PT 527 Unit 2: Joint play

Determinants of a dysfunctional joint can present with one or more of the following

- less quantity of movement (think A/PROM) - a change in the quality of movement - a more abrupt end to motion with an abnormal end-feel - an exaggerated amount of motion beyond what you normally expect - capsular pattern present

Typical mobility examination order

1. AROM 2. PROM 3. JPA CDM: hypomobility, hypermobility, normal (unimpaired)

Documentation: what is included

1. amount:hyper, normal, hypo 2. endfeel 3. symptoms

General guidelines for JPA

1. explain the procedure (passive motion) 2. position/ drape accordingly 3. stay close to the joint as possible with sensitive hands 4. Use appropriate body mechanics 5. glides parallel to the treatment plane 6. distractions perpendicular to the treatment plane

JPA reliability Spine: posterior to anterior 1. hypomobility 2. hypermobility 3. inter examinar

1. good reliability 2. poor reliability 3. inter- examiner consistently less than intra-examiner

JPA procedures

1. joint in resting position 2. determine treatment plan 3. determine direction using concave/ convex rule 4. pt and body part well supported 5. pt and therapist relaxed 6. mobilizing force close to PTs COG 7. compare involved with uninvolved 8. check one joint at a time, one movement at a time 9. stabilize one bone and move the other 10. therapist's hands should be as close to joint as possible 11. when possible work with gravity 12. position joint in loose packed position

Loose packed position of ankle

10 degrees PF

Loose packed position knee flexion

25-30 degrees flexion

Loose packed position hip

30 degrees flexion 30 degrees abduction and slight ER

Average amount of movement with JPA?

4-6 mm

Loose packed position of GH

55 deg abduction 30 deg horizontal add (in scapular plane)

Loose packed position of elbow

70 deg flex 10 deg supination

Capsular pattern

A characteristic, proportional, pattern of limitation within each joint that when present implicates the capsule for the ROM impairment present

Most limited motion at the shoulder (capsular pattern)

ER

What two joints have capsular pattern that we need to focus on?

GH and hip

Hip capsular pattern

IR limit > flexion > abduction > ext 45> 120> 45 > 20

Joint play assessment occurs during which part of the visit

PT examination: Test and measures

What kind of technique is joint play assessment considered?

Passive manual

What do you assess for with PROM

Symptoms End feel Amount: hyper, hypo, normal

3 assessments for motion

amount of motion end feel symptoms

When we find impairments determine if they

are relevant and when we are going to intervene based on judgement and findings

JPA use to evaluate

arthrokinematic movements of a joint

Mobility examination: JPA

arthrokinematics/ accessory motions and capsular tension movements within the joint and surrounding tissues that are necessary for normal ROM but that cannot be performed by the patient via voluntary muscle contraction

How do you want hands to be positioned with JPA?

as close as possible too far apart would produce a larger movement like knee flexion

Shoulder PROM ER 24 (74% loss) Abd 92 (49% loss) IR 45 (36% loss) suggests

can determine the loss compared to norms and follows the capsular pattern common pattern in osteoarthritis

Least arthrokinematic motion in

closed packed position

Joint mobility quantity classification 6

complete instability

Treatment plane is parallel to

concave member of the joint

Joint mobility quantity classification 1

considerably decreased movement

Joint mobility quantity classification 5

considerably increased movement

Clinical relevance of JPA

continue to consider different hypothesis based on your observation of the patient and history begin to link these hypotheses with actual tests and measures

Beighton index tests

elbow hyperextension thumb to forearm finger ext greater than 90 knee hyperextension palms to floor

Mobility examination: PROM

end feels, normal, soft, firm, hard assess: SEA

Capsular pattern at shoulder

ext rot limit > abduction > IR limit 90 > 180 > 70

Hypomobility

feel the joint play is limited from what you would expect or compared to the uninvolved side may be limited in just one direction or several directions based on clinical judgement

Treat what you

find

What would you expect the end feel to be with hypermobility

firm if a little hyper if it keeps going maybe soft because the endfeel is not well defined

Shoulder has a greater limit in ____ than _____

greater limit in ER then abd then IR

End feel

hard soft firm empty

Must have normal arthrokinematic motion in oder to

have full osteokinematic motion

Amount of motion

hypomobile normal hypermobile

CDM with typical mobility examination

hypomobility, hypermobility, normal (unimpaired)

Appreciate how your skills will

improve reliability of the exam if standardization of the tool/ test is used (fixation, positioning, following the procedure)

Anterior glide of the tibia on the femur assesses the

integrity of the ACL

How do we position for JPA?

loos packed position

People with swelling or edema commonly sit in what position

loose packed

Beighton scale + 7-9 tests

marked systematic hypermobility

Beighton scale + for 3-4 tests =

mild systematic hypermobility

Beighton scale + 5-6 tests =

mod systematic hypermobility

Osteokinematic/ Physiological

movement between two bones can be done actively by the patient or passively by the therapist, or some combination

Arthrokinematic/ accessory

movement between two joint surfaces. Movements not under voluntary control but necessary for full painless joint motion. Cannot be achieved actively.

Loose packed position of fingers/ toes

neutral flex/ ext

Loose packed position of wrist

neutral flex/ ext slight UD

Loose packed position spine

neutral flexion/ extension

Joint mobility quantity classification 0

no movement

Beighton Horan Scale + 0 - 2 tests =

normal

Joint mobility quantity classification 3

normal movement

Mobility examination: AROM

osteokinematic or classic motion movements pt can do voluntarily in cardinal planes or combined in planar motions assess for quantity, quality and symptoms

Closed packed position

osteokinematic position where there is the least arthrokinematic motion

Loose packed position

osteokinematic position where there is the most arthrokinematic mtion

Gliding moves

parallel to the treatment plane

Traction moves

perpendicular to the treatment plane

Distractions occur

perpendicular to the treatment plane (treatment plane: parallel to concave member of the joint)

4 JPA principles

positioning stabilization mobilization comfort

What do you assess for with AROM

quantity, quality and symptoms

movements of joint arthrokinematics

roll, glide/slide and spin

JPA assesses the

slide/ glide, roll and spin movement of a joint

Joint mobility quantity classification 2

slightly decreased movement

Joint mobility quantity classification 4

slightly increased movement

JPA summary assessing

symptom response end feel amount of motion where resistance begins in the ROM

Stabilize the distal end of

the proximal bone of the joint

Convex moving on concave

the translation is in the opposite direction of the roll

concave moving on convex

the translation is in the same direction as the roll

Complete tests and measures with an

understanding to their limitations and purposes

What is capsular pattern based on

work of James Cyriax

What guides you physical examination?

working hypothesis that you created during history portion

Can you use impaired/unimpaired with JPA?

yes but does not tell you if hypo or hyper which plays a role in intervention