Lecture 2: introduction

Question 1

Methods of Joint Examination

Answer 1

1. Inspection & Palpation:
   Looking for:
   Swelling
   Skin changes
   Muscles, above and below the joint (wasting) compare to non injured side
   Deformity of any kind, bones misaligned, valgus or varus
2. Range of Motion (active vs passive):
   Range of motion is a measurement of the amount of movement around a specific joint. We use a goniometer to measure ranges of motion in the human body in degrees. It measures the amount of movement allowed by the shape of the joint and by the surrounding soft tissues. It may show the joint’s movement is limited, normal or excessive. For a joint to have use of its full range of motion it must also have good flexibility. The flexibility is measured in degrees and measures the joints range of motion. This measurement could result from ligaments, tendons, muscles, bones or joints affecting it.

We have 2 common ways to measure range of motion:

Passive (or relaxed): the therapist makes the motions of the joint while the patient is relaxed through the unrestricted range, the patient does not contract muscles. The anatomic barrier is the end of the passive range of motion.

Active: the patient “actively” contracts the voluntary muscles crossing the joint, moving the joint through its range of motion. The physiologic barrier is the end of the active range of motion.

Radiography (x-ray)
Computed tomography (CT scan)
Magnetic Resonance Imaging (MRI)
Conventional & Contrast Arthrography
Ultrasound Arthrography

Question 2

Grading Joint Play:

Sustained Glide or Traction

Answer 2

When applying joint mobilizations to specific joints we always start with the least stress on the joint and go to more and more stress. We use a grading system for both sustained glides or distractions and for oscillations of joints. Each grade has a purpose and function within the grading system for a therapeutic
effect on joints.

Grade I:

Initiation of movement of the opposing joint surfaces
Perpendicular to the joint surfaces for a distraction joint mobilization or parallel for a glide joint mobilization.
A non-corrective grade of mobilization.

Grade II:

Movement of the opposing joint surfaces is up to the first tissue stop
Perpendicular to the joint surfaces (distraction) or parallel (glide).
A non-corrective grade of mobilization

Grade III:

Movement of the opposing joint surface is up to and through the first tissue stop.
A corrective grade of mobilization. This grade of mobilization stretches the joint capsule. Perform this grade with caution.

note:

Grades I and II:

These grades are used for pain management, introductory assessment and joint play (Grade 2) and assessment techniques.

Grade III:

This grade is used as a corrective technique to stretch the joint capsule and restore glide motions within the joint.

Question 3

Grading: Oscillations

Answer 3

Grade I:

Small amplitude oscillatory movement performed between the initiation of movement and the (not to) tissue resistance. This oscillatory movement is at the start of the motion.
Performed at approximately 5 cycles per second

Grade II:

Large amplitude oscillatory movement performed between the initiation of movement and the (not to) tissue resistance, not reaching the end of ROM.
This is performed at 2-3 cycles per second.

Grade III:

Large amplitude oscillatory movement performed within the (before) tissue resistance and backing out again. To the start of the limited end of ROM.
This is performed at approximately 2-3 cycles per second.

Grade IV:

Small amplitude oscillatory movement performed within the tissue resistance to the end of the limited ROM.
This is performed at approximately 5 cycles per second.

Grade V:

High velocity, small amplitude, non-oscillatory movement that starts at the tissue resistance and follows through in a thrust manipulation. This is commonly called a thrust, adjustment, or manipulation.

This is not in the scope of practice of registered massage therapists in British Columbia.

• Summary:

Grades I and II
Used as a non-corrective oscillatory type mobilization. For pain relief, warm ups or introductory techniques.

Grades III and IV
Used as corrective oscillatory type mobilizations to mobilize and stretch joint capsules.

Grade V
Used to reduce subluxations, osseous positional faults, facet locks & disc herniations.

Question 4

End Feels

Answer 4

End Feels

When assessing passive movements, the therapist applies overpressure at the end of the range to determine the quality of the end feel. This is the sensation the therapist “feels” in the joint as it reaches the end of the ROM of each passive movement.

Normal End Feels:

Bony End Feel
a “hard” unyielding sensation that is painless
Soft tissue approximation
a yielding compression, or “mushy” feel
Tissue stretch End Feel
firm springy type of movement with a slight give, an elastic resistance, may be hard (capsular) or soft (elastic)

Abnormal End feels: and common causes

Early spasm: caused by muscle/ligament tear, often acute

Late spasm: caused by instability

Capsular: hard (chronic) & soft or boggy (acute), caused by capsule damage

Empty: caused by ligament rupture or tear, very painful

Bone to bone: caused by osteophyte, early restriction in ROM

Springy block: caused by internal derangement inside joint, common in meniscus, early restriction