Peripheral Joint Mobilization
Joint Mobilization:
• Joint mobilization refers to manual therapy techniques that are used to modulate pain and treat joint dysfunctions that limit range of motion (ROM) by specifically addressing the altered mechanics of the joint.
• The altered joint mechanics may be due to
o pain and muscle guarding
o joint effusion
o contractures or adhesions in the joint capsules or supporting ligaments, or malalignment or subluxation of the bony surfaces.
• Joint mobilization stretching techniques differ from other forms of passive or self-stretching in that they specifically address restricted capsular tissue by replicating normal joint mechanics while minimizing abnormal compressive stresses on the articular cartilage in the joint.
• When indicated, joint mobilization is a safe, effective means of restoring or maintaining joint play within a joint and can also be used for treating pain.
Mobilization/Manipulation
• Mobilization and manipulation are two words that have come to have the same meaning and are therefore interchangeable.
• 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.
• The varying speeds and amplitudes could range from a small-amplitude force applied at high velocity to a large-amplitude force applied at slow velocity; that is, there is a continuum of intensities and speeds at which the technique could be applied.
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. Brian Mulligan of New Zealand originally described these techniques.
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.
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
o Component motions and
o Joint play.
Component motions are those motions that accompany active motion but are not under voluntary control. The term is often used synonymously with accessory movement. For example, 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.
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.
N.B. Procedures to distract or slide the joint surfaces to decrease pain or restore joint play are the fundamental joint mobilization techniques described in this text.
BASIC CONCEPTS OF JOINT MOTION: ARTHROKINEMATICS
• In ovoid 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, respectively; similar to a horseback rider being in complementary opposition to the shape of a saddle.
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
o rolling and
o sliding, or
o 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.
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, 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.
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.
• 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.
N O T E:
• This mechanical relationship is known as the convex-concave rule and is the basis for determining the direction of the mobilizing force when joint mobilization gliding techniques are used.
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.
• 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.
N O T E:
• When the therapist passively moves the articulating surface using the slide component of joint motion, the technique is called translatoric glide, translation, or simply glide.
• It is used to control pain when applied gently or to stretch the capsule when applied with a stretch force.
Spin
Characteristics of one bone spinning on another include the following.
• 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 .
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 significantly magnifies the force at the joint.
• The force causes excessive joint compression in the direction of the rolling bone (see Fig. 5.3).
• The roll without a slide does not replicate normal joint mechanics.
Joint glide (mobilization) stretching procedures,as when the translatoric slide component of the bones 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.
Other Accessory Motions that Affect the Joint
Compression
Compression is the decrease in the joint space between bony partners.
• Compression normally occurs in the extremity and spinal joints when weight bearing.
• Some compression occurs as muscles contract, which provides stability to the joints.
• As one bone rolls on the other, some compression also occurs on the side to which the bone is angulating.
• Normal intermittent compressive loads help move synovial fluid and thus help maintain cartilage health.
• Abnormally high compression loads may lead to articular cartilage changes and deterioration.
Traction/Distraction
Traction and distraction are not synonymous.
Traction is a longitudinal pull. Distraction is a separation, or pulling apart.
• Separation of the joint surfaces (distraction) does not always occur when a traction force is applied to the long axis of a bone. For example, 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.
• For clarity, whenever there is pulling on the long axis of a bone, the term long-axis traction is used. Whenever the surfaces are to be pulled apart, the term distraction, joint traction, or joint separation is used.
N O T E:
• For joint mobilization techniques, distraction is used to control or relieve pain when applied gently or to stretch the capsule when applied with a stretch force.
• A slight distraction force is used when applying gliding techniques.
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.
• 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.
• 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. Joint motion provides sensory input relative to:
o Static position and sense of speed of movement (type I receptors found in the superficial joint capsule)
o Change of speed of movement (type II receptors found in deep layers of the joint capsule and articular fat pads)
o Sense of direction of movement (type I and III receptors; type III found in joint ligaments)
o Regulation of muscle tone (type I, II, and III receptors)
o Nociceptive stimuli (type IV receptors found in the fibrous capsule, ligaments, articular fat pads, periosteum, and walls of blood vessels)
INDICATIONS FOR JOINT MOBILIZATION
• Pain, Muscle Guarding, and Spasm
• Reversible Joint Hypomobility
• Positional Faults/Subluxations
• Progressive Limitation
• Functional Immobility
1. Pain, Muscle Guarding, and Spasm
• Painful joints, reflex muscle guarding, and muscle spasm can be treated with gentle joint-play techniques to stimulate neurophysiological and mechanical effects.
Neurophysiological Effects
• Small-amplitude oscillatory and distraction movements are used to stimulate the mechanoreceptors that may inhibit the transmission of nociceptive stimuli at the spinal cord or brain stem levels.
Mechanical Effects
• Small-amplitude distraction or gliding movements of the joint are used to cause synovial fluid motion, which is the vehicle for bringing nutrients to the avascular portions of the articular cartilage (and intra-articular fibrocartilage when present).
• Gentle joint-play techniques help maintain nutrient exchange and thus prevent the painful and degenerating effects of stasis when a joint is swollen or painful and cannot move through the ROM.
N O T E:
• The small-amplitude joint techniques used to treat pain, muscle guarding, or muscle spasm should not place stretch on the reactive tissues.
2. Reversible Joint Hypomobility
• Reversible joint hypomobility can be treated with progressively vigorous joint-play stretching techniques to elongate hypomobile capsular and ligamentous connective tissue.
• Sustained or oscillatory stretch forces are used to distend the shortened tissue mechanically.
3. Positional Faults/Subluxations
• Malposition of one bony partner with respect to its opposing surface may result in limited motion or pain. This can occur with a traumatic injury, after periods of immobility, or with muscle imbalances. The malpositioning may be perpetuated with maladapted neuromuscular control across the joint so whenever attempting active ROM there is faulty tracking of the joint surfaces resulting in pain or limited motion.
• MWM techniques attempt to realign the bony partners while the person actively moves the joint through its ROM.
• Manipulations are used to reposition an obvious subluxation, such as a pulled elbow or capitate-lunate subluxation.
4. Progressive Limitation
• Diseases that progressively limit movement can be treated with joint-play techniques to maintain available motion or retard progressive mechanical restrictions.
• The dosage of distraction or glide is dictated by the patient’s response to treatment and the state of the disease.
5. Functional Immobility
• When a patient cannot functionally move a joint for a period of time, the joint can be treated with non-stretch gliding or distraction techniques to maintain available joint play and prevent the degenerating and restricting effects of immobility.
LIMITATIONS OF JOINT MOBILIZATION TECHNIQUES
• Mobilization techniques cannot change the disease process of disorders such as rheumatoid arthritis or the inflammatory process of injury.
• In these cases, treatment is directed toward minimizing pain, maintaining available joint play, and reducing the effects of any mechanical limitations.
• The skill of the therapist affects the outcome. The techniques described in this text are relatively safe if directions are followed and precautions are heeded; but if these techniques are used indiscriminately on patients not properly examined and screened for such maneuvers or if they are applied too vigorously for the condition, joint trauma or hypermobility may result.
CONTRAINDICATIONS AND PRECAUTIONS
The only true contraindications to stretching techniques are
• Hypermobility
• joint effusion, and
• Inflammation.
Hypermobility
• The joints of patients with potential necrosis of the ligaments or capsule should not be stretched.
• Patients with painful hypermobile joints may benefit from gentle joint-play techniques if kept within the limits of motion. Stretching is not done.
Joint Effusion
• There may be joint swelling (effusion) due to trauma or disease.
• Rapid swelling of a joint usually indicates bleeding in the joint and may occur with trauma or diseases such as hemophilia.
• Medical intervention is required for aspiration of the blood to minimize its necrotizing effect on the articular cartilage.
• Slow swelling (more than 4 hours) usually indicates serous effusion (a buildup of excess synovial fluid) or edema in the joint due to mild trauma, irritation, or a disease such as arthritis.
• Do not stretch a swollen joint with mobilization or passive stretching techniques. The capsule is already on a stretch by being distended to accommodate the extra fluid. The limited motion is from the extra fluid and muscle response to pain, not from shortened fibers.
• Gentle oscillating motions that do not stress or stretch the capsule may help block the transmission of a pain stimulus so it is not perceived and may also help improve fluid flow while maintaining available joint play.
• If the patient’s response to gentle techniques results in increased pain or joint irritability, the techniques were applied too vigorously or should not have been done with the current state of pathology.
Inflammation
• Whenever inflammation is present, stretching increases pain and muscle guarding and results in greater tissue damage.
• Gentle oscillating or distraction motions may temporarily inhibit the pain response.
Conditions Requiring Special Precautions for Stretching
In most cases, joint mobilization techniques are safer than passive angular stretching, in which the bony lever is used to stretch tight tissue and joint compression results. Mobilization may be used with extreme care in the following conditions if the signs and the patient’s response are favorable.
• Malignancy
• Bone disease detectable on radiographs
• Unhealed fracture (depends on the site of the fracture and stabilization provided)
• Excessive pain (determine the cause of pain and modify treatment accordingly)
• Hypermobility in associated joints (associated joints must be properly stabilized so the mobilization force is not transmitted to them)
• Total joint replacements (the mechanism of the replacement is self-limiting, and therefore the mobilization gliding techniques may be inappropriate)
• Newly formed or weakened connective tissue such as immediately after injury, surgery, or disuse or when the patient is taking certain medications such as corticosteroids (gentle progressive techniques within the tolerance of the tissue help align the developing fibrils, but forceful techniques are destructive)
• Systemic connective tissue diseases such as rheumatoid arthritis, in which the disease weakens the connective tissue (gentle techniques may benefit restricted tissue, but forceful techniques may rupture tissue and result in instabilities)
• Elderly individuals with weakened connective tissue and diminished circulation (gentle techniques within the tolerance of the tissue may be beneficial to increase mobility)
PROCEDURES FOR APPLYING PASSIVE JOINT MOBILIZATION TECHNIQUES
Examination and Evaluation
If the patient has limited or painful motion, examine and decide which tissues are limiting function and the state of pathology. Determine whether treatment should be directed primarily toward relieving pain or stretching a joint or soft tissue limitation.
Quality of pain
The quality of pain when testing the ROM helps determine the stage of recovery and the dosage of techniques used for treatment.
• If pain is experienced before tissue limitation—such as the pain that occurs with muscle guarding after an acute injury or during the active stage of a disease—gentle pain-inhibiting joint techniques may be used. The same techniques can also help maintain joint play (see next section on Grades or Dosages of Movement). Stretching under these circumstances is contraindicated.
• If pain is experienced concurrently with tissue limitation— such as the pain and limitation that occur when damaged tissue begins to heal—the limitation is treated cautiously. Gentle stretching techniques specific to the tight structure are used to improve movement gradually yet not exacerbate the pain by reinjuring the tissue.
• If pain is experienced after tissue limitation is met because of stretching of tight capsular or periarticular tissue, the stiff joint can be aggressively stretched with joint-play techniques and the periarticular tissue with the stretching techniques.
Capsular Restriction
The joint capsule is limiting motion and should respond to mobilization techniques if the following signs are present.
• The passive ROM for that joint is limited in a capsular pattern.
• There is a firm capsular end-feel when overpressure is applied to the tissues limiting the range.
• There is decreased joint-play movement when mobility tests (articulations) are performed.
• An adhered or contracted ligament is limiting motion if there is decreased joint play and pain when the fibers of the ligament are stressed; ligaments often respond to joint mobilization techniques if applied specific to their line of stress.
Subluxation or Dislocation
• Subluxation or dislocation of one bony part on another and loose intra-articular structures that block normal motion may respond to thrust techniques. Some of the simpler manipulations are described in appropriate sections in this text.
Grades or Dosages of Movement
Two systems of grading dosages for mobilization are used.
• Graded Oscillation Techniques
• Sustained Translatory Joint-Play Techniques
Dosages
• Grade I:
o Small-amplitude rhythmic oscillations are performed at the beginning of the range.
• Grade II:
o Large-amplitude rhythmic oscillations are performed within the range, not reaching the limit.
• Grade III:
o Large-amplitude rhythmic oscillations are performed up to the limit of the available motion and are stressed into the tissue resistance.
• Grade IV:
o Small-amplitude rhythmic oscillations are performed at the limit of the available motion and stressed into the tissue resistance.
• Grade V:
o A small-amplitude, high-velocity thrust technique is performed to snap adhesions at the limit of the available motion. Thrust techniques used for this purpose require advanced training.
Uses
• Grades I and II are primarily used for treating joints limited by pain. The oscillations may have an inhibitory effect on the perception of painful stimuli by repetitively stimulating mechanoreceptors that block nociceptive pathways at the spinal cord or brain stem levels. These non-stretch motions help move synovial fluid to improve nutrition to the cartilage.
• Grades III and IV are primarily used as stretching maneuvers.
Techniques
The oscillations may be performed using
• Physiological (osteokinematic) motions or
• Joint-play (arthrokinematic) techniques.
Sustained Translatory Joint-Play Techniques
Dosages
• Grade I (loosen):
o Small-amplitude distraction is applied where no stress is placed on the capsule. It equalizes cohesive forces, muscle tension, and atmospheric pressure acting on the joint.
• Grade II (tighten):
o Enough distraction or glide is applied to tighten the tissues around the joint. Kaltenborn called this “taking up the slack.”
• Grade III (stretch):
o A distraction or glide is applied with an amplitude large enough to place stretch on the joint capsule and surrounding periarticular structures.
Uses
• Grade I distraction is used with all gliding motions and may be used for relief of pain.
• Grade II distraction is used for the initial treatment to determine how sensitive the joint is. 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.
Treatment Force and Direction of Movement
• The treatment force (either gentle or strong) is applied as close to the opposing joint surface as possible. The larger the contact surface, the more comfortable is the patient with the procedure. For example, instead of forcing with your thumb, use the flat surface of your hand.
• The direction of movement during treatment is either parallel or perpendicular to the treatment plane. Treatment plane was described by Kaltenborn as a plane perpendicular to a line running from the axis of rotation to the middle of the concave articular surface. The plane is in the concave partner, so its position is determined by the position of the concave bone.
• Distraction techniques are applied perpendicular to the treatment plane. The entire bone is moved so the joint surfaces are separated.
• Gliding techniques are applied parallel to the treatment plane. The direction of gliding is easily determined by using the convex-concave rule (described earlier in the chapter). If the surface of the moving bony partner is convex, the treatment glide should be opposite to the direction in which the bone swings. If the surface of the moving bony partner is concave, the treatment glide should be in the same direction.
• The entire bone is moved so there is gliding of one joint surface on the other. The bone should not be used as a lever; it should have no arcing motion (swing), which would cause rolling and thus compression of the joint surfaces.
Ref: Therapeutic Exercise by Kisner & Colby (5th Edition)
• Joint mobilization refers to manual therapy techniques that are used to modulate pain and treat joint dysfunctions that limit range of motion (ROM) by specifically addressing the altered mechanics of the joint.
• The altered joint mechanics may be due to
o pain and muscle guarding
o joint effusion
o contractures or adhesions in the joint capsules or supporting ligaments, or malalignment or subluxation of the bony surfaces.
• Joint mobilization stretching techniques differ from other forms of passive or self-stretching in that they specifically address restricted capsular tissue by replicating normal joint mechanics while minimizing abnormal compressive stresses on the articular cartilage in the joint.
• When indicated, joint mobilization is a safe, effective means of restoring or maintaining joint play within a joint and can also be used for treating pain.
Mobilization/Manipulation
• Mobilization and manipulation are two words that have come to have the same meaning and are therefore interchangeable.
• 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.
• The varying speeds and amplitudes could range from a small-amplitude force applied at high velocity to a large-amplitude force applied at slow velocity; that is, there is a continuum of intensities and speeds at which the technique could be applied.
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. Brian Mulligan of New Zealand originally described these techniques.
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.
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
o Component motions and
o Joint play.
Component motions are those motions that accompany active motion but are not under voluntary control. The term is often used synonymously with accessory movement. For example, 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.
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.
N.B. Procedures to distract or slide the joint surfaces to decrease pain or restore joint play are the fundamental joint mobilization techniques described in this text.
BASIC CONCEPTS OF JOINT MOTION: ARTHROKINEMATICS
• In ovoid 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, respectively; similar to a horseback rider being in complementary opposition to the shape of a saddle.
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
o rolling and
o sliding, or
o 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.
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, 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.
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.
• 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.
N O T E:
• This mechanical relationship is known as the convex-concave rule and is the basis for determining the direction of the mobilizing force when joint mobilization gliding techniques are used.
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.
• 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.
N O T E:
• When the therapist passively moves the articulating surface using the slide component of joint motion, the technique is called translatoric glide, translation, or simply glide.
• It is used to control pain when applied gently or to stretch the capsule when applied with a stretch force.
Spin
Characteristics of one bone spinning on another include the following.
• 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 .
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 significantly magnifies the force at the joint.
• The force causes excessive joint compression in the direction of the rolling bone (see Fig. 5.3).
• The roll without a slide does not replicate normal joint mechanics.
Joint glide (mobilization) stretching procedures,as when the translatoric slide component of the bones 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.
Other Accessory Motions that Affect the Joint
Compression
Compression is the decrease in the joint space between bony partners.
• Compression normally occurs in the extremity and spinal joints when weight bearing.
• Some compression occurs as muscles contract, which provides stability to the joints.
• As one bone rolls on the other, some compression also occurs on the side to which the bone is angulating.
• Normal intermittent compressive loads help move synovial fluid and thus help maintain cartilage health.
• Abnormally high compression loads may lead to articular cartilage changes and deterioration.
Traction/Distraction
Traction and distraction are not synonymous.
Traction is a longitudinal pull. Distraction is a separation, or pulling apart.
• Separation of the joint surfaces (distraction) does not always occur when a traction force is applied to the long axis of a bone. For example, 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.
• For clarity, whenever there is pulling on the long axis of a bone, the term long-axis traction is used. Whenever the surfaces are to be pulled apart, the term distraction, joint traction, or joint separation is used.
N O T E:
• For joint mobilization techniques, distraction is used to control or relieve pain when applied gently or to stretch the capsule when applied with a stretch force.
• A slight distraction force is used when applying gliding techniques.
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.
• 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.
• 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. Joint motion provides sensory input relative to:
o Static position and sense of speed of movement (type I receptors found in the superficial joint capsule)
o Change of speed of movement (type II receptors found in deep layers of the joint capsule and articular fat pads)
o Sense of direction of movement (type I and III receptors; type III found in joint ligaments)
o Regulation of muscle tone (type I, II, and III receptors)
o Nociceptive stimuli (type IV receptors found in the fibrous capsule, ligaments, articular fat pads, periosteum, and walls of blood vessels)
INDICATIONS FOR JOINT MOBILIZATION
• Pain, Muscle Guarding, and Spasm
• Reversible Joint Hypomobility
• Positional Faults/Subluxations
• Progressive Limitation
• Functional Immobility
1. Pain, Muscle Guarding, and Spasm
• Painful joints, reflex muscle guarding, and muscle spasm can be treated with gentle joint-play techniques to stimulate neurophysiological and mechanical effects.
Neurophysiological Effects
• Small-amplitude oscillatory and distraction movements are used to stimulate the mechanoreceptors that may inhibit the transmission of nociceptive stimuli at the spinal cord or brain stem levels.
Mechanical Effects
• Small-amplitude distraction or gliding movements of the joint are used to cause synovial fluid motion, which is the vehicle for bringing nutrients to the avascular portions of the articular cartilage (and intra-articular fibrocartilage when present).
• Gentle joint-play techniques help maintain nutrient exchange and thus prevent the painful and degenerating effects of stasis when a joint is swollen or painful and cannot move through the ROM.
N O T E:
• The small-amplitude joint techniques used to treat pain, muscle guarding, or muscle spasm should not place stretch on the reactive tissues.
2. Reversible Joint Hypomobility
• Reversible joint hypomobility can be treated with progressively vigorous joint-play stretching techniques to elongate hypomobile capsular and ligamentous connective tissue.
• Sustained or oscillatory stretch forces are used to distend the shortened tissue mechanically.
3. Positional Faults/Subluxations
• Malposition of one bony partner with respect to its opposing surface may result in limited motion or pain. This can occur with a traumatic injury, after periods of immobility, or with muscle imbalances. The malpositioning may be perpetuated with maladapted neuromuscular control across the joint so whenever attempting active ROM there is faulty tracking of the joint surfaces resulting in pain or limited motion.
• MWM techniques attempt to realign the bony partners while the person actively moves the joint through its ROM.
• Manipulations are used to reposition an obvious subluxation, such as a pulled elbow or capitate-lunate subluxation.
4. Progressive Limitation
• Diseases that progressively limit movement can be treated with joint-play techniques to maintain available motion or retard progressive mechanical restrictions.
• The dosage of distraction or glide is dictated by the patient’s response to treatment and the state of the disease.
5. Functional Immobility
• When a patient cannot functionally move a joint for a period of time, the joint can be treated with non-stretch gliding or distraction techniques to maintain available joint play and prevent the degenerating and restricting effects of immobility.
LIMITATIONS OF JOINT MOBILIZATION TECHNIQUES
• Mobilization techniques cannot change the disease process of disorders such as rheumatoid arthritis or the inflammatory process of injury.
• In these cases, treatment is directed toward minimizing pain, maintaining available joint play, and reducing the effects of any mechanical limitations.
• The skill of the therapist affects the outcome. The techniques described in this text are relatively safe if directions are followed and precautions are heeded; but if these techniques are used indiscriminately on patients not properly examined and screened for such maneuvers or if they are applied too vigorously for the condition, joint trauma or hypermobility may result.
CONTRAINDICATIONS AND PRECAUTIONS
The only true contraindications to stretching techniques are
• Hypermobility
• joint effusion, and
• Inflammation.
Hypermobility
• The joints of patients with potential necrosis of the ligaments or capsule should not be stretched.
• Patients with painful hypermobile joints may benefit from gentle joint-play techniques if kept within the limits of motion. Stretching is not done.
Joint Effusion
• There may be joint swelling (effusion) due to trauma or disease.
• Rapid swelling of a joint usually indicates bleeding in the joint and may occur with trauma or diseases such as hemophilia.
• Medical intervention is required for aspiration of the blood to minimize its necrotizing effect on the articular cartilage.
• Slow swelling (more than 4 hours) usually indicates serous effusion (a buildup of excess synovial fluid) or edema in the joint due to mild trauma, irritation, or a disease such as arthritis.
• Do not stretch a swollen joint with mobilization or passive stretching techniques. The capsule is already on a stretch by being distended to accommodate the extra fluid. The limited motion is from the extra fluid and muscle response to pain, not from shortened fibers.
• Gentle oscillating motions that do not stress or stretch the capsule may help block the transmission of a pain stimulus so it is not perceived and may also help improve fluid flow while maintaining available joint play.
• If the patient’s response to gentle techniques results in increased pain or joint irritability, the techniques were applied too vigorously or should not have been done with the current state of pathology.
Inflammation
• Whenever inflammation is present, stretching increases pain and muscle guarding and results in greater tissue damage.
• Gentle oscillating or distraction motions may temporarily inhibit the pain response.
Conditions Requiring Special Precautions for Stretching
In most cases, joint mobilization techniques are safer than passive angular stretching, in which the bony lever is used to stretch tight tissue and joint compression results. Mobilization may be used with extreme care in the following conditions if the signs and the patient’s response are favorable.
• Malignancy
• Bone disease detectable on radiographs
• Unhealed fracture (depends on the site of the fracture and stabilization provided)
• Excessive pain (determine the cause of pain and modify treatment accordingly)
• Hypermobility in associated joints (associated joints must be properly stabilized so the mobilization force is not transmitted to them)
• Total joint replacements (the mechanism of the replacement is self-limiting, and therefore the mobilization gliding techniques may be inappropriate)
• Newly formed or weakened connective tissue such as immediately after injury, surgery, or disuse or when the patient is taking certain medications such as corticosteroids (gentle progressive techniques within the tolerance of the tissue help align the developing fibrils, but forceful techniques are destructive)
• Systemic connective tissue diseases such as rheumatoid arthritis, in which the disease weakens the connective tissue (gentle techniques may benefit restricted tissue, but forceful techniques may rupture tissue and result in instabilities)
• Elderly individuals with weakened connective tissue and diminished circulation (gentle techniques within the tolerance of the tissue may be beneficial to increase mobility)
PROCEDURES FOR APPLYING PASSIVE JOINT MOBILIZATION TECHNIQUES
Examination and Evaluation
If the patient has limited or painful motion, examine and decide which tissues are limiting function and the state of pathology. Determine whether treatment should be directed primarily toward relieving pain or stretching a joint or soft tissue limitation.
Quality of pain
The quality of pain when testing the ROM helps determine the stage of recovery and the dosage of techniques used for treatment.
• If pain is experienced before tissue limitation—such as the pain that occurs with muscle guarding after an acute injury or during the active stage of a disease—gentle pain-inhibiting joint techniques may be used. The same techniques can also help maintain joint play (see next section on Grades or Dosages of Movement). Stretching under these circumstances is contraindicated.
• If pain is experienced concurrently with tissue limitation— such as the pain and limitation that occur when damaged tissue begins to heal—the limitation is treated cautiously. Gentle stretching techniques specific to the tight structure are used to improve movement gradually yet not exacerbate the pain by reinjuring the tissue.
• If pain is experienced after tissue limitation is met because of stretching of tight capsular or periarticular tissue, the stiff joint can be aggressively stretched with joint-play techniques and the periarticular tissue with the stretching techniques.
Capsular Restriction
The joint capsule is limiting motion and should respond to mobilization techniques if the following signs are present.
• The passive ROM for that joint is limited in a capsular pattern.
• There is a firm capsular end-feel when overpressure is applied to the tissues limiting the range.
• There is decreased joint-play movement when mobility tests (articulations) are performed.
• An adhered or contracted ligament is limiting motion if there is decreased joint play and pain when the fibers of the ligament are stressed; ligaments often respond to joint mobilization techniques if applied specific to their line of stress.
Subluxation or Dislocation
• Subluxation or dislocation of one bony part on another and loose intra-articular structures that block normal motion may respond to thrust techniques. Some of the simpler manipulations are described in appropriate sections in this text.
Grades or Dosages of Movement
Two systems of grading dosages for mobilization are used.
• Graded Oscillation Techniques
• Sustained Translatory Joint-Play Techniques
Dosages
• Grade I:
o Small-amplitude rhythmic oscillations are performed at the beginning of the range.
• Grade II:
o Large-amplitude rhythmic oscillations are performed within the range, not reaching the limit.
• Grade III:
o Large-amplitude rhythmic oscillations are performed up to the limit of the available motion and are stressed into the tissue resistance.
• Grade IV:
o Small-amplitude rhythmic oscillations are performed at the limit of the available motion and stressed into the tissue resistance.
• Grade V:
o A small-amplitude, high-velocity thrust technique is performed to snap adhesions at the limit of the available motion. Thrust techniques used for this purpose require advanced training.
Uses
• Grades I and II are primarily used for treating joints limited by pain. The oscillations may have an inhibitory effect on the perception of painful stimuli by repetitively stimulating mechanoreceptors that block nociceptive pathways at the spinal cord or brain stem levels. These non-stretch motions help move synovial fluid to improve nutrition to the cartilage.
• Grades III and IV are primarily used as stretching maneuvers.
Techniques
The oscillations may be performed using
• Physiological (osteokinematic) motions or
• Joint-play (arthrokinematic) techniques.
Sustained Translatory Joint-Play Techniques
Dosages
• Grade I (loosen):
o Small-amplitude distraction is applied where no stress is placed on the capsule. It equalizes cohesive forces, muscle tension, and atmospheric pressure acting on the joint.
• Grade II (tighten):
o Enough distraction or glide is applied to tighten the tissues around the joint. Kaltenborn called this “taking up the slack.”
• Grade III (stretch):
o A distraction or glide is applied with an amplitude large enough to place stretch on the joint capsule and surrounding periarticular structures.
Uses
• Grade I distraction is used with all gliding motions and may be used for relief of pain.
• Grade II distraction is used for the initial treatment to determine how sensitive the joint is. 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.
Treatment Force and Direction of Movement
• The treatment force (either gentle or strong) is applied as close to the opposing joint surface as possible. The larger the contact surface, the more comfortable is the patient with the procedure. For example, instead of forcing with your thumb, use the flat surface of your hand.
• The direction of movement during treatment is either parallel or perpendicular to the treatment plane. Treatment plane was described by Kaltenborn as a plane perpendicular to a line running from the axis of rotation to the middle of the concave articular surface. The plane is in the concave partner, so its position is determined by the position of the concave bone.
• Distraction techniques are applied perpendicular to the treatment plane. The entire bone is moved so the joint surfaces are separated.
• Gliding techniques are applied parallel to the treatment plane. The direction of gliding is easily determined by using the convex-concave rule (described earlier in the chapter). If the surface of the moving bony partner is convex, the treatment glide should be opposite to the direction in which the bone swings. If the surface of the moving bony partner is concave, the treatment glide should be in the same direction.
• The entire bone is moved so there is gliding of one joint surface on the other. The bone should not be used as a lever; it should have no arcing motion (swing), which would cause rolling and thus compression of the joint surfaces.
Ref: Therapeutic Exercise by Kisner & Colby (5th Edition)
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