EXERCISE THERAPY NOTES

 JOINT MOBILIZATION

It is a type of passive movement applied to joint and related soft tissue at varying speed and amplitude.

It is usually target synovial joint.

It refers to manual therapy technique that are used to modulate pain and treat joint dysfunction that limit ROM by altered mechanics of joint.

The altered joint mechanics may be due to pain and muscle guarding, joint effusion, contracture or adhesions in the joint capsule or supporting ligaments or subluxation of bony surfaces. 

GENERAL TERMS

MOBILIZATION: passive joint movement for increasing ROM or decreasing pain. Applied to joints and related soft tissues at varying speeds and amplitude using physiologic or accessory motions for therapeutic purposes. Force is light enough that patient can stop the movement.

MANIPULATON: passive joint movement for increasing joint mobility. It incorporates a sudden, forceful thrust that is beyond the patients control.

SELF MOBILIZATION: it refers to self-stretching techniques that specifically use joint traction or glides that direct the stretch force to the joint capsule.

MOBILIZATION WITH MOVEMENTS: concurrent application of a sustained accessory mobilization by physiotherapist to end range and physiological movement applied by the patient. It applied in a pain free direction.

THRUST: it is a high velocity, short amplitude motion such that the patient cannot prevent the motion. The motion is performed at the end of the pathological limit of the joint. Pathological limit means the end of the available range of motion when there is restriction.

PHYSIOLOGICAL MOVEMENTS: these are movements the patients can do voluntary. These are the results of concentric and eccentric active muscle contractions e.g. flexion, extension, abduction, adduction and rotation. 

ACCESSORY MOVEMENTS: these are movements in the joints and surrounding tissues that are necessary for normal ROM but that cannot be actively performed by the patient. Some terms that are related to accessory movements are component motion and joint play-  

COMPONENT MOTIONS – motions that accompany active motion but are not under voluntary control. E.g. motion such as upward rotation of scapula, which occur with shoulder flexion.

JOINT PLAY – motions that occur between the joint surfaces. The movement include distraction, sliding, compression, rolling and spinning. 

JOINT SHAPES

The type of motion occurring between bony partners in a joint is influenced by the shape of the joint surfaces. The shape may be described as ovoid or sellar.

In OVOID joints one surface is convex, the other is concave.

In SELLAR joints one surface is concave in one direction and convex in the other.

                                                                   TYPES OF MOTION

ROLL: a series of points on one articulating surface comes into contact with a series of points on another surface. Occurs on incongruent surfaces. E.g. Ball rolling on ground, femoral condyles rolling on tibial plateau.

                    
SLIDE: specific point on one surface comes into contact with a series of points on another surface. Surface are congruent. When a passive mobilization technique is applied to produce a slide in the joint-referred as a GLIDE.

SPIN: this motion is occur when one bone rotates around a stationary longitudinal axis. Shoulder with flexion/extension, the hip with flexion/extension, and radial head at the humeroradial joint during pronation/supination

                                                 

COMPRESSION: Decrease In Space Between Two Joint Surfaces. It adds stability to a joints. Normal reaction of a joint to muscle contraction.

DISTRACTION: Two surfaces are pulled apart. Often use in combination with joint mobilization to increase stretch of capsule. 

TRACTION: It is a longitudinal pull at the long axis of bone.

CONVEX – CONCAVE RULE

CONCAVE – CONVEX RULE : concave joint surfaces slide in the same direction as the bone movement. In this convex is stable. If concave joint is moving on stationary convex surface, glide occurs in same direction as roll.

CONVEX – CONCAVE RULE : convex joint surfaces slide in the opposite direction of the bone movement. In this concave is stable. If convex surface is moving on stationary concave surface, gliding occurs in opposite direction to roll. 

NOTE: One surface Mobile & one is Stable.

  

GRADES OF MOBILISATION

Two systems of grading for mobilization are used, which are as follows :-

1. Graded oscillation technique.

2. Sustained translatory joint play techniques. 

Graded oscillation technique (Maitland)

GRADE I : Small amplitude rhythmic oscillations are performed at the beginning of the range.

GRADE II : Large amplitude rhythmic oscillations are performed within the range, not reaching the limit.

GRADE III : Large amplitude rhythmic oscillations are performed up to the limit of the available motion and are stressed into the tissue resistance.

GRADE IV : Small amplitude rhythmic oscillations are performed at the limit of the available motion and are stressed into the tissue resistance.

GRADE V : A Small amplitude, high velocity thrust technique is performed to snap adhesions at the limit of the available motion.

USES : 

Grades I and II are primarily used for treating joints limited by pain. 

Grades III and IV are primarily used to increase motion.

       

Sustained translatory joint play techniques (kaltenborn)

GRADE I (Loosen): Small amplitude distraction is applied where no stress is placed on the capsule. 

GRADE II (Tighten) : Enough distraction or glide is applied to tighten the tissue around the joint.

GRADE III (Stretch) : Large enough distraction is applied to place stretch on the joint capsule and peri articular structures.

USES :

Grade I is used for relief of pain. 

Grade II is used to inhibit pain and maintain joint play when ROM is not allowed.

Grade III is used to stretch the joint structures and thus increase joint play.

EFFECTS OF JOINT MOBILIZATION

Neurophysiological effect :- 

Increase in awareness of position and motion because of afferent nerve impulses.

Stimulates mechanoreceptors to decrease pain.

Nutritional effect :- 

Synovial fluid movement which improve nutrient exchange.

Mechanical effect :- 

Improve mobility of hypomobile joints.

Maintain extensibility and tensile strength of articular tissues.

INDICATIONS

Painful joints

Muscle guarding

Decrease range of motion

Spasm

Progressive limitation

Functional immobility

Positional fault

Subluxation.

CONTRAINDICATION

Hypermobility

Inflammation

Joint effusion

Malignancy

Unhealed fracture

Total joint replacement

Osteoporosis

Injury

Immediate after surgery

Elderly individual with weekend tissue.

PRECAUTIONS

Osteoarthritis

Pregnancy

Severe scoliosis

Poor general health

Patients inability to relax.

LIMITATIONS

Mobilization technique cannot change the disease process of disorders such as Rheumatoid arthritis or the inflammatory process of injury.

In these cases, treatment is directed towards minimizing pain, maintaining available joint play, and reducing effects of any mechanical limitations.

The techniques are relatively safe if directions are followed and precautions are taken properly.

If precautions are not taken or applied to vigorously, joint trauma or hyper mobility may result.

JOINT MOBILIZATION APPLICATION

All joint mobilizations follow the convex – concave rule.

Patient should be relaxed.

Explain purpose of treatment and sensations to expect to patient.

Evaluate before and after treatment by goniometry.

Stop the treatment if it is too painful for the patient.

Use gravity to assist the mobilization technique if possible.

Begin and end treatment with grade I or grade II oscillations.

POSITIONING & STABILIZATION

Patient and extremity should be positioned so that the patients can relax.

Initial mobilization is performed in a loose packed position.

Firmly and comfortably stabilize one joint segment, usually the proximal bone, by help of hand, belt, or assistant. 

Appropriate stabilization prevents unwanted stress and makes the stretch force more specific and effective.