Treatments - Joint Mobilisations

Question 1

Explain Joint Motion

Answer 1

> Osteokinematic

• ‘Physiological’ movement
• movement of bones about an axis (‘swinging movement)
• Measured as an angular displacement in an anatomical plane
• Closed chain = distal aspect fixed (e.g squat)
• Open chain = distal aspect free (e.g leg ext)

> Arthrokinematic movement

• movement of joint surface (Roll/spin/glide)
• type of movement will depend on shape of surfaces
• requires adequate capsular laxity = ‘joint play’
• Roll - e.g tibia on femoral condyles
• Spin e.g proximal radio-ulnar joint
• Slide e.g proximal phalanx or fixed metacarpals

Question 2

Concave-convex rule

Answer 2

> if convex = moving
- arthrokinematic = opposite direction to bony lever

> if concave = moving
- arthrokinematic motion = same direction to bony lever

Question 3

Closed packed position

Answer 3

Position of maximum congruency
*try to be out of closed packed for mobilisations but if closed packed is where symptoms are then we may need to mobilise here

Question 4

Importance of joint motion

Answer 4

> Enables function + movement

• synovial fluid = circulated + produced (providing nutrition for joint surfaces - healthier + stronger cartilage + bone
• mechanical stress can also encourage growth of bone/cartilage
• Improves soft tissue length + oxygenation

Question 5

If joint = immobilised

Answer 5

> Loss of function + RoM

• muscle atrophy
• soft tissue length changes
• cartilage changes
• Bony changes
• Can result in a pain state

Question 6

What are joint mobilisations

Answer 6

> Passive motion inducing intra-capsular movement

• passively producing arthrokinematic movement
• Reduced accessory motion = reduced physiological motion

Question 7

What do we use accessory movements for?

Answer 7

> Assessment 
- hypomobile = joint issue
- hypermobile = ligament issue/joint instability 
> Treatment technique 
- only for hypomobile

Question 8

When to use joint mobilisations

Answer 8

> Maintain or restore joint function + movement (+ is specific to a joint)
> Reduce Pain 
> Decrease Muscle Spasm 
> Increase Soft tissue length 
\+ Therapeutic Alliance (hands on)

Question 9

How do joint mobilisations maintain/restore joint function + movement

Answer 9

> Improve accessory RoM = improve passive/active RoM

Question 10

How do joint mobilisations reduce pain

Answer 10

> Pain gate theory
- stimulates mechanoreceptors (A beta fibres = low threshold + myelinated) which create a decreased response to pain fibres (A delta + C fibres) at dorsal horn
Central Pain Control (Neuromodulation)
- Descending Inhibition
- Periaqueductal grey (PAG) in brainstem = stimulated
- Dorsal PAG (dPAG) releases a non-opioid (noradrenaline) which blocks substance P at spinal cord level
- Ventral PAG (vPAG) releases opioid (serotonin)
- Overall this increases the stimuli needed to create a pain response

Question 11

How do joint mobilisations reduce muscle spasm

Answer 11

> Influence muscle tone in deep + superficial joint muscles

> disperses inflammatory products (aid in reducing pain)

Question 12

How do joint mobilisations increase soft tissue length

Answer 12

> Capsular stretch

> targets receptors inside soft tissue

Question 13

Contraindications

Answer 13

> Infection
Local tumour
Acute inflammation
Fractures/Dislocations - unless is healed or able to fix fracture
Rheumatoid Arthritis - may cause flare up

Question 14

Precautions

Answer 14

> Instability e.g history of dislocation
Hypermobility
Sero-negative athropathies (rheumatic inflammatory diseases)
High severity/irritability of SIN factor
Diabetes (circulation + sensation issues)

Question 15

How do we guide dosage

Answer 15

> SIN Factor guides dose (grade/time/reps)
higher SIN factor = lower dose (prevent aggravation)
Limit to movement will guide grade of mobilisation (if pain is main limiting factor - is mobilisation worth it)

• Typical dose = 3x 30 seconds (long enough to see benefit but not enough to cause inflammation)
• reassess between sets

Question 16

SIN Factor - Severity

Answer 16

> How bad is it (low/moderate/high)
> Constant vs. intermittent
- Constant = inflammatory/central/pathology 
- Intermittent = mechanical 
> NPRS/VAS/medication
> night symptoms
> function

Question 17

SIN Factor - Irritability

Answer 17

> Reproducibility of symptoms (low/moderate/high)
> Aggravating factors
\+ time for onset/settle
> Easing factors
\+ time required

Question 18

SIN Factor - Nature

Answer 18

> Why (acute/sub-acute/chronic)
> Cause of pain
- myogenic/neurogenic/arthrogenic etc
> Stage of healing
> Pain mechanism 
- Central/Peripheral sensitisation
> Psychosocial factors

Question 19

Grades of joint mobilisation

Answer 19

> 1: small movement - no resistance
2: large movement - no resistance
3: large movement - into resistance
4: small movement - into resistance

Question 20

How SIN Factor guides dose/grade

Answer 20

> Grades 1-2 + low dose

• High severity/irritability
• higher levels of pain (7+ on VAS)
• acute condition

> Grades 3-4 + higher dose

• Stiffness more than pain
• low to moderate severity/irritability
• lower levels of pain (2-4)
• sub acute to chronic stage
• movement related pain or end range pain