University of Oklahoma Health Sciences Center Division of Rehabilitation Sciences

Evaluations & Interventions I PHTH/OCTH 7233 Spring

PRINCIPLES OF JOINT MOBILIZATION by Vince Lepak, PT, MPH, CWS Lectures 1 & 2 HISTORICAL DEVELOPMENTS -Hippocrates 460 - 380 BC -Galan 131 - 202 AD - Bonesetters vs. Physicians - 17th and 18th centuries - During the 19th century 2 categories of healers: - Osteopathy - Andrew Still -1892 Law of the Artery - Chiropractic - Daniel Palmer, a grocery worker and former patient of Dr. Still - 1895 Law of the Nerve - Allopathic medicines knowledge of using manual therapy was furthered by two physicians James Mennell and Cyriax. Physical therapists have a published record of practicing manipulation dating from the 1920s to the present. Physical therapy journals and medical journals from the 1920s to the present contain more than a thousand articles on manipulation and mobilization by physical therapists. The U.S. Clinical Practice Guideline Acute Low Back Problems in Adults based its recommendations for spinal manipulation on clinical trials. The professions who provided spinal manipulation for those studies were physical therapists (6 studies), medical doctors (4), osteopaths (2), and chiropractors (2). (AHCPR, 1994) Physical therapists, Doctors or Osteopathy, Doctors of Allopathy, are trained to use mobilization and manipulation to treat disorders of the back, neck, arm, or leg. The public is safe in the hands of physical therapists who provide mobilization and manipulation services. Two of the nation's largest physical therapist liability insurers (Maginnis and Associates and Kirke-Van Orsdel) found no evidence of higher claims loss due to physical therapists utilizing manipulative or mobilization procedures. MOBILIZATION Definition: - passive by the therapist - slow - patient can stop the movement - oscillatory or sustained - aimed at decreasing pain and/or increasing mobility

MANIPULATION - Definition: - high velocity, low amplitude thrust (non-oscillatory) performed by the therapist

ACCESSORY AND PHYSIOLOGICAL MOVEMENTS - Physiologic movements - can be done actively by patient or passively by therapist.

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- Accessory movements - movements within the joint and surrounding tissues that are necessary for full ROM but cannot be performed actively in isolation: - Joint play - movements not under voluntary control but necessary to full painless joint function - cannot be achieved actively, no active movement or contraction of a muscle can reproduce it - Component movements - accompany active movements and are necessary for active full painless joint motion. *These concepts help us compartmentalize. Nevertheless, they are not necessarily mutually exclusive when they describe the accessory movements at each joint. - Importance of treating accessory movements vs. simply using physiological movements to maintain/improve ROM ACCESSORY MOVEMENTS include: (Tomberlin & Saunders, 1995; Hertling & Kessler, 1996) 1. Spin - rotation around a stationary axis 2. Roll - New points on one articular surface meet new points on opposing articular surface. 3. Glide - Same point on one articular surface encounters new points on opposing articular surface - pure glide never occurs because no joint surfaces are completely congruent - RULE OF CONVEXITY/CONCAVITY: - if moving surface is concave - glide occurs in same direction as bone movement - if moving surface is convex - glide occurs in opposite direction of bone movement 4. Compression - decreased space between articular surfaces 5. Traction - Separation of bony surfaces

PRINCIPLE OF JOINT MOBILIZATIONS (Tomberlin & Saunders, 1995; Hertling & Kessler, 1996) 1. Place joint in resting position Closed pack position - maximal congruency & compression of the articular surfaces - the ligaments and capsule are taut Loose pack position - Any position that is not close packed. 2. Determine treatment plane: Draw a line over the articular surface of the concave joint partner. When the concave surface is moving the treatment plane moves but when the convex surface is moving the treatment plane remains the same. - Gliding - Move the joint surface parallel to the treatment plane. - Traction and compression - Move the joint surface perpendicular to the treatment plane.

3. 4. 5. 6. 7. 8. 9.

Determine direction of mobilization using concave/convex rule. Patient and body part well supported Patient and therapist relaxed Mobilizing force should be close to therapists center of gravity Compare involved extremity to uninvolved. Check one joint at a time, one movement at a time Stabilize one bone and mobilize the other. Usually stabilize proximal bone. Contact should not be painful.

10. Therapists hands should be as close to joint surfaces as possible. 11. When possible work with force of gravity rather than against it. 12. Stop the mobilization test or treatment if too painful. 13. Initial mobs are in the loose pack position. 14. Treat deficiencies in joint play before attempting to treat component motions. 15. Assess before and after treatment. ASSESSING PHYSIOLOGICAL & ACCESSORY MOVEMENTS 1. 2. Quantity Quality of motion Note where in the range pain was felt and where in the range resistance was felt. End Feel

INDICATIONS FOR JOINT MOBILIZATIONS (not an inclusive list) 1. Pain 2. Subluxation or Dislocation 3. Joint Hypomobility - majority of the time treating a capsular pattern Definition of a Capsular Pattern: Irritation of the joint capsule or the synovium producing characteristic, proportional limitation of movement.

ABSOLUTE CONTRAINDICATIONS TO JOINT MOBILIZATIONS (not an inclusive list) Malignancy Rheumatoid collagen necrosis Fracture - recent or unhealed Joint ankylosis Vertebrobasilar insufficiency

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Active inflammatory or infective arthritis

RELATIVE CONTRAINDICATIONS TO JOINT MOBILIZATIONS (not an inclusive list) Osteoporosis Pregnancy History of malignancy Hypermobility Dizziness Neurological signs Spondylolisthesis

TREATMENT VARIABLES 1. 2. 3. 4. 5. Position of joint Direction of mobilization Type - sustained or oscillatory Grade of mobilization Length of mobilization

SUSTAINED VS. OSCILLATORY MOBILIZATION Oscillatory - passive oscillatory movements, two or three per second, of small or large amplitude, and applied anywhere in a range of movement. Sustained - sustained stretching often with tiny amplitude oscillations at the limit of the range.

MAITLANDS GRADES OF OSCILLATORY MOBILIZATIONS Grade I Grade II Small amplitude movement performed at the beginning of the range. Large-amplitude movement performed within the range but not reaching the limit of the range. It can occupy any part of the range that is free of any stiffness or muscle spasm. Large amplitude movement performed up to the limit of the range.

Grade III

Grade IV

Small amplitude movement performed at the limit of the range

MANIPULATION (non-oscillatory motion) Grade V High velocity thrust performed at the limit of the range

When pathology or a mechanical disorder limits the range of movement, the grades are decreased in range. Generally, grades I and II treat pain, while grade III maintains ROM, and grade IV increases ROM. SUSTAINED (TRACTION) MOBILIZATIONS Grade I Small amplitude movement with no appreciable movement. Nullifies the normal compression forces.

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Grade II

Sustained movement performed within the ROM to the restriction. The ligaments and joints capsule are taut. The slack is taken up. Sustained movement performed at the end of the ROM through the restriction.

Grade III

DURATION OF MOBILIZATION Sustained - continue mobilization for 20 - 30 seconds Oscillatory - continue mobilization for 60 - 90 seconds

PROPOSED EFFECTS OF JOINT MOBILIZATIONS Pain relief - Stimulation of mechanoreceptors causing increased proprioceptive input to the spinal cord, thereby inhibiting transmission of pain impulses to the anterior horn cells and higher centers. Increase extensibility of joint capsule. Breaking adhesions Stretching the capsule Disrupt abnormal cross-linking Elastic vs. Plastic deformation Can morphological changes occur in the short time that joint mobilizations are applied?

REFERENCES: Hertling, D., & Kessler, R. M. (1996). Management of common musculoskeletal disorders (3rd ed.). Philadelphia: Lippincott. Kaltenborn, F. M. (1989). Manual mobilization of extremity joints: Basic examination. Minneapolis, MN: OTPT. Kisner, C. & Colby L. A. (1996). Therapeutic exercise: Foundations and techniques (3rd ed.). Philadelphia: F. A. Davis. Maitland, G.D. (1977). Peripheral Manipulation. (2nd ed.). London: Butterworths. Maitland, G.D. (1986). Vertebral Manipulation. (5th ed.). London: Butterworths. Nordin, M. & Frankel, V. H. (1989). Basic biomechanics of the musculoskeletal system (2nd ed.). Philadelphia: Lea & Febiger. Randall, T., Portney, L., & Harris, B. A. (1992, July). Effects of joint mobilization on joint stiffness and active motion of the metacarpal-phalangeal joint. Journal of Orthopedic and Sports Medicine, 16 (1), 30-36. Tomberlin, J. P. & Saunders, D. H. (1995). Evaluation, treatment and prevention of musculoskeletal disorders: Extremities (3rd ed., Vol. 2). Chaska, MN: Educational Opportunities.

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