ACCESSORY MOBILIZATIONS Flashcards
JOINT MOBILZATION: def & ≠ mobilization & manipulation
= manual therapy technique comprising continuum of “skilled” passive movements to joint complex, applied at varying speeds & amplitudes, including small amplitude/high velocity therapeutic movement (manipulation) with intent to restore optimal motion, function and/or reduce pain
- Joint mobilization is on continuum with manipulation
- Both involve passive movements
- Mobilization => under patient ś control
- Manipulation => at speed where patient cannot stop motion
- Manipulation techniques beyond scope of this course
Steps of objective examination
- Active range of motion (AROM)
- Passive range of motion (PROM)
- Accessory motions/tests/end feel (joint palpation)
- Special tests
MOBILIZATION DIRECTIONS
- A-P (anteroposterior)
- P-A (posteroanterior)
- Longitudinal (caudad & cephalad) - Medial glide
- Lateral glide
- Superior glide
- Inferior glide
Physiological joint motion & accessory motion def
- Physiological joint motion = mvt that patient can do voluntarily & analyzed for quality & symptom response
- Accessory motion = necessary for normal joint motion but cannot be voluntarily performed or controlled. Mvts include roll, spin & slide (or glide) which accompany physiological mvts of joint. Accessory movements examined passively to assess range & symptom response in open pack position of joint
JOINT MOBILIZATION: effects & on pain
Neurophysiological effects
- Pain relief: neuromodulation at central nervous system level
- Small-amplitude joint mobilisation oscillations
Nutritional effects
- Synovial fluid movement
- Distraction or small gliding movements
Mechanical effects
- By stretching collagen structures
- By loosening / breaking down adhesions
- Inhibitory effects on joint afferent receptors
Descending Nociceptive Inhibition
- From midbrain (mainly periaqueductal grey matter & rostral ventral medulla)
- Suppresses release of excitatory transmitters in dorsal horn
- Suppresses postsynaptic responses
- Catastrophizing, avoidance, somatization prevent effective descending inhibition & activate descending facilitation
Closed packed-position: def & characteristics
= blocked position
- Joint positions most congruent
- Surrounding tissue (capsules & ligaments) under maximal tension
- Intracapsular space minimal
- Locked, statically efficient for load bearing & dynamically dangerous
- Testing position
Resting position / open packed: def & characteristics
- Surrounding tissue as lax as possible (maximum incongruency)
- Intracapsular space as large as possible
- Position sought at rest or following acute trauma to accommodate maximal fluid accumulation
- Unlocked, statically inefficient for load bearing & dynamically safe - Treatment position (maximum amount of joint play available)
Concave & convex motion rules
Concave Motion Rule
- Choosing direction of mobilization dependent on desired effect & knowledge of arthrokinematics
- Concave surface sliding on convex surface- gliding occurs in same direction as mvt (knee joint, interphalangeal joints)
Convex motion Rule
- Convex surface moving on stable concave surface- gliding occurs in opposite direction (Glenohumeral joint)
TABLEAU JOINT MOBILIZATION
tableau
END FEEL: ≠ types & def
- Move joint passively & see what end of ROM feels like
- How to assess end feel: move patient passively through ROM then apply over pressure. Repeat if necessary
• Hard (bony): motion stopped when bone contacts bone. Normal end for some joints, abnormal if there are loose fragments in joint that stop motion
• Soft: motion stopped by soft tissues being compressed. Normal for some joints, abnormal if there is boggy feel to motion, indication of oedema
• Firm or springy: motion stopped by soft tissue that have reached there limit of stretch. If motion limited => sign of tissue shortening • Empty: motion stopped in response to patients request (experiencing considerable pain). Always abnormal.
• Spasm: muscle contraction & pain expected at end of ROM. Always abnormal
CONTRAINDICATIONS: absolute & relative
A: - Malignancy in area of treatment - Infectious arthritis
- Metabolic bone disease
- Neoplastic disease
- Fusion or ankylosis
- Osteomyelitis
- Fracture or ligament rupture
- Herniated disc with nerve compression - Hyper-mobile joint for grade III & IV
R: - Excessive pain or swelling - Arthroplasty
- Pregnancy
- Hypermobility
- Spondylolisthesis
- Rheumatoid arthritis
- Vertebrobasilar insufficiency
IN DOUBT, DON’T DO IT
MOBILIZATION TREATMENT PRINCIPLES: oscillations & prolonged techniques
Oscillations
- 60-120/min (sinusoidal)
- 1-5 sets of 5-60s
- Generally used to treat pain
Prolonged hold / sustained techniques
- 5-30s
- 1-5 reps
- Typically applied at end range to treat stiffness
Grafes of mvt of normal joint
- Grade I: small amplitude mvt at beginning of available ROM, no resistance - Grade II: large amplitude mvt through middle of ROM, no resistance
- Grade III: large amplitude mvt from middle to limit of ROM
- Grade IV: small amplitude mvt at very end ROM
- Grade V: high velocity thrust of small amplitude beyond ROM. Manipulation requires advanced training & not commonly used in physiotherapy
Mobilization treatment & considerations
Grades I & II
- Pain relief. Oscillations stimulate joint mechanoreceptors to inhibit nociceptive feedback into joints
- Often used before & after treatment with grades III & IV
- Neutralizes joint pressures
- Prevents grinding
Grades III-V
- Mechanical effect used to treat stiffness or hypo mobility
- Increase ROM through promotion of capsular mobility
- Mechanical distension and/or stretching of shortened tissues - Uncomfortable but not painful
Normal joint mobility: characteristics
- Distinguishing between normal & abnormal joint mobility requires practice. Develop sense of touch => detect what is normal or abnormal in joint
- Once identify normal mobility, abnormal mobility will be easier to identify
- Important to compare with contralateral side
- Normal mobility varies for ≠ populations, depends on factors such as age, disease, occupation, sport…
