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