Joint Mobilization

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Joint Mobilization
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Peripheral Joint Mobilization

• Mobilization - is a passive movement performed
  slowly by the athletic trainer/therapist, it is
  controlled enough that the patient can stop the
  movement any time
• Goal is to provide a safe and effective means for
  restoring normal joint play and/or decreasing
  pain
• Manipulation - involves a sudden, short
  amplitude, high velocity movement the patient
  cannot prevent - not in ATCs realm

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Why?
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Mobilization - Indications and Goals

• Indications
• Capsular pattern - pattern of motion loss
• Pain - small amplitude oscillations to treat
• Muscle spasm/guarding - gentle oscillations and
  sustained stretch to maintain joint play
• Joint hypomobility/stiffness - oscillatory forces
  used to stretch joint capsule
• Goals
• Gentle joint play techniques stimulate both
  mechanical and neurophysiological effects

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Examples of Capsular Patterns

• When a capsular pattern is present, full joint
  ROM will not be attained until you address
  capsular tightness
• Glenohumeral
• lateral rotation gt abduction abduction gt flexion
• Hip
• medial rotation, abduction, flexion gt extension
• Knee
• flexion gt extension
• Ankle
• PF gt DF INV gt EV

gt means motion is more limited
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Mobilization

• Mechanical effects -
• increased nutrition to the avascular portions of
  the articular cartilage
• physically stretching the capsule which maintains
  the potential for normal ROM
• Neurophysiological effects -
• stimulate mechanoreceptors that inhibit
  transmission of nociceptive stimuli gate
  control
• Golgi tendon organ autogenic inhibition

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Mobilization

• CONTRAINDICATIONS
• Hypermobility
• Joint effusion
• Acute inflammation
• Fractures/Osteoporosis
• LIMITATIONS
• techniques cannot change a disease process
• Be careful with unexplained pain syndromes
• therapist/athletic trainer skill will affect the
  outcome

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Basic Concepts of Joint Motion

• Physiological movements - - Osteokinematics
• the patient can perform these voluntarily
• traditional movements such as flexion,
  extension, abduction, rotation
• Accessory movements - Arthrokinematics
• joint play and accessory motion
• necessary for and accompanying normal ROM, but
  cannot be performed by the patient - examples are
  slide, roll, spin, distraction, compression

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Basic Concepts of Joint Motion

• Type of motion is influenced by the shapes of the
  joint surfaces
• Ovoid - one surface is convex the other concave
  most common
• Sellar (saddle) - one surface is concave in one
  direction and convex in the other, being
  opposite of the other joint surface

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Arthrokinematics

• Roll
• Incongruent surfaces new pts to new pts
• Rolling occurs in the same direction as
  physiological movement
• Slide (Glide)
• Congruent surfaces one pt to new point
• Concave-Convex Rule
• Spin
• Bone rotates around a stationary axis

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RULE OF CONCAVE-CONVEX

• The shape of the joint surface influences the
  direction of the accessory movement
• If surface of moving bone is convex, sliding is
  in the opposite direction of the bones
  physiological movement
• If the surface of the moving bone is concave,
  sliding is in the same direction as the
  physiological movement of the bone

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RULE OF CONCAVE-CONVEX
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Techniques of Joint Mobilization
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INDICATIONS FOR JOINTMOBILIZATION

• 1- Pain, Muscle Guarding, and Spasm can be
  treated with gentle joint-play techniques to
  stimulate
• Neurophysiological Effects
• Small-amplitude oscillatory and distraction
  movements stimulate mechanoreceptors inhibt
  transmission of nociceptive stimuli at the spinal
  cord

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• Mechanical Effects
• Small-amplitude distraction or gliding movement
  produce synovial fluid motion, for bringing
  nutrients to the avascular portions of the
  articular cartilage to prevent degeneration of
  the joint surfaces

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• 2- Reversible Joint Hypomobility
• 3- Positional Faults/Subluxations
• 4-Functional Immobility

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LIMITATIONS OF JOINTMOBILIZATION TECHNIQUES

• Mobilization techniques cannot change the disease
  process(rheumatoid arthritis or the inflammatory.
  In these cases, treatment is directed toward
  minimizing pain, maintaining available joint
  play,

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CONTRAINDICATIONSAND PRECAUTIONS

• Hypermobility
• Joint effusion
• Inflammation

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10 simple steps

1. Evaluation and Assessment
2. Determine grades and dosage
3. Patient position
4. Joint position
5. Stabilization
6. Treatment force
7. Direction of movement
8. Speed and rhythm
9. Initiation of treatment
10. Reassessment

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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- only w/ training!

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Normal motion
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Grades of Oscillations (Maitland)
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Mobilization

• If there is pain before tissue limitation, use
  gentle techniques for decreasing pain and no
  stretching
• Grades I and II
• If pain is concurrent with tissue limitation,
  treat cautiously with gentle techniques, then
  gradually increase movement without exacerbating
  pain
• Grade I and II
• If pain is experienced after tissue limitation, a
  stiff articulation can be aggressively mobilized
  with joint play techniques
• Grades III and IV

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Recommendations for using the Grades

• Pain and spasm
• I and II
• Tissue resistance
• III and IV
• Treatment amplitude
• Low - I, IV
• High - II, III
• Treatment speed
• Fast I, IV
• Slow II, III

• Gentle techniques
• I, II
• Treatment force
• Low I, II
• High III, IV

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Procedures for Application of Joint Mobilization
Techniques

• 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.
• Stabilize proximal bone
• Position joint in open (loose packed) position
• Apply treatment force close to the joint line as
  possible (decrease lever)
• Use treatment plane

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Open Pack Positions

• Knee 20-25o flexion
• Ankle 10o plantar flexion, mid range
  eversion/inversion
• Hip 30o flexion, 30o abduction
• Wrist - Neutral
• Elbow
• Humeroulnar/Radioulnar - 70o flexion (supination
  varies)
• Humeroradial Full extension and supination
• Shoulder 55o flexion, 20-30o horiz. abduction

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• Treatment Plane
• Traction apply perpendicular
• Gliding apply parallel

• Technique
• 2-3 oscillations per second
• Pain 1 to 2 mins.
• Tightness 20 to 60s

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Be sure to PRACTICE!!!