Principles Of Joint Mobilization - Physiopedia
Principles of Joint MobilizationEdward P. Mulligan, MS, PT, SCS, ATCVP, National Director of Clinical EducationHealthSouth Corporation – Grapevine, TXClinical InstructorUniversity of Texas Southwestern PT DepartmentDallas, TXThe contents of this presentation are copyrighted 2001 by continuing ED. They may not be utilized,reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, or by anyinformation storage or retrieval system, without permission in writing from Edward P. Mulligan.continuing EDJoint Mobilizationskilled passivemovement of thearticular surfacesperformed by aphysical therapistto decrease painor increase jointmobilitycontinuing ED1
Presentation ObjectivesDefine osteokinematic and arthrokinematic motionExplain the arthrokinematic rules of motionDetect and classify joint dysfunctionDefine the resting and closed pack position of a jointUnderstand the treatment application principlesthat govern passive joint mobilizations Investigate what the literature suggests regardingmobilization effectiveness and efficacyt Memorize the morphological and capsular characteristics of each jointu Demonstrate selected joint mobilization techniquesnopqrcontinuing EDObjective 1Define osteokinematic andarthrokinematic motioncontinuing ED2
Osteokinematics“Motion You SEE”observable movements of bones in space asrepresentedby a change in the angle of adjacent articularsegmentscontinuing EDArthrokinematics“Motion You FEEL” Unobservable articular accessory motion betweenadjacent joint surfaces¾roll, glide, and spin These accessory motions take place with allactive and passive movements and are necessaryfor full, pain free range of motion Arthrokinematic motion can not occur independently or voluntarily and if restricted, can limitphysiological movementcontinuing ED3
Types of Arthrokinematic MotionJoint Play¾ movement not under voluntary control (passive)¾ can not be achieved by active muscular contractionversusComponent Movement¾ involuntary obligatory joint motion occurring outsidethe joint accompanies active motion– i.e. - scapulohumeral rhythmcontinuing EDArthrokinematic ROLL new points on onesurface come intocontact with newpoints on the othersurface (wheel) rolling only occurswhen the twoarticulatingsurfaces areincongruentcontinuing ED4
Arthrokinematic GLIDE translatory motion in whichone constant point on onesurface is contacting newpoints or a series of pointson the other surface pure gliding can occurwhen two surfaces arecongruent and flat orcongruent and curved glide also referred to astranslationbraking analogycontinuing EDArthrokinematic SPIN rotation around alongitudinal stationarymechanical axis (onepoint of contact) in aCW or CCW directionloss of traction analogycontinuing ED5
Arthrokinematic MotionsConcave on Convexcontinuing EDArthrokinematic MotionsConvex on Concavecontinuing ED6
ROLLING and GLIDING Since there is never pure congruencybetween joint surfaces; all motionsrequire rolling and gliding to occursimultaneously This combination of roll and glide issimultaneous but not necessarily inproportion to one anothercontinuing EDArthrokinematic MotionsThe more congruent - the more the glidingThe more incongruent - the more the rollingBPure Spin: B contacts point 1xA123continuing ED7
Arthrokinematic MotionsThe more congruent - the more the glidingThe more incongruent - the more the rollingPure Glide: A contacts point 2BxAA123continuing EDArthrokinematic MotionsThe more congruent - the more the glidingThe more incongruent - the more the rollingPure Roll: B contacts point 3BxBA123continuing ED8
Arthrokinematic MotionsThe more congruent - the more the glidingThe more incongruent - the more the rollingGlide and Roll: B contacts point 2BxA1B23continuing EDObjective 2Explain the arthrokinematicrules of motioncontinuing ED9
Joint MorphologyJoint surfaces are defined as:Convex:male; rounded or archedConcave: female; hollowed or shallowcontinuing EDJoint MorphologyJoint surfaces are defined as:Ovoid:concave and convex articular partner surfaceSellar: saddle shape with each articular surface having aconcave and convex component in a specificdirection Examples would include thesternoclavicular and 1st carpometacarpaljointscontinuing ED10
Concave and Convex Characteristics convex surfaces have morecartilage at the center concave surfaces have morecartilage on the periphery where surfaces appear flat the larger articular surfaceis considered convexcontinuing EDRules of MotionConcave Motion Rule convex surface is stationary andconcave surface moves osteo and arthrokinematic motion is in thesame direction arthrokinematic mobilization gliding force is in thesame direction as osteokinematicbony movementGLIDE and ROLL are in the SAME DIRECTIONcontinuing ED11
Rules of MotionConvex Motion Rule concave surface is stationary andconvex surface moves osteo and arthrokinematic motionis in the opposite direction arthrokinematic mobilization glidingforce is in the opposite direction asosteokinematic bony movementGLIDE and ROLL are in the OPPOSITE DIRECTIONcontinuing EDRules of Motion because their is alwaysincongruent surfaces,there must be somecombination of glideand roll arthrokinematic rollalways occurs in thesame direction as bonymovement regardlessof whether the jointsurface is convex orconcave in shape.femur stationarytibia stationarycontinuing ED12
Functional Roll and Glide AnalogyThe more congruent– the more glideThe more incongruent– the more rollJoint incongruencyrequires rolling andgliding in combinationcontinuing EDObligate Translation During AROM translation direction is influenced by thecapsuloligamentous complex Passive restraints act not only to restrict movement butalso to reverse articular movements at the end rangeof motionConvex-Concave Morphology vs.Capsular Obligate Translation At end range, asymmetrical capsular mobility causes obligatetranslation away from the side of tightness Tight capsular structures will cause early and excessiveaccessory motion in the opposite direction of the tightnesscontinuing ED13
secondary to capsular tightness asymmetrycontinuing EDTreatment Plane and Axis of MotionThe treatment plane lies in the concave articular surfaceand is parallel to the joint surface and perpendicular tothe axis in the convex surfaceThe axis of motion always lies in the convex articular surfaceThe treatment plane moves with the concave surface movesThe treatment plane remains essentially still when theconvex surface movescontinuing ED14
TRACTION the process of pullingone bony surface awayfrom the other (jointseparation) passive translatoric bonemovement which is at aright angle to thetreatment planecontinuing EDGLIDING Translatory movementwhere the joint surfacesare passively displacedparallel to thetreatment planecontinuing ED15
Objective 3Detect and classify jointdysfunctioncontinuing EDDetect and Classification of Joint DysfunctionCause of Limited MotionIdentificationTreatment InterventionROM unaffected byproximal or distal jointpositioningCapsular End FeelMOBILIZEShortened Extra-articularMuscle GroupsROM affected by proximalor distal joint positioningSTRETCHMuscle WeaknessROM affected by gravitySTRENGTHENPainEmpty end feelMODALITIESGrade I-II MobsNerve Root AdhesionNeural Tension TestsNEURAL MOBILIZATIONSoft Tissue RestrictionsPalpationSOFT TISSUEMOBILIZATIONIntra-articular Adhesions orPericaspsular Stiffness continuing ED16
Determination of Joint Mobility difficult to assessquantity graded in millimetersquality graded by “end feel”poor intra/intertester reliabilitybest gauged by comparison touninvolved sidecontinuing EDDetermination of Joint MobilityDirect Method manual assessment of decreasedaccessory motion in all directionsIndirect Method after noting decreased active and/or passive range ofmotion; apply the convex/concave rules to determine thedirection of limited mobility This method is used when– patient has severe pain– joint is extremely hypomobile– therapist is inexperienced with direct assessmentcontinuing ED17
CLASSIFICATION of JOINT MOBILITYOrdinal ScaleGRADEDEFINITIONTREATMENT POSSIBILITIESNo attempts should be made to mobilize1No Movement – jointankylosedExtremely hypomobileMobilization2Slightly hypomobileMobilization-Manipulation3NormalNo dysfunction; no treatment needed4Slightly hypermobile5Extremely hypermobile6UnstableLook for hypomobility in adjacent joints.Exercise, taping, bracing, etcLook for hypomobility in adjacent joints.Exercise, taping, bracing, etcBracing, splinting, casting,surgical stabiliztion0continuing EDMOTION SCHEMATICINSTABILITYDisruption StrainDisruptionSLACKJointDislocation Sprain SLACK INSTABILITYActiveJointMovement PlayStrainSprainACTIVE RANGE of MOTIONPHYSIOLOGICAL LIMIT of MOTIONANATOMICAL LIMIT of MOTIONPOTENTIAL DISABILITYcontinuing ED18
Objective 4Define the resting and closedpack position of a jointcontinuing EDJoint Positions and Congruence Articular surfaces are rarely, if ever, in totalcongruence The area of contact or congruence at anyparticular point in the range of motion isrelatively small compared to the surface area Allows for better lubrication and recovery timefor the articular surfacescontinuing ED19
RESTING POSITION Surrounding tissue is as lax as possible– maximum incongruency Intracapsular space is as large aspossible Position sought at rest or following acutetrauma to accommodate maximal fluidaccumulation Unlocked, statically inefficient for load bearing,and dynamically safe Treatment position– max amount of joint play availablecontinuing EDCLOSED PACK POSITION Joint positions are most congruent Surrounding tissue (capsules andligaments) under maximal tension Intracapsular space is minimal Locked, statically efficient for loadbearing, and dynamically dangerous Testing position– ex: apprehension test of GH jointcontinuing ED20
Objective 5Understand the treatmentapplication principles thatgovern passive jointmobilizationcontinuing EDmobilization treatment Mobilization (movement) to a joint may:– fire articular mechanoreceptors– fire cutaneous and muscularreceptors– abate nocioceptors– decrease or relax muscleguardingcontinuing ED21
mobilization treatmentTherapeutic Effects of Mobilization include:– stimulate synovial fluidmovement to nourish cartilage– maintain/promote periarticularextensibility– provide sensory inputcontinuing EDmobilization indications pain relief decrease muscle guardingor spasm treat reversible jointhypomobility of capsularorigincontinuing ED22
mobilization treatment variables Joint position Direction of mobilization Type of mobilization– oscillation vs. sustained hold Grade (intensity) of mobilization Mobilization dosagecontinuing EDtranslatory glide mobilization gradingGrade I – small amplitude movement at the beginning of the available ROMGrade II – large amplitude movement at within the available ROMGrade III – large amplitude movement that reaches the end ROMGrade IV – small amplitude movement at the very end range of motionGrade V – high velocity thrust of small amplitude at the end of the availablerange and within its anatomical range (manipulation)continuing ED23
distraction mobilization gradingGrade I – unweighting or barely supporting the joint surfaces (picolo)– equalizes cohesive and atmospheric forces of the joint– alleviates pain by unloading and decompressing– nullifies normal compressive forcesGrade II – slack of the capsule taken up (eliminates joint pain)Grade III – capsule and ligaments stretchedcontinuing EDmobilization treatment considerations Grades I and II– "neurophysiological effect used daily to treatpain"– pain relief through neuromodulation on thesensoryinnervationofthejointmechanoreceptors and pain receptors– ”gates pain achieved by the inhibition oftransmission of nocioceptive stimuli at thespinal cord and brain stem level– neutralizes joint pressures– prevents grindingcontinuing ED24
mobilization treatment considerationsGrades III-V– “mechanical effect used 3-5 times/week totreat stiffness or hypomobility” increase ROM throughpromotion of capsular mobilityand plastic deformation mechanical distention and/orstretching of shortened tissuescontinuing EDmobilization treatment principlesOscillations– 60-120/min– 1-5 sets of 5-60 sec– generally used to treatpainProlonged Hold– 5-30 seconds– 1-5 reps– typically applied at endrange to treat stiffness Oscillations or prolongedhold at mid-rangestimulates type Imechanoreceptors Oscillations or prolongedhod at end rangestimulates type IImechanoreceptors Low grade sustained holdstimulates type IIImechanorceptors andinhibits guardingcontinuing ED25
articular icGraded or Capsuleprogressive oscillations atDeep CapsuleSilent at rest; fires asmovement beginsIIIInhibitiveBEHAVIORSuperficialActive at RestIIFIRED BYSlow AdaptingPostural KinestheticAwarenessend ROM Tonic StabilizersGraded or Fast Adaptingprogressive Dynamic Sensationoscillations in Phasic MoversStretch or Defensive Receptorsustained hold Gives reflexive inhibitionat end ROM of muscle toneInjury and Non-adaptingInflammation mid ROMLigamentsVery similar infunction and structureto GTOIVNocioceptiveMost TissuesTonic reflexogeniceffect which producescontinuing EDguardingmobilization treatment rulesPosition patient to achieve maximal relaxation; Comfortable room temperature with patientproperly draped; Confident, firm, comfortable hand holds; Remove watches and jewelry; Secure ties, belt buckles, etccontinuing ED26
mobilization treatment rules Articulate initially in resting position andthen “chase” end range Use good body mechanics Allow gravity to assist Your body and the mobilizing part act asone unit Stabilize!! Short lever arms and hands as close tojoint as possible Mobilize below the pain threshold– Avoid muscle guarding– Articulate in opposite direction if needed– DO NOT CAUSE PAIN!!continuing EDObjective 6Recognizecontraindications tomobilization treatmentcontinuing ED27
Absolute Contraindications Malignancy in area of treatmentInfectious ArthritisMetabolic Bone DiseaseNeoplastic DiseaseFusion or AnkylosisOsteomyelitisFracture or Ligament Rupturecontinuing EDRelative Contraindications Excessive pain or listhesisRheumatoid arthritisVertebrobasilar insufficiencycontinuing ED28
Objective 7Investigate what theliterature suggestsregarding mobilizationeffectiveness andefficacycontinuing EDDoes it Work?Analysis of literature identified14 studies that were judged tobe valid demonstrations of theefficacy of manual therapy inthe treatment of spine relateddysfunctionDiFabio R, Phys Ther 72:853-864, 1992continuing ED29
Does it Work in the UE? Manual therapy combined with supervised clinical exerciseresulted in superior outcomes to exercise alone inpatients with shoulder impingement syndrome– Bang, et al J Ortho Sports Phys Ther 30:126-138, 2000 Mobilization decreased 24-hour pain and pain associatedwith subacromial compression test in patients withshoulder impingement syndrome– Conroy, et al J Ortho Sports Phys Ther 28:3-14, 1998 The only effective treatment modality for adhesivecapsulitis is mobilization and exercise therapy– Nicholson J Ortho Sports Phys Ther 6:238-246, 1985 End-range mobilization techniques increased mobility inpatients with adhesive capsulitis–Vermeulen, et al Phys Ther 80:1204-1211, 2000continuing EDDoes it Work in the LE? Addition of talocrural mobilizations to the RICE protocol inthe management of inversion ankle injuries necessitatedfewer treatments to achieve pain-free dorsiflexion and toimprove stride speed more than RICE alone.Green, et al. Phys Ther, 2001 Joint mobilization and physical therapy resulted in asignificant, although temporary, improvement in themobility of the ankle and foot in diabetic patients withlimited joint mobility and neuropathyDijis, et al. Am J Podait Med Assoc, 2000continuing ED30
Objective 8Memorize themorphological andcapsularcharacteristics of eachjointcontinuing EDGLENOHUMERAL JOINTConcave Surface:Convex Surface:Closed Pack Position:Resting Position:Capsular Pattern:glenoid fossahumeral head90 Abduction and ER50-70 scaption with mildexternal rotationER Abd IRcontinuing ED31
HUMEROULNAR JOINTConcave Surface:Convex Surface:ulnahumeral trochleaClosed Pack Position: full extension70 flexion;Resting Position:10 supinationflexion extensionCapsular Pattern:continuing EDHUMERORADIAL JOINTConcave Surface:radial headConvex Surface:humeral capitellumClosed Pack Position: 90 flexion; 5 supinationResting Position:Full extensionsupinationCapsular Pattern:flexion extensioncontinuing ED32
RADIOULNAR JOINTConcave Surface:Convex Surface:Closed Pack Position:Resting Position:Capsular Pattern:ulnar notchradial capitellum5 supination70 flexion;35 supinationEqual limitation ofpro-supinationcontinuing EDWRIST JOINTdistal radius-ulnaConcave Surface:proximal carpal rowConvex Surface:Closed Pack Position: full extension andradial deviationneutral with slightResting Position:ulnar deviationflexion extensionCapsular Pattern:continuing ED33
MCP and IP JOINTSConcave Surface:Convex Surface:Closed Pack Position:Resting Position:Capsular Pattern:distalproximalFull flexionSlight flexionFlexion extensioncontinuing EDSPINAL JOINTSConcave Surface:Convex Surface:Closed Pack Position:Resting Position:Capsular Pattern:variablevariableFull extensionmidway betweenflexion and extensionLateral flexion androtation equallylimited, mild loss ofextensioncontinuing ED34
HIP JOINTConcave Surface:Convex Surface:Closed Pack Position:Resting Position:Capsular Pattern:acetabulumfemoral headfull extension and IR30 flexion, abduction, ERflexion, abduction, IR(order varies)continuing EDKNEE JOINTConcave Surface:Convex Surface:Closed Pack Position:Resting Position:Capsular Pattern:tibial plateaufemoral condylesfull extension25-30 flexionflexion extensioncontinuing ED35
TIBIOFIBULAR JOINTConcave Surface:Convex Surface:Closed Pack Position:Resting Position:Capsular Pattern:tibiafibulamaximum dorsiflexionslight plantarflexionpain with stresscontinuing EDTALOCRURAL JOINTConcave Surface:Convex Surface:Closed Pack Position:Resting Position:Capsular Pattern:tib-fib talar dometalusmaximum dorsiflexion10 plantarflexionplantarflexion dorsiflexioncontinuing ED36
SUBTALAR JOINTConcave Surface:Convex Surface:Closed Pack Position:Resting Position:Capsular Pattern:taluscalcaneusfull supinationSTJ neutralincreasing loss ofvarus until stuck invalguscontinuing EDSUBTALAR JOINTConcave Surface:Convex Surface:Closed Pack Position:Resting Position:Capsular Pattern:taluscalcaneusfull supinationSTJ neutralincreasing loss ofvarus until stuck invalgusMTJ, TMTJ, and First Ray have same resting andclosed pack positionscontinuing ED37
MTP and IP JOINTSConcave Surface:Convex Surface:Closed Pack Position:Resting Position:Capsular Pattern:distalproximal articulationfull hyperextensionslight plantarflexionFlexion extensioncontinuing EDRecommended Readings Kaltenborn FMM, et al. Manual Mobilization of the Joints:The Kaltenborn Method of Joint Examination and Treatment:The Extremities, Vol. 1. OTPT, 1999. Kaltenborn FMM, et al. Spine: Basic Evaluation andMobilization Techniques. OTPT, 1993 Cookson J. Orthopedic Manual Therapy: An Overview, PartsI/II. Phys Ther 59:136-259, 1979 Maitland GD. Peripheral Manipulation.Reed Elsevier Plc Group, 1991. Barak T, et al. Mobility: Passive OrthopedicManual Therapy in Orthopedic and SportsPhysical Therapy. CV Mosby, 1985.continuing ED38
continuing ED39
Nerve Root Adhesion Neural Tension Tests NEURAL MOBILIZATION Soft Tissue Restrictions Palpation SOFT TISSUE MOBILIZATION . 17 continuing ED Determination of Joint Mobility difficult to assess quantity graded in millimeters quality graded by “end feel” .
AR 500-5, Army Mobilization, Army mobilization is a complex activity. To understand how the Army mobilizes, an individual requires knowledge of the authorities for mobilization, the process actors and the sequence of activities necessary to bring a unit or Soldier onto active duty. b. HQDA EX
Mobilization 4 Passive Motion Joint Accessory Motion Testing Joint Play Testing 11 Pioneers of Joint Play Testing The two principal pioneers of joint play testing in manual therapy are Geoffrey Maitland of Australia, and Freddy Kaltenborn of Norway. Both individuals developed tec
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Resource mobilization can be defined as a management process of identifying people who share the values of your organization and take steps to manage this relationship (IDRC, 2010). Resource mobilization is often wrongly considered as fundraising. In fact, fundraising is a component of the resourc
TRAINING MANUAL. Robust and Sustainable Resource Mobilization: . by Sarah Ford and the guide was developed by Meghan Armistead, who also piloted the first training. John Donahue was also directional from the inception of the . successful in resource mobilization, and to think
sive mobilization techniques, vary-ing the plane of elevation or varying the degree of rotation in the end-range position, were applied. Mobilization With Movement The use of MWM for peripheral joints was developed by Mulligan.19,20 This technique combines a sustained appli-cation of a manu
present document. Grade-specific K–12 standards in reading, writing, speaking, listening, and language translate the broad (and, for the earliest grades, seemingly distant) aims of the CCR standards into age- and attainment-appropriate terms. The Standards set requirements not only for English language arts (ELA) but
