Lecture 6- Joint Mobilizations, Selective Tissue Tensioning Flashcards
JOINT MOBILIZATIONS
JOINT MOBILIZATIONS
- What type of tissue is the joint capsule?
- The joint capsule forms a “_______” around the joint.
- What determines the thickness of the joint capsule?
- dense fibrous connective tissue
- sleeve
- stresses placed on it
What are the 3 main roles of the joint capsule?
- seals joint space
- provides passive stability by limiting movements
- provides active stability via its proprioceptive nerve endings
Why is the proprioception of the joint capsule important?
If a PT starts to dislocate, their proprioceptors will sense that and muscles will respond.
Tight capsular structure will cause early and excessive accessory motion in the _________ direction of the tightness.
-opposite
Injury to a joint or structures surrounding a joint will often lead to what?
- pain
- loss of motion (inflammation)
- excessive motion (overstretched)
In what position do we perform our joint mobilizations?
open pack = resting position
Why do we want to perform our joint mobs in the open pack position?
This is where structures are the least tight, allowing for the greatest mobility.
In the open pack position we have:
- surrounding tissue is as ______ as possible
- _________ incongruency
- intracapsular space is as _________ as possible
- ________ amount of joint play available
- lax
- maximal
- large
- maximal
In the closed pack position we have:
- joint positions where joint is ________ congruent
- surrounding tissue (capsules and ligaments) under ______ tension
- ________ stability of the joint
- most
- maximal
- maximal
Why don’t we perform joint mobs in the closed pack position?
This is where the bones are maximally congruent, if you “win” when a PT is in a closed pack position, it could cause damage.
What are the 3 things we are testing when assessing joint mobility?
- gross (quantity of movement)
- end-feel (quality of movement)
- provocation
What are the 3 gross (quantity of movement) classifications?
- hypomobile
- normal
- hypermobile
What are the 3 end-feels (quality of movement)?
- firm
- hard
- empty
What is an example of why it is important to know end feels?
If you are expecting a firm end-feel but it is hard, it’s important to ask why you are felling bone-to-bone at that joint. If you ignore this and keep joint, you could break bones over stretching a patient.
What is an empty end-feel?
When you could have moved the joint further, but the patient stopped due to pain.
The original classification scale for joint mobility was on a scale of 0-6 with 0 being ________, 3 being _________, and 6 being __________.
- no movement
- normal
- unstable
What is hypomobility?
What may cause this?
- motion stops short of anatomical limit, instead stops at pathological point of limitation
- pain, spasm, adhesions, inflammation
What is hypermobility?
Joint moves beyond its anatomical limit because of laxity of surrounding structures
What are the indications for performing joint mobilizations as a treatment?
- break pain cycle
- increase joint extensibility
- increase extensibility of tendons, muscles, fascia
- increase joint ROM
- promote muscle relaxation
- improve muscle performance
What are the biomechanical effects of joint mobilizations?
- motion improvement
- positional improvement
- increase joint capsule extensibility
What are the nutritional effects of joint mobilizations?
- synovial fluid movement
- improve nutrient exchange
What are the neurophysiological effects of joint mobilizations?
- stimulates mechanoreceptors to inhibit pain impulses
- gate control theory
- descending pathway inhibition theory
- peripheral inflammatory modulation
What is the gate control theory?
The gate control theory of pain asserts that non-painful input closes the nerve “gates” to painful input, which prevents pain sensation from traveling to the central nervous system. The gate control theory of pain describes how non-painful sensations can override and reduce painful sensations.
What is the descending pathway inhibition theory?
Joint mobilizations (grade 5) stimulate PAG which activates neurons that release seretonin which is a “feel-good” chemical. Serotonin descends to spinal cord where it forms connections with neurons that help inhibit pain.
What are the absolute contraindications to performing joint mobilizations?
- malignancy in area of treatment
- infectious arthritis
- fusion of the joint
- fracture at the joint
- practitioner lack of ability
- neurological deterioration
- upper cervical spine instability
- cervical arterial dysfunction
What are the relative contraindications to performing joint mobilizations?
- excessive pain or swelling
- arthroplasty
- hypermobility
- osteoporosis
- spondylolisthesis
There are many varied procedures and philosophies for joint mobs but they are most effective when combined with a comprehensive _______________.
treatment plan
What are the 3 joint play movements and describe them?
- Compression- approximation of joint surfaces; force perpendicular to joint plane
- Traction/distraction- seperation of joint surfaces; force perpendicular to the joint plane
- Gliding- force direction parallel to joint surface
What are the 4 types of joint mobilizations?
Distraction -perpendicular to joint surface Oscillation mobilizations -glide parallel to joint surface Sustained hold mobilizations -beginning range, mid range, end range Mobilizations with movement
What is the grading scale for distraction mobilizations called and what are the grades?
Kaltenborn Distraction Grades
- Grade I - piccilo (loosen)
- Grade II - slack (take up the slack)
- Grade III - stretch
Kaltenborn Grade I – piccolo (loosen)
- Distraction force that neutralizes pressure in the joint without producing actual __________ of the joint surfaces.
- No _______ on the joint capsule.
- Can be used with ________ mobilizations to reduce compressive forces on articular surfaces and thereby pain.
- seperation
- stress
- gliding
Kaltenborn Grade II - slack (take up the slack)
- Slack in joint capsule is reduced through sustained __________.
- Separates the articulating surfaces and _______ the play in the joint capsule.
- Can help to determine the _________ of the joint.
- distraction
- eliminates
- sensitivity
Kaltenborn Grade III - stretch
-designed to stretch joint capsule and soft tissues surrounding the joint to increase _________.
mobility
Would we perform a Kaltenborn Grade III stretch on someone with a normal joint? A hypermobile joint?
No, only done with hypomobile patients to get them into plastic region
Toe region = Grade __
Elastic region = Grade ___
Plastic region = Grade ___
- I
- II
- III
What is the grading scale for oscillation mobilizations called and what are the grades?
Maitland Oscillation Joint Mob.
-Grade I - V
Maitland Grade I
- Small amplitude technique performed at beginning of available ROM (first __%)
- Primary goal: ____ and ______ reduction
- 25 (0-25)
- pain and spasm
Maitland Grade II
-Large amplitude technique performed in middle of available ROM (middle __%)
Primary goal: ____ and _____ reduction
- 50 (25-75)
- pain and spasm
Maitland’s Grades I and II Oscillations
- _____ relief and muscle _________
- No direct mechanical effect on _________ (not reaching plastic region)
- influences mechanical __________
- Often used before and after grade ___ and ____ mobilizations
- pain, guarding
- restrictions
- nociception
- III and IV
Maitland Grade III
- Large amplitude technique performed at end of available ROM (last ___%)
- Primary goal: stretching __________ and associated structures
- 50 (50-100)
- joint capsule
Maitland Grade IV
- Small amplitude technique performed at end of available ROM (last __%)
- Primary goal: stretching __________ and associated structures
- 25 (75-100)
- joint capsule
Maitland’s Grades III and IV Oscillations
- Primarily __________techniques
- Mechanical and ____________ effect
- May activate inhibitory joint and muscle spindle receptors to aid in __________ restriction of movement
- stretching
- neurophysiological
- reducing
Maitland Grade V
- High velocity thrust of small amplitude at end of available range but within its __________ range
- Movement that exceeds the resistance barrier
- Commonly referred to as high velocity thrust technique or joint ___________
- anatomical
- manipulation
SELECTIVE TISSUE TENSIONING
SELECTIVE TISSUE TENSIONING
What is a common obstacle of diagnosing painful condition?
often times pain is felt at a distance from true source
Information to gather during an examination process
- History
- Condition at rest
- Active movements
- Passive movements
- Resisted movements
- Joint mobility
- Special tests
- Palpation
History
- The ______ is the best source of information into their condition.
- History can help to develop __________ order to development of symptoms.
- _______ questions should be avoided.
- patient
- chronological
- leading
What information should be gathered during a history?
- demographics
- past medical history/medications
- progression/evolution of symptoms
- previous treatments
- description of symptoms
- activity limitations
- participation restrictions
- goals
What are the 5 Principles of Diagnosis for Soft Tissue Injuries?
- ) Look for “inherent likelihoods”
- ) Look for objective physical signs
- ) Palpation
- ) Selective tensioning: Non-contractile vs. Contractile Tissue
- ) “The” pain is the pain for which the patient is seeking treatment
1.) Look for “inherent likelihoods”
-Soft tissue lesion behave in ________ ways (Regularly be faced with the same history and the same response to functional testing)
Examiner with knowledge of these patterns can recognize them quickly
-typical
2.) Look for objective physical signs
- Examination of soft tissues is an exercise in applied anatomy
- Test each group of _______
tissues
3.) Palpation
- Can help to narrow down the area/tissue to evaluate
- Can be _________
unreliable
4.) Selective tensioning: Non-contractile vs. Contractile Tissue
- What are some examples of contractile tissues?
- What are some examples of non-contractile tissues?
- Contractile tissue is stressed with _______ contraction, stretching, and palpation while non-contractile tissues are stressed with only _________ and ________.
- Tendons, muscle, musculotendinous junctions, bone adjacent to attachment of tendon
- Joint capsules, ligaments, bursae, aponeuroses, nerves
- isometric, stretching and palpation
- ) “The” pain is the pain for which the patient is seeking treatment
- When pain is evoked must ask “________?”
is that your pain?
Active movements are a quick way to narrow down the _______ of symptoms and the _________ to test in detail.
- source
- structures
With active movements we want to observe for what 4 things?
- pain
- ROM
- quality of movement
- willingness to move
- With active testing we want to compare to _________ side AROM, PROM, resistance testing, and palpation.
- With active testing, we want to compare to _________ results of PROM, resistance testing, and palpation
- contralateral
- ipsilateral
With passive movements, the patient should be completely ________.
relaxed
With passive movements we want to observe for what 4 things?
- pain
- ROM
- willingness to move
- end feel
With passive movements, just like active movements, we want to compare our involved side to what?
uninvolved side and results of other testing on involved side
Resisted movements do best to isolate _____/________. Resist through full ROM to fully rule out suspicious area; _______ need to do resistance through full ROM for all resistance testing.
- muscle/tendon
- DO NOT
With resisted movements we want to observe for what 4 things?
- pain
- willingness to allow contraction
- strength
- compensations
Resistance (S12)
- No pain, normal strength = _______
- Yes pain, normal strength = ________ disorder
- No pain, weak strength = __________
- Yes pain, weak strength = _________
- normal
- contractile tissue
- nerve lesion, complete rupture (could still display pain via secondary muscle guarding or compensation*)
- serious lesion, partial rupture (could also present as tendonitis)
With palpation of a stationary joint, what do we want to look out for?
- temperature
- swelling
- gaps (possible complete tear)
- tenderness
- pulsation
With palpation of moving joints, what do we want to look out for?
- crepitis (sign of arthritis; crunching in joint)
- clicks (good if not painful)
- end-feel
- hypermobility
- hypomobility
- willingness to move
- pain
What if everything is negative for selective tissue tensioning?
- a negative examination does not necessarily mean that an injury is absent
- may be a problem in a neighboring tissue which was not systematically tested in examination
What if the patient has very slight pain?
- Examination can be totally ________
- Palpation is very ________ in these cases
- May ask patient to come back if symptoms return
- May provoke signs by having the patient exercise sufficiently to produce ________
- ________ is of great importance
- negative
- dangerous
- symptoms
- history
What if the patient has very severe pain?
- All of examination components may be _______
- Hard for the patient to state accurately _______ and _____ pain is felt
- __________ testing and its interpretation are also difficult, either because excessive physical signs are presented or because the patient cannot move and is opposed to carrying out certain maneuvers
- _______ is of great importance
- positive
- where and when
- functional
- history
Muscle or Tendon Strain, Tendonitis, or Possible Small Tear
-AROM: Likely limited due to ______ and/or _______, though may be able to move through full range, but with pain.
pain, weakness
Muscle or Tendon Strain, Tendonitis, or Possible Small Tear
-PROM: if truly passive would have full pain free motion in all directions, EXCEPT direction which __________ involved area may be limited due to pain (empty end feel)
stretches
Muscle or Tendon Strain, Tendonitis, or Possible Small Tear
-Isometric: likely ____ and _________ when testing involved area
weak and painful
Muscle or Tendon Strain, Tendonitis, or Possible Small Tear
-Palpation: involved area painful to __________
palpation
What 3 things are usually indicative of a muscle strain, tendonitis, or small tear?
- hurt on contraction with resistance
- hurt with stretch
- hurt with palpation
Muscle or Tendon Complete Tear
-AROM: Very limited due to weakness, likely not as much pain as seen with a partial tear, but much more _________
weakness
Muscle or Tendon Complete Tear
-PROM: if truly passive would have full pain free motion in all directions, EXCEPT direction which stretches involved area may be limited due to pain (empty end feel) if there is muscle _________ in the area
guarding
Muscle or Tendon Complete Tear
-Isometric: _________ weak
extremely
Muscle or Tendon Complete Tear
-Palpation: Involved area _________ to palpation
painful
Joint Capsule
-AROM: Limited, possibly painful at _____ranges*
end
Joint Capsule
-PROM: Limited in _____ direction as AROM with a firm end feel, possibly painful at end ranges*
same
Joint Capsule
-Isometrics: If done at mid range should not produce significant pain and should be strong; though may have pain due to __________ or ___________ of surrounding musculature
compensation or guarding
Joint Capsule
-Palpation: Depends on depth of joint capsule, but more often than not ______ palpate deep enough to feel joint capsule though surrounding structures may also be inflamed and cause discomfort with palpation
cannot
If AROM and PROM restrictions present with the capsular pattern, what are we suspicious of?
joint capsule (still can be joint capsule without a capsular pattern)
Ligament Injury
-AROM: Full but pain at ___ range that stretches ligament
end
Ligament Injury
-PROM: Full but pain at ___ range that stretches ligament
end
Ligament Injury
-Isometrics: Strong and no pain when tested at mid range, unless there is ________ in the area
guarding
Ligament Injury
-Palpation: Involved ligaments are ________ to palpation
painful
What is Shoulder Adhesive Capsulitis?
Frozen Shoulder
-joint capsule around GH gets inflammed, then tightens and shrinks down after inflammatory phase
Shoulder Adhesive Capsulitis
- PROM and AROM _______ limited, for this condition it is often in a ________ pattern
- Isometrics and Palpation: possible secondary pain with palpation and resistance due to possible muscle __________
- equally, capsular
- guarding
What is Patellar Tendon Tendonitis?
inflammation of patellar tendon
Patellar Tendon Tendonitis
- AROM: possible limited knee _________ due to pain if inflamed enough may be weak as well
- PROM: Full all directions except likely pain with end range knee ________ possible limitation in end range knee flexion
- Isometrics: resisted knee __________ painful possibly weak
- Palpation: painful palpation of patellar tendon
- extension
- flexion
- extension
Lateral Ankle Sprains (ligaments)
- AROM: pain into ______
- PROM: pain into _______
- Isometrics: if done in mid range, likely _______ and ____ free
- Palpation: painful over _______ ligaments
- inversion
- inversion
- strong and pain
- lateral
