Joint Play, Mobilization & Manipulation

Primary Fixation/Dysfunction Checklist

-occiput-atlas -L5/pelvis (includes coxa articulation) -CT -thoracolumbar (T8-L2) AND -foot/ ankle complex -SC, AC and scapulothoracic -biceps and common flexors of forearm -hamstrings/iliopsoas/ external rotators of hip -inner unit

Sandoz ROM

After Active ROM: physiologic barrier Elastic barrier: end of passive ROM (joint play assessed here) Paraphysiologic space: realm of manipulations/adjustments Anatomic barrier: End of paraphysiologic space

How to Test Joint play

By definition all synovial joints have same amount of joint play (4mm) Examiner must stabilize one bone in joint complex and move adjacent bone in its normal physiologic motion until passive end range is achieved Springy end feel due to ligaments as opposed to hard end feel(bad) All patients are different and each patient must be examined against themselves Care must be taken in joints where movement is supplied by muscular contraction (excludes AC, SC, subtalar and SI joints) because of overly aggressive contact or exerted force can cause reactive muscle spasm which can be perceived as a joint restriction

Joint Manipulation

Defined as a specific technique to passively separate the joint and stretch the articular capsule by delivering a quick thrust maneuver to the joint Neurologic Biomechanical

Joint Mobilization

Defined as externally imposed, passive motion that is intended to produce gliding or traction at a joint

Mobilization

Grade I: small amplitude movement at beginning of range of motion Grade II: Large amplitude movement within midrange of movement Grade III: Large amplitude movement from mid-range to pathological limit Grade IV: Small amplitude movement at end range of motion to extend it Grade V: Manipulation

Characteristics of Grade V Mobilization

High velocity Low amplitude Bring joint to end range of motion, then impulse Once initiated, pt can not halt a manipulation Used to increase ROM, stimulate the nervous system and restore the body to ease, to assist the self-healing qualities (once known as innate)

Effects of Manual Loading on Cells

Increases matrix synthesis Increases metabolic activity Increases replication rates Modifies their production of matrix component

Neurologic Effects of Adjustment

Inhibits spinothalamic tract for pain transmission Inhibits spinoreticular tract for autonomic response to pain, such as nausea/vomiting Autonomic nerves serving visceral organs tonified (better bladder control, for ex.) Stimulation of joint receptor and golgi tendon nerve fibers Inhibit pain nerve fibers (A delta and C) Inhibit sympathetic hyperactivity Inhibit alpha motor neuron to relieve muscle spasms Affect gamma motor neurons to reset muscle tone

Misconceptions about Manipulation

Joint issue is not result of bony misalignment For bony misalignment to occur, there must be enough tissue damage and instability for displacement to occur Ex: Dislocation of shoulder: never manipulated except for initial repositioning of joint; ligaments were torn and stretched so further stretching is contraindicated Manipulation increases mobility, stretches ligaments and should therefor not be used on joints that are already too mobile

History

Joint mobilization/manipulation has been a part of medicine since recorded history There is evidence that manual techniques were used in Thailand around 2000 BC as well as in ancient Egypt Hippocrates used manual traction to treat spinal deformities

What Does Manipulation Do?

Mechanical and Neurologic Joint receptors greatly stimulated, sends to CNS

Osteokinematic Motion

Movement that occurs about a joint through either concentric or eccentric contraction of muscles or when gravity causes a positional change at the joint (flexion/extension, abduction, etc.) Affected by mobilization

Joint Play

Normal extensibility and pliability of the joint noted at its END RANGE OF MOTION or ELASTIC BARRIER Normal joint play motion is necessary for full, pain-free osteokinematic motion to occur

Creep

Over time, ligaments lengthen under the influence of mechanical stress

Indications for Mobilization Grades I and II

Primarily used for pain Pain must be treated prior to stiffness Painful conditions can be treated daily Small amplitude oscillations stimulate mechanoreceptors - limits pain perception

Indications for Mobilization Grades III and IV

Primarily used to increase motion There is a pathologic limit to the motion Stiff of hypomobile joints should be treated 3-4 times per week Alternate with active motion exercises

Guidelines for Adjusting

Restore normal mobility only in joints that exhibit primary joint fixation In acute phase, adjust only one area (does not include stretching or other therapies); daily or even 2x a day Re-palpate to determine progress after manipulation Never adjust the patient where they ask you to adjust them - it almost always is a bad idea - less is more Absolutely do not rely on pain as an indicator for an adjustment, never, ever, NEVER NO EXCEPTIONS Gradually reduce the number of times a week you see the patient once the symptoms have reduce but continue active care until the patient is as restriction free and flexible as their body can be

What does manipulation do?

Restores the joint to normal after capsular and ligamentous changes following trauma and the inflammatory cascade Therefore manipulation should be applied only to hypomobile joints Serial adjusting is always indicating depending on chronicity and severity

Secondary Joint Restriction

Restricted in few plans of motion Moderately restricted and feel Can be acutely painful and have associated inflammation Limitation in movement is often due to protective muscle spasm Immediate response to treatment (manipulation but pain tends to recur often worse than before treatment Typically best treatment for secondary restrictions is to leave them alone and search for primary Use therapeutic modalities at these focuses of pain and spasm Body's ability to compensate for abnormal motion is great - hypomobile right SI --> hypermobile left SI for example

Primary Joint Restriction

Restricted in several directions Very hard end feel Typically not acutely painful Longstanding/chronic due to an old injury Greatest impact on the kinematic chain Slowest response to treatment After manipulation of primary, secondary fixations often resolve spontaneously Needs repeated manipulation and aggressive home exercise programs

Arthrokinematic Motion

Small amplitude movement between two articulating surfaces (roll, glide, spin) AKA joint play or component motions Affected by manipulation

Grade v Mobilization

Small amplitude movement from pathological limit to anatomical limit Manipulation Usually accompanied by a popping sound (cavitation) Velocity of thrust more important/effective than force of thrust Great deal of skill and judgment necessary for safe and effective treatment

Hysteresis

Soft tissues are lengthening due to stress, so they are not as efficient in their function

Principle of SAID

Specific adaptations to imposed demand Stressors may be neurological or biomechanical

Secondary Fixation/Dysfunction List

Upper ribs (iliocostalis lumborum and longisimus thoracic) Mid-cervicals Thoracics, T3-T6 Knee and popliteus spasm External rotators of the hi Scalenes and 1st rib Wrist - carpals Glenohumeral joint Occ-At, Pelvis, T/L and CT