Joint Mobilization (Week 1)

Question 1

What are Joint mobilizations?

Answer 1

Manual therapy techniques used to modulate pain & treat joint impairments that limit ROM by addressing the altered mechanics of the joint.

Question 2

What is mobilization?

Answer 2

Patient can voluntarily contract a muscle to stop the movement

Question 3

What is manipulation?

Answer 3

Patient cannot stop the movement

Question 4

What are Articulations?

Answer 4

Synovial joints rely on the laxity of the joint capsule & surrounding structures & the potential space between the bones for optimal movement

Question 5

What is Osteokinematic Movement?

Answer 5

• voluntary motion the patient performs
• osteokinematic terms describe the movement (or swing) of bone in space

Question 6

What are Arthrokinematic Movements?

Answer 6

• involuntary movements within the joint and surrounding tissues that are necessary for normal and pain-free ROM

Question 7

What are the Arthrokinematic Motions?

Answer 7

• roll
• slide
• spin
• compression
• distraction
• roll, slide, &. spin are the primary movements,
• compression and distraction are accessory movements that affect the joint

Question 8

What is Arthrokinematic Motion (Roll) ?

Answer 8

• occurs between joint surfaces when new point on moving surface contacts new point on stationary surface
• in normal joint, occurs with slide or spin
• results in movement (swing) of bone
• always occurs in direction that bone is moving, regardless of whether moving surface is convex or concave

Question 9

What is Arthrokinematic Motion (Slide)?

Answer 9

• occurs when same point on moving surface contacts new points on stationary surface
• direction of slide depends on whether moving surface of joint is concave or convex
• slide occurs in sAme direction as roll if moving surface is concAve
• slide occurs in opposite direction of roll if moving
surface is convex
• relationship is known as CONCAVE-CONVEX RULE

Question 10

What is Arthrokinematic Motion (Spin)?

Answer 10

• occurs when same point on moving surface contacts same point on stationary surface
• spin involves rotation of segment about a stationary axis

Question 11

What is Arthrokinematic Motion (Compression)?

Answer 11

• occurs when there is decrease in space between two articulating joint surfaces
• compression normally occurs during weight bearing
• compression can occur when muscles contract – this can provide stability to the joint
• normal compression encourages movement of synovial fluid which helps maintain cartilage health
• abnormally high compression can lead to deterioration of articular cartilage

Question 12

What is Arthrokinematic Motion (Distraction)?

Answer 12

• force applied perpendicular to treatment plane – it’s a separation or pulling apart of articular surfaces

Question 13

What is Arthrokinematic Motion (Traction)?

Answer 13

• longitudinal pull/pull along long axis of bone – often called long-axis traction

Question 14

What is Arthrokinematic Motion (Mobilizing)?

Answer 14

• applied to joint surfaces to decrease pain or restore normal arthrokinematics
• distractions can be applied on their own or in combination with glide
• when possible, grade I distraction should be applied with glide mobilization
• distractions & glides are applied using sustained or oscillatory techniques

Question 15

What is Arthrokinematic Motion (Glide)?

Answer 15

• glide is when you mobilize bone in direction that is parallel to treatment plane
• treatment plane is plane that lies parallel to concave surface of joint

Question 16

What are Grades of Mobilization Techniques?

Answer 16

Mobilizations are applied using either sustained or oscillating pressure & with different levels of force (i.e. grades).

Question 17

What is Sustained Mobilization?

Answer 17

Applied with consistent pressure in specific direction using specific level of force.

Question 18

There are three grades of sustained mobilization. What are they?

Answer 18

Grade I (loosen): minimal force, no stress on joint capsule
Grade II (tighten): sufficient force to tighten tissues around joint
Grade III (stretch): force large enough to place stretch on capsule & periarticular structures but not to anatomic limit

Question 19

What is Oscillatory Mobilization?

Answer 19

Applied with specific frequency of movement, in specific direction, using specific level of force

Question 20

There are four grades of oscillatory mobilization. What are they?

Answer 20

Grade I: small-amplitude, at beginning of range
Grade II: large-amplitude, not up to tissue resistance
Grade III: large-amplitude, into tissue limit
Grade IV: small-amplitude, into tissue limit

Question 21

What are Parameters of Mobilization?

Answer 21

Provide baseline structure for application. Parameters must be modified to ensure mobilization is safe & effective for given patient.

Question 22

What are Parameters of Mobilization (Sustained)?

Answer 22

• into specific direction (distraction or glide)
• hold for approximately 10 seconds
• rest for 3-5 seconds
• repeat for total of 1-3 minutes

Question 23

What are Parameters of Mobilization (Oscillatory)?

Answer 23

• into specific direction (distraction or glide)
• small-amplitude are applied like vibrations
• large-amplitude are applied 2-3/sec
• both small - & large-amplitude oscillations are applied for approximately 1 minute
• rest for 3-5 seconds
• repeat for total of 1-3 minutes

Question 24

What are Effects of Mobilization?

Answer 24

• neurophysiological: small-amplitude oscillatory & distraction movements may stimulate mechanoreceptors that inhibit transmission of pain signals
• mechanical: small-amplitude distraction & gliding movements facilitate synovial fluid motion which
encourages nutrition to avascular structures
• higher grade mobilization (sustained or oscillatory) will distend joint capsule & peri-articular joint
structures
• mobilization (especially with movement) can realign bony segments

Question 25

What are Uses of Mobilization?

Answer 25

• grade I distraction: prior to glides (when possible)
• grade II distraction: initial Ax to determine joint sensitivity & available movement
• grade I and II oscillatory: decrease pain, increase nutrition
• grade I and II sustained: decrease pain
• grade II oscillatory and sustained: <-> ROM
• grade III sustained/III & IV oscillatory: increase ROM, reduce positional faults/subluxations

Question 26

What are Indications for Mobilization?

Answer 26

• pain, muscle guarding, & spasm can be treated with low grade oscillatory mobilizations
• reversible joint hypomobility can be treated with ‘progressively vigorous’ mobilizations
• positional faults/subluxations can be corrected with higher grade mobilizations (esp. with movement)
• conditions that limit ROM: mobilizations can maintain ROM & possibly slow progression
• immobilization: mobilization can help maintain ROM & offset degenerative/restrictive effects

Question 27

Joint mobilizations cannot?

Answer 27

• alter disease processes (e.g., RA)
• alter inflammatory process

Question 28

Inappropriately applied joint mobilizations can?

Answer 28

• create/exacerbate hypermobility
• traumatize joints/joint surfaces
• initiate spasm/muscle guarding

Question 29

What are Absolute Contraindications to Joint Mobilization?

Answer 29

• any undiagnosed lesion
• joint ankylosis
• high grade mobilizations only
• hypermobility, ligamentous rupture, instability
• joint effusion
• inflammation
• malignancy
• osteoporosis
• osteomyelitis
• recent fracture
• herniated discs with nerve compression

Question 30

What are Relative Contraindications to Joint Mobilization?

Answer 30

• be careful & if in doubt, don’t mobilize
• osteoarthritis
• unhealed fracture (also note hand positioning)
• hypermobility
• total joint replacements
• conditions that weaken CT (e.g., RA, advanced diabetes)
• pregnancy (esp. lumbar spine & pelvis)
• internal derangement

Question 31

What is the CMTO’s Perspective of Joint Mobilization?

Answer 31

• don’t mobilize in close-pack position
• communicate
• assess (grade II distraction) before treating
• distract before mobilizing when possible
• joint tissues must be prepped prior to mobilizing (high grade only)
• high velocity low amplitude (HVLA) thrust mobilizations are not applied to spine

Question 32

What are the General Principles of Mobilization?

Answer 32

• prepare surrounding tissue prior to higher-grade mobilizations
• make sure patient is comfortable, stable, & body segment being mobilized is supported
• make sure your hand contact & any other means of stabilization is comfortable
• when possible, your hands must be as close to joint as possible
• assess joint movement with grade II distraction prior to mobilization
• when possible, apply grade I distraction prior to any glide mobilization
• your body & mobilizing segment should be moving as one (i.e., use your body effectively & efficiently)
• mobilize one joint, in one direction, at one time
• never mobilize through pain
• never mobilize in close-pack position

Question 33

How should we be Progressing a Mobilization?

Answer 33

• mobilizing in resting/loose-pack position is safest from which to start but not the most effective position in which to treat
• to progress treatment, position joint at or near end of available & PAIN-FREE ROM prior to mobilizing – this will place restricting tissue in its most tensioned position where stretch force can be more specific & effective

Question 34

What are patient responses to joint mobilization’s?

Answer 34

• grade III & IV mobilizations can cause post-treatment soreness (but should not cause pain)
• if patient experiences pain, soreness lasting more than 24 hours, worsening symptoms, swelling, or
spasm, your treatment was likely too aggressive
• between treatments, the patient should perform ROM into any newly gained range
• mobilization (including self-mobilizations) should be applied every other day

Question 35

What are Muscle Energy Techniques (MET)?

Answer 35

• these techniques use active contraction of muscles that attach near joint to correct joint misalignment
• contractions are applied at the ‘barrier’ & progressed
• usual precautions apply but also note any localized muscle pain/strains

Question 36

What is the Application of Muscle Energy Techniques (MET)?

Answer 36

• contractions are isometric & gentle/submaximal
• contract for 5-10 seconds
• wait for the muscle to completely relax (usually about 3-5 seconds)
• reposition to the next barrier/point of joint restriction
• repeat 3-5x