Peripheral joint mobilization

1. Peripheral joint mobilization Made by Sajida Mazhar

2. Joint mobilization • Joint mobilization refers to manual therapy techniques that are used to • modulate pain and • treat joint dysfunctions • regain range of motion (ROM) • addressing the altered mechanics of the joint.

3. The altered joint mechanics may be due to • pain • muscle guarding • joint effusion • Contractures • adhesions in the joint capsules • Adhesions in supporting ligaments • Malalignment • subluxation of the bony surfaces

4. Joint mobilization • It differ from stretching in that they • specifically address restricted capsular tissue by replicating normal joint mechanics • minimizing abnormal compressive stresses on the articular cartilage in the joint. • practitioner must know • anatomy • arthrokinematics and • pathology of the neuromusculoskeletal system • recognize when the techniques are indicated • when other techniques would be more effective for regaining lost motion. • False use of may lead to potential harm to the patient’s joints.

5. Mobilization/Manipulation • They are passive skilled manual therapy techniques • applied to joints and related soft tissues • at varying speeds and amplitudes using physiological or accessory motions for therapeutic purposes. • speeds and amplitudes could range from • a small-amplitude force applied at high velocity • to a large-amplitude force applied at slow velocity

6. Self-Mobilization (Auto-mobilization) • Self-mobilization refers to self-stretching techniques • specifically use joint traction or glides that direct • the stretch force to the joint capsule.

7. Mobilization with Movement • Mobilization with movement (MWM) is • accessory mobilization Applied by a therapist • an active physiological movement to end range applied by the patient The techniques are always applied in • a pain-free direction and • described as correcting joint tracking from a positional fault

8. Physiological Movements • Physiological movements are movements the patient can do voluntarily • (e.g., the classic or traditional movements, • such as flexion, abduction, and rotation) • term osteokinematics is used for these

9. Accessory Movements • Accessory movements are movements in the joint and surrounding tissues • that are necessary for normal ROM • cannot be actively performed by the patient. • Component motions • Accompany active motion • but are not under voluntary control. • E.g. motions such as upward rotation of the scapula and rotation of the clavicle, which occur with shoulder flexion, ext rotation of the tibia in knee extension.

10. Accessory Movements • joint play. • the motions that occur between the joint surfaces • the distensibility or “give” in the joint capsule • necessary for normal joint functioning through the ROM • Demonstrated passively • but they cannot be performed actively • The movements include • distraction, • Sliding, • compression, • rolling, • spinning of the joint surfaces. • The term arthrokinematics is used for these motions

11. Thrust • Thrust is a high-velocity, • short-amplitude motion • that the patient cannot prevent the motion. • The motion is performed at the end of the pathological limit (end of the available ROM when there is restriction.) • Is alter positional relationships • snap adhesions, • stimulate joint receptors.

12. Manipulation Under Anesthesia • Manipulation under anesthesia • is a medical procedure • used to restore full ROM • by breaking adhesions around a joint • while the patient is anesthetized. • The technique may be a rapid thrust or a passive stretch • using physiological or accessory movements

13. Muscle Energy • Muscle energy techniques use • active contraction of deep muscles that attach near the joint and • whose line of pull can cause the desired accessory motion. • The therapist stabilize the segment on which the distal aspect of the muscle attaches. • A command for an isometric contraction of the muscle, that causes accessory movement of the joint

14. BASIC CONCEPTS OF JOINTMOTION: ARTHROKINEMATICS • Joint Shapes • The type of motion occurring between bony partners in a joint • is influenced by the shape of the joint surfaces.

15. Joint Shapes • 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

16. Types of Motion • As a bony lever moves about an axis of motion, • also movement of the bone surface on the opposing bone surface in the joint. • The movement of the bony lever is called swing • as flexion, extension, abduction, adduction, and rotation. • measured in degrees with a goniometer and is called ROM. • Motion of the bone surfaces in the joint is a combination of rolling and sliding, or spinning. • These accessory motions allow greater angulations of the bone as it swings. • For the rolling, sliding, or spinning • There must adequate capsule laxity or joint play.

17. Types of Motion • Roll • Characteristics of one bone rolling on another are as follows. • The surfaces are incongruent. • New points on one surface meet new points on the opposing surface. • Rolling results in angular motion of the bone (swing). • Rolling is always in the same direction as the swinging bone motion whether the surface is convex or concave.

18. Rolling Rolling, if it occurs alone, causes • compression of the surfaces on the side to which the bone is swinging • separation on the other side. • Passive stretching using • bone angulations alone may cause stressful compressive forces to portions of the joint surface, • potentially leading to joint damage. • In normally functioning joints, pure rolling does not occur alone but in combination with joint sliding and spinning

19. Slide/Translation Slide/Translation Characteristics of one bone sliding (translating) across another include the following. • For a pure slide, the surfaces must be congruent, either • Flat or curved • The same point on one surface comes into contact with • the new points on the opposing surface.

20. Slide/Translation • Pure sliding does not occur in joints • because the surfaces are not completely congruent. • The direction in which sliding occurs depends on • whether the moving surface is concave or convex. • Sliding is in the opposite direction of the angular movement of the bone if the moving joint surface is convex. • Sliding is in the same direction • as the angular movement of the bone • if the moving surface is concave.

21. Combined Roll-Sliding in a Joint • The more congruent the joint surfaces are, the more sliding • The more incongruent the joint surfaces are, the more rolling

22. Spin • There is rotation of a segment about a stationary mechanical axis • The same point on the moving surface creates an arc of a circle as the bone spins

23. 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

24. Other Accessory Motions • Compression • Compression is the decrease in the joint space between • bony partners. • weight bearing jts • With muscle contration (stabilization) • With rolling • help move synovial fluid and thus help maintain cartilage health. • Abnormally high loads may lead • articular cartilage changes and deterioration

25. Traction/Distraction • Traction isa longitudinal pull. • Distraction is a separation, or pulling apart • if traction is applied • to the shaft of the humerus, it results in a glide of the joint surface Distraction of the glenohumeral • joint requires a pull at right angles to the glenoid fossa • whenever there is pulling on the long axis of a bone, the term long-axis traction • the surfaces are to be pulled apart, the term distraction, joint traction, or joint separation is used.

26. Open and close pack position Position patient in a relaxed, distracted, supported position so the joint capsule is lax (loose(open)-packed position). Close-packed position is one in which there is maximal contact of the articulating surfaces.

29. 10 simple steps • Evaluation and Assessment • Determine grades and dosage • Patient position • Joint position • Stabilization • Treatment force • Direction of movement • Speed and rhythm • Initiation of treatment • Reassessment

30. 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-

31. Normal motion

32. Grades of Oscillations (Maitland)

33. INDICATIONS FOR JOINTMOBILIZATION • Pain, Muscle Guarding, and Spasm • Painful joints, reflex muscle guarding, and muscle spasm treated gentle joint-play techniques to stimulate neurophysiological and mechanical effects • neurophysiological and mechanical effects • stimulate the mechanoreceptors • Inhibit nociceptive stimuli • mechanical effects • Synovial fluid motion provide neutrients to jts

34. The small-amplitude joint techniques used to • treat pain, muscle guarding, or muscle spasm should not • place stretch on the reactive tissues

35. Reversible Joint Hypomobility • joint-play stretching techniques to elongate • hypomobile capsular and ligamentous connective tissue • Positional Faults/Subluxations • Malposition / regain ROM • realign the bony partners • Progressive Limitation • Diseases that progressively limit movement can be treated with joint-play • Functional Immobility • Patient functionaly imobile

36. CONTRAINDICATIONSAND PRECAUTIONS • Hypermobility • Joint Effusion • Inflammation

37. Conditions Requiring SpecialPrecautions for Stretching • Malignancy • Bone disease detectable on radiographs • Unhealed fracture • Excessive pain • Hypermobility in associated joints • Total joint replacements • Newly formed or weakened connective tissue • Systemic connective tissue diseases such as rheumatoid • Elderly individuals