away from side of tightness
 Tight capsular structures will cause early and excessive accessory motion in the opposite direction of the tightness

TREATMENT PLAN AND AXIS OF MOTION
 The treatment plan lies in concave articular surface and is parallel to the joint surface and perpendicular to the axis in the convex surface
 The axis of motion always lies in the convex articular surface
 The treatment plane moves with the concave surfaces moves
 The treatment plane remains essentially still when the convex surface moves

MOBILIZATION TREATMENT
Mobilization to a joint may;
 Fire articular mechanoreceptors
 Fire cutaneous and muscular receptors
 Abate nociceptors
 Decrease or relax muscle guarding
GLIDE MOBILIZATION GRADING (TRANSLATORY)
GRADE I- small amplitude movement at the beginning of the available ROM
GRADE II- large amplitude movement at within the available ROM
GRADE III- large amplitude movement that reaches the end ROM
GRADE IV- small amplitude movement at the very end ROM
GRADE V- high velocity thrust of small amplitude at the end of the available range and within its anatomical range (manipulation)

DISTRACTION MOBILIZATION GRADING
GRADE I- unweighting or barely supporting the joint surfaces
• Equalizes cohesive and atmospheric forces of the joint
• Alleviates pain by unloading and decompressing
• Nullifies normal compressive forces
GRADE II- slack of the capsule taken up (eliminates joint pain)
GRADE III- capsule and ligamentous stretch

MOBILIZATION TREATMENT CONSIDERATIONS
GRADE I-II
• "neurophysiological effect used daily to treat pain"
• pain relief through neuromodulation on the sensory innervation of the joint mechanoreceptors and pain receptors
• gates pain achieved by the inhibition of transmission of nociceptive stimuli at the spinal cord and brain stem level
• neutralizes joint pressures
• prevents grinding
GRADE III-IV
• mechanical effect used 3-5 times/week to treat stiffness or hypomobility”
• increase ROM through promotion of capsular mobility and plastic deformation
• mechanical distention and/or stretching of shortened tissues

MOBILIZATION TREATMENT PRINCIPLES
• Oscillations or prolonged hold at midrange stimulates Type-I mechanoreceptors
• Oscillations or prolonged hold at end range stimulates type II mechanoreceptors
• Low grade sustained hold stimulates type III mechanoreceptors and inhibits guarding
OSCILLATIONS
– 60-120/min
– 1-5 sets of 5-60 sec
– generally used to treat pain
PROLONGED HOLD
– 5-30 seconds
– 1-5 reps
– typically applied at end range to treat stiffness
MOBILIZATION TREATMENT RULES
• Position patient to achieve maximal relaxation
• Articulate initially in resting position and then chase end range
• Use good boy mechanics
• Allow gravity to assist
• Your body and the mobilizing part act as one unit
• Short lever arms and hands as close to joint as possible
• Mobilize below pain threshold
• Avoid muscle guarding
• Articulate in opposite direction if needed
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 passive joint mobilization is applied as described in the previous section following the principles of kaltenborn
• 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
• Utilization knowledge of joint anatomy and mechanics, sense of tissue tension and sound clinical reasoning
• The therapists investigate various combinations of parallel or perpendicular accessory glides to find the pain-free direction and grade of accessory movement
• While the therapists sustain the pain-free accessory mobilization, the patient is request to perform the comparable sign
• The comparable sign should now be significantly improved; there should be increased ROM
• Failure to improve the comparable sign would indicate that the therapist has not found the correct direction of accessory mobilization
• The previously restricted and painful motion or activity is repeated 6-10 times by the patient while the therapist continues to maintain the appropriate accessory mobilization.
GOALS FOR THE APPLICATION OF JOINT MOBILIZATION
Mobilization application and treatment is based on specific biomechanical assessment of joint hypomobilty and hypermobility.
If abnormal end-feel and a slight or significant hypomobility is observed in patient apply
 Grade II relaxation-mobilization
 Grade III stretch-mobilization
If slight or significant hypermobility is observed in patient apply
 Stabilizing treatment to normalize joint function
REMEMBER!
 Class O hypomobile ankylosed joints cannot be mobilized
 Class 6 dislocation, hypermobility, ligamentous laxity with instability require surgical intervention.

APPLICATION OF JOINT MOBILIZATION TECHNIQUES
PAIN-RELIEF MOBILIZATION TECHNIQUE
GRADE I-II (slack zone)
If the symptoms are associated with severe pain, spasm, paresthesia without toleration of grade III stretching technique, then treatment should be focused on symptom control
Apply pain-relief mobilizations as intermittent Slack Zone Grade I and /I movements in the resting position or actual resting position.
PAIN-RELIEF TRACTION MOBILIZATION
Intermittent Grade I and II traction-mobilizations in the Slack Zone, applied in the resting position or actual resting position
As soon as decreased symptoms allow the patient to tolerate full biomechanical testing with end-feel assessment, the focus of treatment can shift to the appropriate mobilization for hypomobility or stabilization for hypermobility.
VIBRATIONS AND OSCILLATIONS
Short amplitude, oscillatory joint movements can also be applied in the Grade lI TZ and III range, interspersed with stretch mobilizations, to minimize discomfort (pain and muscle spasm)
The movements are effective in the application of very high frequency and very short amplitude movement
RELAXATION MOBILIZATION
GRADE I – II
 Relaxation mobilization can be applied anywhere in Grade I-II range
 It may include Slack zone and Transition zone
 Relaxation mobilizations should not produce or increase pain
APPLICATION
Apply relaxation joint mobilizations as intermittent Grade I and II movements in the actual resting position to decrease pain and relax muscles.
RELAXATION-TRACTION MOBILIZATION
GRADE I-II
APPLICATION
 Apply intermittent traction-mobilizations in the actual joint resting position within the Grade I or II range, including the Transition Zone.
 Slowly distract the joint surfaces, then slowly release until the joint returns to the starting position.
 Rest the joint a few seconds in the starting position before you repeat the procedure.
It is rare for Grade I or II intermittent traction to increase a patient's symptoms. If it does, you should:
 Adjust patients positioning
 Monitor changes in actual resting position
 Minimize traction force
 Correct underlying positional fault
 Discontinue traction treatment in case of any form of stretch to injured fibers
STRETCH MOBILIZATION
GRADE III
It is one of the most effective means for restoring normal joint play by stretching shortened connective tissue in muscles, ligaments and joint capsules.
 It can increase and maintain mobility
 Delay progressive stiffness
 Reduce loss of range of movement
APPLICATION
 Sustain a stretch mobilization for a minimum of seven seconds, up to a minute or longer as long as the patient can comfortably tolerate the stretch
 Apply 30 to 40 seconds of stretch with the assistance of a mobilization belt in the larger joints
 continue the treatment for 10-15 minutes in a cyclic manner
 Warming tissues surrounding the joint prior to Grade III mobilizations makes them easier to stretch.
GUIDELINES FOR PROGRESSION OF STRETCH MOBILIZATION
 If reassessment reveals increased range of movement or normalization of end-feel and decreased symptoms, then Grade III stretch-mobilization treatment may continue.
 If reassessment indicates no change in mobility or symptoms, reevaluate patient positioning and the vigor (i.e., time and force) and direction of treatment
 It is important to stretch a joint in all restricted directions in which the joint would normally move
 A joint can be restricted in one direction (e.g., flexion) and hypermobile in another direction (e.g., extension). In this case mobilization may be indicated for the restricted flexion and contraindicated for the hypermobile extension.
 Begin stretch mobilization treatments with a sustained traction-mobilization pre-positioned in the resting position (or actual resting position) and progressively re-position nearer and nearer to the point of restriction, as tissue response tolerates and allows.

MANIPULATION
• Use translatoric linear traction thrust
• Practice manipulation at high velocity, small amplitude, linear movement in the actual resting position
ROTATION IMMOBILIZATION
• The safest way to increase joint rotation range is to use a Grade III stretch-traction mobilization in conjunction with specific three-dimensional positioning
• Pre-position the specific joint near the point of its restricted rotation, and then apply a Grade III traction mobilization at a right angle to the joint treatment plane
• progress to a linear stretch-glide mobilization at the end-range of the restricted rotation, with a simultaneous Grade I traction force to protect the joint.