Peripheral Joint Mobilization

What is Congruency?

-how well opposing surfaces "match" -a joint is in congruency when both articulating surfaces are in contact throughout the total joint surface area -joints are rarely in total congruence with motion

Final Notes to Remember

*Remember: use new ROM* -stretching -ROM exercises -strengthening -balance -functional activities Definition of Grades of movement related to a joint Ankylosis (stiffening) Greatly decreased ROM Minimal decrease in ROM Normal Slight increase in ROM Significant instability Total instability

Graded Oscillations

- Grade I: Small oscillations performed only at the beginning of the available range (loosen). - Grade II: Larger amplitude motion occurring from the beginning of the ROM to mid-range (tighten). - Grade III: Larger amplitude motion occurring from the mid- range of the motion to the end of the available range. - Grade IV: Small oscillations that occur at the very end of the available range (stretch). - Grade V: A small amplitude, high velocity thrust technique at the limit of the available range.

Physiological Movements: Osteokinematics

- biomechanical description of the motion of the bone as it swings through a ROM (ie: shoulder flexion) -movements of a joint that occur with active or passive ROM -can be measured goniometrically

Determining what grade of Joint Mobs to use

-Determine the goal of the treatment -Pain may be the indicator of the type of treatment to initiate: •Pain before tissue limitation: Gr I, II •Pain concurrent with tissue limitation: use judgment •Pain after tissue limitation: Gr III, IV If joint capsule is limiting motion: Gr III, IV --PROM is limited in a capsular pattern --Firm capsular end feel with overpressure --Decreased joint play movement when mobility testing is performed --Adhered or contracted ligament is limiting motion—apply to specific lines of stress

Capsular & Non-Capsular Patterns

-Every joint has pattern •Non-capsular restriction Reasons: 1. Ligamentous adhesions -injury to capsule or accessory ligaments cause restriction in one direction 2. Internal derangements -displaced or loose cartilage/bone/ligament. 3. Extra-articular lesion -bursitis, muscle strains, neural irritation

Contraindications to Joint Mobs

-Hypermobility -Joint effusion -Inflammation

Mobilization Rules...

-Mobilize initially in resting position and then "move towards" end range -Use good body mechanics -Allow gravity to assist -Your body and the mobilizing part act as one unit -Stabilize!! -Short lever arms and hands as close to joint as possible -Mobilize below the pain threshold -Avoid muscle guarding -Articulate in opposite direction if needed *DO NOT CAUSE PAIN!!*

Arthrokinematics/Osteokinematics during AROM

-Optimal kinematics allow fully stable closed packed position -Optimal ground reaction and gravitational forces distributed through the joint; minimal stress and work with particular muscles. -Altered biomechanics, muscle overuse injuries, arthritis -Other joint breakdown, pain

Pt. Response to Mobs

-Stretching maneuvers usually cause soreness -Perform the maneuvers on alternate days. -If (+) increased pain after 24 hours decrease dosage or duration -Joint and ROM should be assessed after treatment and again before the next treatment

Accessory Motion: Roll

-Surfaces are incongruent -New points on one surface meet new points on the opposing surface (tire rolling on the pavement) -Rolling is ALWAYS in the same direction as the osteokinematic motion -If rolling occurs alone, will cause compression on the side to which the bone is angulating, and separation on the opposite side. (passive stretching with poor arthrokinematics) -In normal joints, a pure roll does NOT occur alone, rather occurs in conjunction with either a glide or spin.

Joint Shapes: Sellar

-each side of the joint is both convex and concave

What is Convex/Concave?

-describes the shape of the joint -moving segment is described first (i.e. GH joint is convex on concave)

Joint Shapes: Ovoid

-joints are made up of a concave and a convex surface -other structures (i.e. mensicus/labrum) often help congruency

Performing Joint Mobilization

1. Determine grade to be used 2. Position the patient 3. Joint position 4. Stabilization

Initiate & Progress

1. Determine patient's ability to relax 2. ALWAYS unload the joint first (gr I-II) 3. Treat with chosen grade of motion 4. Re-assess continuously -adjust appropriately -increased pain and sensitivity = reduce amplitude -same or better = repeat same maneuver or progress 5. Re-assess the next treatment session *Warm-up exercises or heat prior to Grade III or IV may help*

Abnormal End Feels

1. Empty -motion is limited by pain without muscle spasm 2. Guarded/Spasm -pain accompanied by a halt of movement that prevents full ROM -rebound 3. Springy block/internal derangement -full ROM is limited by "springy" sensation -sometimes accompanied by pain 4. Loose end feel -joint hypermobility -no resistance at end of ROM-signifies excessive joint looseness 5. Boggy -mushy due to joint effusion 6. Capsular (if felt before normal ROM)

Traction vs. Distraction

1. Traction applied to the shaft of the humerus results in caudal gliding of the joint surface. 2. Distraction of the glenohumeral joint requires separation at right angles to the glenoid fossa.

What is Joint Mobilization?

A manual therapy techniques that specifically addresses altered joint mechanics -stretching alone addresses loss of flexibility in the contractile element of the muscle but does not address altered joint mechanics

Treatment Plane

At right angles to a line drawn from the axis of rotation to the center of the concave articulating surface

Closed Packed Positions CPP

Closed Pack Position = when there is the least amount of intercapsular space -maximum congruency between joint surfaces -capsule and ligaments are TAUT - joint compression increases as a joint moves toward close pack position -used for testing the integrity and stability of ligaments and capsular structures

Speed, Rhythm & Duration

Grade I and IV: rapid oscillations Grades II and III: smooth, 2-3 second x 1-2 minutes Sustained: Pain: distraction 7-10 seconds

Distraction Grades

Grade 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 forces Grade II: -slack of the capsule taken up (eliminates joint pain) Grade III: -capsule and ligaments stretched

Concave ON Convex Surface

If a concave joint surface is moving on a convex joint surface, the roll and glide are in the SAME direction

Convex ON Concave Surface

If a convex joint surface is moving on a concave joint surface, the roll and glide are in the OPPOSITE direction

Mobilization vs. Manipulation

Mobilization: -a low velocity, passive movement applied within or at the limits of ROM -applied at a speed low enough to allow the client to stop the movement Mobilization with movement: -concurrent application of sustained accessory mobilization applied by the therapist with active physiological movement to end range applied by the patient Manipulation: "thrust" -a sudden, high velocity technique applied at end of ROM -cannot be stopped by the client *PTA's do not perform

Joint End Feels

Normal: 1. Bony 2. Capsular/Elastic resistance 3. Soft tissue approximation 4. Musculature

Open (Loose) vs. Closed Packed Position

Open Pack Position = when there is the greatest amount of intercapsular space -any other joint position besides closed pack position Joint resting position = Joint capsule and ligaments are most relaxed, loose and allow maximal amount of joint play

What does Joint Mobs Address?

Restricted capsular tissue by replicating normal joint mechanics and minimizing compressive stresses on the articular cartilage in the joint -uses manual, passive, accessory joint movement -specific to articulating surfaces -uses oscillatory or sustained movement -should not be used indiscriminately -can be used in conjunction with passive stretching

Accessory Motion: Glide or Slide

Same point on one surface come in contact with new points on the opposing surface (tire sliding on ice) Spin: -rotation of a segment about a stationary axis -rarely occurs alone in joints, rather in conjunction with a roll or glide. -examples of spin: 1. humerus/scapula 2. femur/pelvis 3. radius/humerus

Accessory Motions: Traction

Separation of joint surfaces •Distraction -when joint surfaces are pulled apart at right angles to the joint surface •Long axis traction -pulling on the long axis of the bone

Accessory Motions: Compression

The decrease of joint space between bony partners •In weight bearing •With muscle contraction Normal Intermittent Compressive Loads: -help move synovial fluid -maintains healthy cartilage

Convex-Concave Rule

The direction of gliding follows the Convex-Concave Rule -If a convex joint surface is moving on a concave joint surface, the roll and glide are in the OPPOSITE direction -If a concave joint surface is moving on a convex joint surface, the roll and glide are in the SAME direction *Joint mobilization techniques are directed toward influencing the gliding motion within the joint to restore normal joint play* The "grey" area of physical therapy: positional fault; joint capsule restrictions; •Watch and listen to your patient regarding mobility.

Accesory Movements: Arthrokinematics (Joint Play)

The motion of the joint surface within a joint when a bone moves through a ROM -motion specific to joint surfaces -necessary for normal ROM—if full accessory motion does not occur, will be limitation in normal osteokinematic plane movements. -cannot be actively controlled by a patient but can passively be reproduced by another person -includes roll, spin, slide and glide

Arthrokinematic Roll

There must be some combination of glide and roll -arthrokinematic roll always occurs in the same direction as bony movement regardless of whether the joint surface is convex or concave in shape *If excessive, can cause degeneration*

Roll/Slide/Spin with Convex/Concave Surface

Top: Convex on Concave Bottom: Concave on Convex

What is the Purpose of Joint Mobs?

• Decrease pain • Increase ROM

Treatment Force (Hand Positions)

•As close to the opposing joint surface as possible. •The larger the contact, the more comfortable the procedure

Special Precautions for Joint Mobs

•Malignancy -potential for METS -fx risk •Bone disease/infection -i.e. osteoporosis, avascular necrosis -fx risk •Unhealed fracture/dislocations -must be able to stabilize the area and not stress fx while mobilizing •Excessive pain -especially if patient is unable to tolerate even Grade I -could indicate a bigger problem -could also be a malingerer •Hypermobility in associated joints -ex. hypermobility in the elbow when mobilizing shoulder •Total joint replacements -components could be self limiting -mobilizations could damage prosthesis •Pregnancy -hormones increase joint mobility and flexibility -increased risk for dislocation or injury •Newly formed connective tissue -after injury -if patient is taking corticosteroids -after injections -aggressive mobs can be destructive • Systemic connective tissue disease -i.e. RA or Lupus - connective tissue is weak and forceful techniques may rupture tissues and lead to instabilities -Hemophilia •Medications -Corticosteroids, tamoxifen -Anticoagulants

Indications for Joint Mobs: Grade I & II

•Neurophysiologic Effects: -inhibit transmission of pain stimuli at the spinal cord -stimulates mechanoreceptors in joint capsule and ligaments (those that sense touch and pressure) that can inhibit transmission of pain •Mechanical Effects: -joint motion stimulates biologic activity by moving synovial fluid -brings nutrients to the avascular portions of cartilage -helps maintain nutrient exchange and prevent degenerating effects of immobilization

Functional Immobility

•Patient cannot move joint for period of time •Paralysis or neurological injury -distraction or joint play

Indications for Joint Mobs: Grade III & IV

•Reverse joint hypomobility •Positional faults -faulty tracking of one joint surface upon another •Progressive limitations: -progressive diseases not in active stage -distraction or joint play -cannot change disease processes -directed towards maintaining available joint play, minimize pain