Chapter 5 Flashcards
Mobilization/Manipulation
passive, skilled manual therapy techniques applied to joints and related soft tissues at varying speeds and amplitudes using physiologic or accessory motions for therapeutic purposes
What causes altered joint mechanics?
- pain
- muscle guarding
- joint effusion
- contractures
- adhesions in joint capsule or ligaments
- aberrant joint motion
Interventions unique to PT (according to APTA):
- spinal and peripheral mobilization/manipulation, which are components of the manual therapy techniques
- selected sharp debridement, which is a component of wound management
Thrust manipulation/high-velocity thrust (HVT)
high-velocity, short amplitude techniques; performed at the end of the pathological limit of the joint and is intended to alter positional relationships, snap adhesions, or stimulate joint receptors
Self-mobilization
self-stretching techniques that specifically use joint traction or glides that direct the stretch force to the capsule
Mobilization with movement (MWM)
concurrent application of sustained accessory mobilization applied by a therapist and an active physiological movement to end-range applied by the patient
Physiological movement
movements the patient can do voluntarily
Accessory movements
movements in the joint and surrounding tissues that are necessary for normal ROM but that cannot be actively performed by the patient (AKA component motions)
Examples of accessory or component motions.
upward rotation of scapula and rotation of clavicle during shoulder flexion; rotation of the fibula during ankle motion
Joint play
motions that occur between the joint surfaces and also the distensibility or give of the joint capsule, which allows the bone to move (distraction, sliding, compression, rolling, and spinning of joint surfaces - arthrokinematics)
Muscle energy techniques
use active contraction of deep muscles that attach near the joint and whose line of pull can cause the desired accessory motion
Ovoid joints
one surface is convex, the other is concave
Sellar joint
AKA saddle joint, concave/convex in one direction and convex/concave in the opposing direction
Manipulation under anesthesia
therapist can assist the surgeon in the operating room and continue with follow-up care
The movement of a bony lever is called _____ accessory motions that occur allowing greater angulation of the bone as it swings are _____ & ________, or _________.
swing; rolling/sliding, spinning
The more congruent the joint surfaces are, the more ________ there is of one bony partner on the other with movement.
sliding
The more incongruent the surfaces are, the more _______ there is of one bony partner on the other with movement.
rolling
Examples of spin occurring in joints of the body:
shoulder with flexion/extension, hip with flexion/extension, radiohumeral joint with pronation/supination
What are some benefits of compression in the joint space?
- provides stability to joints
- move synovial fluid, maintain cartilage health
Traction
longitudinal pull (long-axis traction)
Distraction
separation, or pulling apart (joint traction, joint separation)
Potential side effects of immobilization:
- atrophy of articular cartilage
- fibrofatty proliferation causing intra-articular adhesions
- potential decrease in proprioceptive feedback that may decrease balance response
Effects of joint motion:
- motion of synovial fluid
- maintenance of articular extensibility
- afferent nerve input
- sense of speed of motion
- sense change of speed of motion
- sense of direction
- regulation of muscle tone
- nociceptive stimuli
Neurophysiological effects of joint-play techniques:
stimulate mechanoreceptors that may inhibit the transmission of nociceptive stimuli at the spinal cord or brain stem levels
Mechanical effects of joint-play techniques:
cause synovial fluid motion, which is the vehicle for bringing nutrients to the avascular portions of the articular cartilage (and intra-articular fibrocartilage when present)
Indications for the use of joint manipulation:
- pain, muscle guarding, and spasm
- reversible joint hypomobility
- positional faults/subluxations
- progressive limitations
- functional immobility
Limitations of joint manipulation:
- hypermobility
- joint effusion (swelling)
- inflammation
Precautions for joint manipulation:
- malignancy
- bone disease
- unhealed fracture
- excessive pain
- total joint replacements
- new or weakened connective tissue
- systemic connective tissue diseases
- elderly patients
Quality of pain:
- before tissue limitation
- concurrently with tissue limitation
- after tissue limitation
Capsular restriction:
- PROM limited
- firm end-feel with overpressure
- decreased joint-play with mobility tests
- adhered or contracted ligament is limiting motion if there is decreased joint-play
Maitland Grading Dosages
Grade I - small-amplitude oscillations at beginning of range
Grade II - large-amplitude oscillations performed within range (not to limit)
Grade III - large-amplitude oscillations performed up to limit of available motion, stressed into tissue resistance
Grade IV - small-amplitude oscillations at the limit of available motion and stressed into tissue resistance
Two points of resistance:
R1 - hardly any pressure, takes up all the slack, just barely deforms
R2 - push to the barrier and you can’t go any farther
(All dosing is relative to R1/R2)
Indications for Maitland grading dosages:
Grades I and II - primarily used for treating joints limited by pain or muscle guarding
Grades III and IV - primarily used for stretching maneuvers (III for stiff/not painful, IV for stiff/painful)
Kaltenborn Grading Dosages
Grade I - small-amplitude distraction is applied when no stress is placed on capsule
Grade II - enough distraction or glide is applied to tighten the tissues around the joint
Grade III - distraction or glide is applied with an amplitude large enough to place stretch on the joint capsule and surrounding periarticular structures
Speed and duration of oscillations:
- Grades I & IV rapid oscillations
- Grades II & III smooth oscillations
- hold stretch for 7-10 seconds
To increase shoulder abduction:
- GH caudal glide - sustained grade III
- GH caudal glide progression
- GH elevation progression to increase beyond 90 deg. of abduction
To increase shoulder flexion/IR
- GH posterior glide
- GH posterior glide progression when flexion approaches 90 deg. also increase horizontal adduction
To increase shoulder extension/ER:
- GH anterior glide
- GH ER progressions
To increase AC joint mobility:
- stabilize acromion, push clavicle anterior
SC joint retraction and depression of the clavicle:
- posterior glide to increase retraction
- superior glide to increase depression
SC joint protraction and elevation of the clavicle:
- anterior glide to increase protraction
- caudal glide to increase elevation
Where else might you mobilize if the patient has good mobility in GH, AC, and SC, but still experiencing some restriction in shoulder motion?
ST soft tissue mobilization (elevation, depression, protraction, retraction, upward and downward rotation)
To increase elbow flexion OR extension:
- humeroulnar distraction and progression (grade III or IV)
- humeroradial dorsal glide of radius for extension
- humeroradial volar glide of radius for flexion
To increase elbow flexion:
- humeroulnar distal glide (with scoop)
To increase mobility of the humeroradial joint; to manipulate a pushed elbow:
- humeroradial joint distraction
To reduce a pulled elbow subluxation:
- humeroradial compression
To increase pronation:
Proximal Radioulnar
- dorsal glide of radius
Distal Radioulnar
- volar glide of radius
To increase supination:
Proximal Radioulnar
- volar glide of radius
Distal Radioulnar
- dorsal glide of radius
For testing, initial treatment, pain control; general mobility of wrist:
- radiocarpal joint distraction
To increase wrist flexion:
- radiocarpal joint dorsal glide
To increase wrist extension:
- radiocarpal joint volar glide
To increase wrist ulnar deviation:
- radiocarpal joint radial glide
To increase wrist radial deviation:
- radiocarpal joint ulnar glide
What are the mobilizations to increase wrist ROM?
radiocarpal joint, specific carpal mobilizations
Specific carpal mobilizations to increase wrist extension:
- volar glide of scaphoid on stabilized radius
- volar glide of lunate on stabilized radius
- volar glide of scaphoid on stabilized trapezium-trapezoid
- volar glide of capitate on stabilized lunate
- volar glide of hamate on stabilized triquetrum
Specific carpal mobilizations to increase wrist flexion:
- volar glide of radius on stabilized scaphoid
- volar glide of radius on stabilized lunate
- volar glide of trapezium-trapezoid on stabilized scaphoid
- volar glide of lunate on stabilized capitate
- volar glide of triquetrum on stabilized hamate
Ulnar-Meniscal-Triquetral Articulation
- to unlock the disk, apply a glide of the ulna volarly on a fixed triquetrum
To increase mobility of the arch of the hand:
- stabilize the carpals and glide the proximal portion of the metacarpal volar
For test, initial treatment, pain control, and general mobility of the 1st CMC:
1st CMC distraction
1st CMC glides:
- ulnar glide to increase flexion
- radial glide to increase extension
- dorsal glide to increase abduction
- volar glide to increase adduction
(stabilize trapezium)
MCP and IP Glides and Progression:
- distraction for general mobility, testing, pain, etc.
- volar glide to increase flexion
- dorsal glide to increase extension
- radial or ulnar glide depending on finger to increase abduction or adduction
Hip distraction of the weight-bearing surface:
caudal glide
To increase hip flexion/IR:
hip posterior glide (supine - Thomas test position)
To increase hip extension/ER:
hip anterior glide (prone, bent over table, prone with figure 4, side-lying)
For testing, initial treatment, pain control, and general mobility of the knee:
- tibiofemoral distraction/long-axis traction (sitting, supine, or prone)
To increase knee flexion:
- tibiofemoral posterior glide (sitting, drawer)
- PF distal glide
To increase knee extension:
- tibiofemoral anterior glide (prone)
- PF proximal glide
To increase general PF mobility:
PF medial or lateral glide
To increase movement of the fibular head; to reposition a posteriorly subluxed head:
proximal tibiofibular anterior glide (side-lying)
To increase mobility of the mortise when it is restricting ankle dorsiflexion:
distal tibiofibular anterior or posterior glide
For testing, initial treatment, pain control, and general mobility of the ankle:
talocrural distraction (supine)
To increase dorsiflexion:
talocrural dorsal glide (supine)
To increase plantarflexion:
talocrural anterior glide (prone)
For testing, initial treatment, pain control, and general mobility for inversion/eversion:
subtalar distraction
To increase eversion:
subtalar medial glide (prone or side-lying)
To increase inversion:
subtalar lateral glide (prone or side-lying)
To increase plantarflexion accessory motions:
Intertarsal and Tarsometatarsal plantar glide (supine or sitting with leg off table)
To increase the dorsal gliding accessory motion necessary for pronation:
Intertarsal and Tarsometatarsal dorsal glide (prone with knee bent)
Intermetatarsal, Metatarsophalangeal, and Interphalangeal Joint Mobility
- stabilize the proximal bone and glide the distal bone plantar for flexion, dorsal for extension, or medially or laterally for adduction or abduction
