Addressing Joint Mobility Deficits with the use of Joint Mobilization Techniques Flashcards
Manual Therapy
Anything involving hands on the patient
What tissues are we talking about
- Synovial membrane
- Synovial fluid
- Hyaline Cartilage
- Joint Capsule (thickening og the synovial lining to provide stability)
- Capsular ligaments
- Blood vessels
- Sensory nerves (mechanoreceptors and pain receptors)
- Central pain processing centers
Both anatomy and nervous tissue affected
Conditions associated with JOINT mobility deficits?
ROM limitations both actively and passively that appear to be related to joint limitations that may or may not be associated with:
- Long term immobilization (Fracture)
- “Painful” joint conditions (Ex: Frozen Shoulder)
- Joint (intra-articular) swelling (Post surgery)
- Arthritic changes
Examination findings associated with Joint mobiltiy deficits
- Subjective: reports tightness/stiffness and/or referred pain in familiar pattern associated with joint. Pain with initial movement but gets better with more movement. (Ex: After sitting for a while tightens up; tight in morning gets a little better but still limited)
- AROM: loss of motion. Feeling of tightness in joint OR pinching in joint toward the direction of motion (Bend knee, have pain in posterior portion of the knee)
- PROM: AROM loss of motion = PROM loss of motion
- End range overpressure: CAPSULAR end feel with or without pain (Ex: Expected soft tissue approx with bend knee and feel capsular; Shoulder ex rot capsular end feel comes earlier)
- Palpation: MAY have tenderness to joint with or without referral that REPRODUCES patient’s pain
- Motor: MAY have weakness of muscles that cross the joint
Deficits or loss of coordination of muscles that cross a joint
Referral Patterns from joints (Cervical and Lumbar Facets)
Intervention options for Joint Mob Deficits
Joint mob techniques:
* * NON-Thrust mobilizations
– Arthrokinematic mobilizations
– Osteokinematic mobilizations
* Thrust mobilizations (aka: manipulations)
* Mobilization with movement techniques (may demonstrate but will not be responsible for knowing these yet)
Non-Thrust Mobilization definition
Passive joint movement (accessory or physiologic motion) applied at varying points in the ROM and at different amplitudes.
Pressure to humeral head and move it or grab the humerus and move it (Arthrokinematic/accessory motion vs osteokinematic/physiologic motion)
Thrust Mobilization Definition
Passive joint movement that includes a high velocity, low amplitude (HVLA) thrust at mid or end range of motion (sometimes referred to as “Manipulation”)
Mobilization with movement definition
PT applies passive force tojoint, patient moves whileforce is applied
Ex: PT applies pressure from posterior humerus and ask patient to rotate from internal to external motion.
Joint Mobilization are intended to:
Modulate (decrease) pain
Increase ROM
Improve joint mechanics
Decrease mm tone
Restore functional movement
Decrease patients fear of movement
Can tap into all 3: Cognition, Mob, Motor
“Mechanisms” of Joint Mobilization
Biomechanical: restore normal arthrokinematics by improving joint capsule extensibility (restore necessary slide and glide to the joint)
Neurophysiological: Modulate and/or decrease pain output by stimulating peripheral and central nervous system (Anytime we put our hands on the patient)
Biopsychosocial: perception that the technique is helpful based onpatient’s own personal belief(Anytime we put our hands on patient; positive or negative)
Biomechanical Mechanism
- Based on the concept of restoring the osteokinematic and arthrokinematic motion of the joint and/or improving joint capsule extensibility
- Osteokinematic motion: Physiological motion (flexion, extension, abd, etc); Can control motion
- Arthrokinematic motion: Accessory motion (roll, slide, spin); Cannot control
Need both arthro and osteo to have full ROM
Arthrokinematic Concepts CONVEX ON CONCAVE Motion
Direction of the force we apply during the mobilization is based on biomechanical principles
Convex articular surface moving on a fixed concave surface
The gliding motion of the convex joint surface moves in the OPPOSITE direction to the motion of the bone that is moving
Otherwise stated: The osteokinematic motion and the arthrokinematic motion occur in the OPPOSITE direction
To facilitate shoulder abduction, need an inferior glide of the humeral head.
Arthrokinematic Concepts (cont.) CONCAVE ON CONVEX Motion
- Concave articular surface moving on a fixed convex surface
- The gliding motion of the concave joint surface moves in the SAME direction to the motion of the bone that is moving
- Otherwise stated: The osteokinematic motion and the arthrokinematic motion occur in the SAME direction
Knee Extension
Tibia is stationary, Femur is moving: Arthro goes in a posterior direction, Osteo goes in an anterior direction; PT should push in a posterior direction.
Tibia is moving, Femur is fixed: arthro and osteo is same direction; provide an anterior force
Distal is moving - Open: Prixmal part of joint is moving - closed
Direction of force for Mobilization Techniques MAY be dependent on arthrokinematic principles
Where restriction is and what part of joint is moving.
PT Mobilization force is applied in the OPPOSITE direction of the ostekinematic motion
PT Mobilization force is applied in the SAME direction of the ostekinematic motion
Use joint play assessment to determine vigor of technique
Normal vs. Hypermobility vs. Hypomobility
All of these depend on the irritability of the patients symptoms
Where they feel the pain when we move the joint
R1: First resistance
R2: End resistance
More vigorious at R2
Neurophysiological Mechanism
-
Peripheral neurological response
– Stimulate joint mechanoreceptors
— gait theory of pain
— Reduces inflammatory mediators (i.e.: cytokines) -
Central neurological response
– Decrease activity of pain processing centers in the brain (anterior cingular cortex, amygdala, periaqueductal gray (PAG), rostral ventromedial medulla (RVM))
– Enhance and sharpen somatosensory cortex and body maps through movement(enhance motor control/quality of movement of the joint)
– Newer research through functional MRI’s
Change cortical pathway and pain pathway
Changes in the brain with peripheral or spinal joint
Neurophysiologic response that results in…
Decrease pain, decrease tone of muscles and increased motion
Dorsal area of the ____ and ____ have been shown to selective produce ____ and cause ____ and ____
Dorsal area of the PAG and RVM have been shown to selective produce analgesia and cause sympatho-excitation and the release of endorphins and enkephalins (Decrease the output of pain)
Movement associated with joint mobilization helps to sharpen the body image of the somatosensory cortex which becomes distorted/ blurred (“smudged”)with pain and/or immobility
Psychosocial Mechanism
- Patient expectation (i.e.: patient BUY IN!) influences effectiveness of treatment (placebo response?)
- Patient senses motion but without the THREAT or anticipation of pain
- Low fear of the mobilization technique: Good outcomes
- High fear on the mobilization technique: Less favorable outcome
- PT’s need to address the fear and “SELL” the treatment
Changes their belief and perception of movement
Variable techniques depend on ____ and ____
Variable techniques depending on goal of the TX and irritability of symptoms
Grades of Mobilization
Grade 1: Small Oscillations/Beginning Range
Grade 2: Large Oscillations/Beg to Mid
Grade 3: Large Oscillations/Mid to end
Grade 4: Small Oscillations/End range
Important considerations for all joint mobilization techniques:
- Consider the arthrokinematics of the joint if necessary (convex on concave OR concave on convex) to consider the appropriate direction of force for arthrokinematic mobilization techniques
- Place patient in appropriate position with proximal segment of the joint stable
- Provide maximal support of the distal segment of the joint
- If performing arthrokinematic motions (glide, rotation, etc)
o ELBOW must be in line with direction of force
o Use as much surface contact with the mobilizing hand as possible while still providing the force in the appropriate direction
o Mobilizing hand must be as close to the joint axis as possible
o Provide force through the trunk (with UE locked into trunk) as much as possible - ALWAYS explain to the patient what you are doing and the clinic rationale
- GAIN CONSENT FROM THE PATIENT
- Ask for patient feedback while you are doing the technique
o Gauge pressure, hand placement, intensity of pain
NON-THRUST MOBILIZATION: LOW GRADE MOBILIZATION (I-II)
- Goals: Decrease pain by stimulation of mechanoreceptors and relaxation of tense musculature
- Performed in beginning range or mid range of available joint motion(Beginning to R1)
- High irritability of symptoms (intensity, how much to provoke, and how long to resolve)
- Grade I: Small amplitude oscillatory movement at the beginning of motion
- Grade II: Large amplitude oscillatory movement within mid-range of motion (Beginning to R1)
- Often performed in open pack position of joint
Early in ROM or not engaging the capsular barrier
Open pack: Joint capsule on slack; more joint gliding.
NON-THRUST MOBILIZATION: HIGH GRADE MOBILIZATION (III-IV)
- Goal: Stress to joint capsule to achieve greater stimulation of mechanoreceptors and possible soft tissue stretching
- Performed toward end range of available joint motion
- Low irritability of symptoms
- Grade III: Large amplitude oscillatory movement from mid-range to end range (R1 to R2) of motion
- Grade IV: Small amplitude oscillatory movement at to end range of motion (End of R2)
- Progress to closed pack position of joint
Open Pack (Loose Pack)
- Any other position other than closed pack
- Decreased joint congruity and joint surface contact
- Ligaments are on slack
- Maximal joint volume
- Minimal joint stability
Closed Pack
- Maximal joint congruency
- Ligaments are maximally taught
- Maximal stability of the joint
- Minimized joint volume
- Increased compressive forces of the joint
Don’t use on high irritabiltiy
Stages of Irritability and Joint Mobilization Selection
High Irritabiltiy = Low Grades of Mobilization (open pack)
Moderate irritability = Low to High Grades (open to closed pack)
Low Irritability = High Grade (closed pack)
THRUST MOBILIZATION
aka Manipulation
- Much more of a neurophysiological response
- Goal: Intended to provide a neurophysiologic response as described earlier
- Not necessarily a continuum from the other grades
- High velocity, low amplitude thrust technique at mid to end range of motion
- May be associated with a “pop”, however, not needed for effectiveness (does not dictate effectiveness in joint to have good outcomes)
- Defined group of patients benefit most from thrust mobilization
- #1 indicator: acuity (acuteness) of symptoms
- #2 indicator: NON-RADIATING symptoms (nociceptive)
- Neurophysiological
– Reduction in muscle tone, muscle guarding, patient fear, patient guarding, more allowance of motion as a result of central processing in the brain.
Big low amplitude force to joint is best predictor to good outcomes
Don’t have to build up to get to a thrust
What terms can you NOT use?
Adjustment and spinal subluxation
PT’s use thrust mobilization to address pain and mobility limitations.
Documenting Mobilizations
- Patient position(if appropriate, position of extremity: closed pack or loose pack)
- Thrust vs. non-thrust (if non-thrust: grade?)
- Direction of force
- Body region that the forces is applied to
Position; Grade; Direction; Range of movement
Example: Supine Grade III-IV non-thrust mobilization in anterior to posterior (AP) direction to mid-thoracic spine
OR
Supine Grade III-IV non-thrust AP mob to mid thoracic
Contraindications to Thrust Mobilizations - Relative
Relative and Absolute
- Relative: Clinical judgment
- STABLE peripheral neurological signs (Myotomal weakness, sensory def, reflex changes (hyporeflexia)
- Early RA
- Joint laxity
- Early osteoporosis
- Surgery (once healed); Need confirmation from a physician
High Velocity, Low amplitude vs High Velocity , High amplitude
High Velocity, Low amplitude is the safest and has the same benefits!
Contraindications for Non-Thrust Mobilizations
- Safe
- Don’t do with fracture or joint displacement
Contraindications to THRUST mobilization - Absolute
- PROGRESSING neurological signs especially in the spine (getting weaker, more sensory loss)
- Premature stress on surgical repaired structures
- Acute systemic inflammation (not acute pain); Fever, joint redness
- Vascular disease (ex: AAA, DVT); Cervical (Vertebral A.) and lumbar (abdominal A.)
- Advanced osteoporosis
- Advanced RA
- C1-C2 instability of c-spine (for neck)
- Joint infection
To help keep the effect of the Thrust
Self ROM, Self Stretching or Active ROM, Active Exercise
