Joint assessment and mobilization

Question 1

What can joint injury result in

Answer 1

Joint dysfunction

Question 2

Dysfunctions in joints

Answer 2

• Increase and decreases in normal motion
• Aberrant “trick” movements

Question 3

What to do with hypomobility

Answer 3

mobilization /manipulation to joint, stretching, ROM

Question 4

What to do with joint hypermobility

Answer 4

• stabilization/strengthening activities
• Muscles are the joints dynamic stabilizers
• The static stabilizers may have been stretched (ligaments and capsule)

Question 5

How can joint dysfunction lead to joint degeneration

Answer 5

• Less fluid/nutrition in a tight joint
• In a loose joint with too much movement can also cause degeneration

Question 6

What are the goals of PT with joint dysfunction

Answer 6

Correct the dysfunction
Alleviate joint pain
Restore normal joint function

Question 7

What are the classifications of movement

Answer 7

• Osteokinematics: Goniometric ranges; AROM, PROM
• Accessory movements:
  1. Joint play = end feel → gives you an idea of if the joint is normal, tight, or has too much mobility
  2. Component: Arthrokinematics: roll, glide, spin
  3. Grading system: Quantity (range) quality (end feel)

Question 8

Joint mobility categories

Answer 8

• quantity (range) and quality (end feel)
• Hypomobility: Decreased ROM, Increased tissue resistance (capsule is tight)
• Hypermobility: Increased ROM, Decreased tissue resistance (Capsule is lax)

Question 9

Capsular pattern vs non capsular involvement

Answer 9

• ROM is limitations specific to joints
• AROM = PROM, both painful in same direction at end range
• Resisted isometrics in their mid range is not painful (means that it is capsular not Musculotendious)
• If resisted Isometrics is painful it is a musculotendinous issue

Question 10

Joint play

Answer 10

• small involuntary movements of joints
• Detect restrictions in joint capsule
• Needed to have full pain free voluntary movement

Question 11

End fields

Answer 11

• a test of joint play
• End range passive test
• Quality of resistance felt at end range (how stiff is this joint)
• Joints and tissue

Question 12

End feel specific to structures being stressed

Answer 12

• Muscle, ligament, joint capsule

Question 13

What does testing end feels aim to determine

Answer 13

• Nature of pathology in the joint or soft tissue
• Normal vs abnormal end feels
• Hypermobility or hypomobility
• Abrupt stop = adhesion, loose body, osteophyte (bone spur)

Question 14

Normal end feels

Answer 14

1. Bone to Bone:
   - Hard stop that is painless
   - Elbow extension
2. Soft tissue approximation:
   - Yielding compression that stops the motion
   - Feels mushy
   - Elbow or knee flexion
3. Normal Capsule:
   - Firm with some creep/give
   - Shoulder motions
   - Knee extension
4. Elastic end feel
   - Tissue stretch
   - Normal muscle ie with DF stretch or PF

Question 16

Abnormal end feels - describe

Answer 16

1. Muscle (muscle spasms)
   - Increases resistance and less elastic end feel
   - Tightness or increase tone
   - Ex: tight hamstring
   - Similar to normal tissue stretch without elastic end feel
2. Capsule:
   - Hard resistance without give/creep
   - Often where you would not expect
   - Leather like
   - Capsular pattern specific to a joint Ie the should: ER is limited more than abduction > IR> flexion
3. Bone to bone:
   - Sudden hard bony block
   - At an abnormal place in the range
   - loose body: fragment of bone, articular cartilage, osteophyte
4. Empty:
   - Pain before any tissue resistance felt
   - Acute subacromial bursitis
5. Springy block
   - Springy rebound
   - Meniscus
   - Occurs where it is unexpected
6. Swelling:
   - boggy/squishy/soft - joint effusion
7. Capsule/ligament laxity:
   - Increased movement
   - Without normal resistance or firm arrest of motion

Question 17

Open pack position of joint

Answer 17

• Ligament and capsule most lax
• Bony surfaces least congruent
• Joint volume greatest - more lubrication
• Where people will hold a joint if it is painful or swollen
• Requires more muscle action around the joint

Question 18

Close pack position of joints

Answer 18

• Ligaments and joint capsule most taut
• Bony surfaces most congruent
• Joint volume least

Question 19

Joint mobilization

Answer 19

• skilled passive movements directed at a joint (glides and tilts)
• Graded movements at various ranges of the joint
• Speed is slow enough that patients can stop the movement

Question 20

Principles of joint mobs

Answer 20

• Joint play must be present for normal and pain free ROM
• Joint play and end feel used assess and treat joints
• Joint play and end feel - assess to see if limitations are from joint or other soft tissue (muscles or ligaments)
• Accuracy may be limited by pain or muscle guarding

Question 21

Effects of joint mobs

Answer 21

• pain relief and increase ROM

Question 22

Pain relief effects of Joint mobs/manips: neurophysiological effects

Answer 22

• Stimulation of articular mechanoreceptors
• Which stimulate A alpha and A beta fibers that inhibit transmission of nociceptive stimuli carries by A delta and C pain fibers
• Via inhibitory interneurons at spinal cord level
• Decreases pain

Question 23

Pain relief mechanical effects

Answer 23

• Increase circulation
• Relaxation of muscles around the joint
• Promotes synovial fluid movement in joints
• Nutrition exchange

Question 24

Psychological effets (pain relief of joint mobs

Answer 24

• Laying of hands on people shows you are helping them and trying to decrease pain
• Skills joint assessment and mobilization
• Finding, reproduction and abating pian
• Expectation effect: saying you will help someone can help them

Question 25

Increase ROM mechanical effects

Answer 25

- capsular /ligament tightness; adhesions - Mechanical effect: - Stretches joint capsule and ligaments - Breaks adhesions - Increases ROM

Question 26

Joint manipulation

Answer 26

- Skilled passive movement directed at a joint - High velocity, small amplitude at end range - Patients not able to prevent the movement

Question 27

1. goals with joint mobilizations/manipulations 2. adverse reactions to joint mobs and manipulations

Answer 27

1. generally to increase ROM and decrease pain 2. Increase in pain, Increase in swelling, Decrease in ROM, If so inappropriate technique and too forceful

Question 28

Distraction joint mobs and grades

Answer 28

- done perpendicular to joint surface - Restores joint play - Grades: 1: unweight joint surface 2: taking up capsule slack 3. Stretching capsule

Question 29

Arthorkinematics in relation to joint mobilizations

Answer 29

1. Concave on convex: - Joint glide and roll in same direction - Mobilizing force imparted in same direction as moving segment 2. Convex on concave: - Joint glide and roll occur in opposite directions - Glide is in opposite direction as moving segments - Mobilization force imparted in the opposite direction to the moving limb

Question 30

Joint mobs treatment grades

Answer 30

- Grade 1: beginning of joint play range (25%) Slow small amplitude - neurophysiological/pain relief - Grade 2 - up to middle of joint play range (50%) Slow a bit larger amplitude than grade 1 - Grade 3: from middle to end range (to restriction) Slow larger amplitude - Grade 4: at end range at restriction changes end feel, Slow small amplitude - Grade 5: mobilization/thrust manipulation, High velocity, Small amplitude motion, At end range

Question 31

Low grade mobilization

Answer 31

- Low grades: 1-2 - Pain relief - stimulate mechanoreceptors - Relax muscle guarding - Oscillations: 2-3 per sec, 3-4 times, 2 minutes

Question 32

High grade mobilizations

Answer 32

- Higher grades 4 and 5 - Modify connective tissue, change end feel - Increase ROM

Question 33

Sustaining the mobilization gains

Answer 33

- Sustained stretched (low load prolonged stretch = hold at end range (TERT = 2 minutes minimum) - Best used in conjunction with high grade 3-4 mobilizations especially with hypomobility patients - Used to modify connective tissue and change end feel - Increase ROM

Question 34

Contraindications of mobilizations

Answer 34

Grade 1, 2 oscillations: few , done for pain relief Higher grades 3-5 - Likelihood of causing osseous or ligamentous damage (Ie disease, osteoporosis, cancer, CT disorders) - Ankylosis (fusion) of that joint - Excessive pain or guarding - serious pathology or fracture - Significant joint inflammation or effusion - Hypermobility

Question 35

Precautions for jt mobs

Answer 35

- Pregnancy due to hormone relaxin

Question 36

Hyper mobility Beighton index criteria and scoring

Answer 36

Patient presents with excessive ROM in several joints: - patient forward bends (without bending knee) can palm floor = 1 point - Knees show hyperextension each side = 1 pt - Elbows show hyperextension - each side 1 pt - Thumb can be ent to touch forearm - each side 1 pt - Little finger be bent past 90º - each side 1 pt Generalized hypermobility present if - + score > than 5/9 currently or historically - Max score i s 9

Question 37

General treatment principle related to restoring joint function

Answer 37

- Restore joint mobility - Then restore muscle length - Then restore strength

Question 38

Joint assessment and mob rules

Answer 38

- Patient relaxed and therapist relaxed - One hand stabilize the other hand mobilizes - Joint in open pack position - Joint assessment or mob technique - consider: treatment plan, direction, velocity and amplitude - Distractions perpendicular to treatment plan - Glides: parallel to treatment plan - One movement in one direction, performed one at a time - Compare to opposite side to determine mobility - Rationale for use of mobilizations - low vs high grades -Reassess after treatment technique (increased joint play, glides, ROM)