Week 1: Joint mobs Flashcards
Injury to a joint or structures surrounding a joint will often lead to:
Pain
Loss of motion (tightening/ inflammation)
Excessive motion (streched JC)
Loss of motion at a joint could be due to several reasons
Pain and muscle guarding Joint hypomobility Joint effusion (swelling) Contractures (scarring) or adhesion in joint capsule or supporting structures Combination
Objectives of manual therapy
Pain modulation
Address tissue extensibility
Address muscle guarding
Peripheral effects (improve circulation, fluid/waste uptake, improve healing, etc.)
Improve tolerance for other interventions
Guarding is when active is
Guarding is when active is more than passive*
How to measure effectivness of manual therapy
test and re-test: measure then intervention and re-test did it get better, worse, or the same
use observable pattern
joint capsule is made of _ tissue and forms a _ around the joint. It can vary in _ according to _ placed on it. Vital to the _ of synovial joint
Dense fibrous connective tissue
Forms sleeve around the joint
Varies in thickness according to stresses placed on it
Vital to function of synovial joints
3 Roles of joint capsules
Seals joint space
Provides stability by limiting movements
Provides active stability via its proprioceptive nerve endings
During AROM translation/glide direction is influenced by the
capsuloligamentous complex
Passive restraints act to
restrict movements but also to reverse articular movements at the end range of motion
Tight capsular structure will cause
early and excessive accessory motion in the opposite direction of the tightness
perform assesment in ___ position of the joint and assess _ and _ of joint mvm
perform assessment in RESTING POSITION of the joint assessing the QUALITY AND QUANTITY of joint mvm
Open packed
zygopophyseal (spine facet) joint
midway between flexion and extension
open packed
temporomandibular
mouth slightly open
open packed
glenohumeral
55 degrees abd/30 degrees horizontal add/slight ER
Open packed
acromoclavicular
arm resting by side
open packed
sternoclavicular
arm resting by side
open packed
ulnohumeral
70 degrees flexion/10 degrees supination
Open packed
radiohumeral
Full extension/ full supination
Open packed
proximal radioulnar
70 degrees flexion/ 35 degrees supination
open packed
distal radioulnar
10 degrees supination
open packed
radiocarpal joint
slight flexion and ulnar deviation
Open packed
carpometacarpal
midway between abd/add and flex/ext
open packed
metacarpophalangeal
slight flexion
open packed
interphalangeal
slight flexion
open packed hip
30 degrees flexion/30 degress abd/ 0-5 degrees ER
open packed
tibiofemoral
25 degrees flexion
open packed
patellofemoral
full extension
open packed
talocrural
10 degrees plantar flexion/midway between extremes of inversion and eversion
open packed
subtalar
midway between extremes of OROM
open packed midtarsal
midway between extremes of ROM
open packed
metatarsophalngeal
neutral
open packed
interphalangeal
slight flexion
what do you asses with joint assessment
gross quantity of mvm
end feel
provocation
gross quantity of mvm levels
hypomobile
normal
hypermobil
end feel possibilities
firm
hard
empty
what does provocation mean
painful painless
Current classification scale, more commonly used toda
hypomobile
normal
hypermobike
define hypomobile
Motion stops short of anatomical limit at pathological point of limitation
Pain, spasm, adhesions, inflammation
define hypermobile
Joint moves beyond its anatomical limit because of laxity of surrounding structures
Manual therapy techniques involving movement of articulating surfaces with intention of:
Regaining normal ROM Improving joint capsule extensibility Regaining normal distribution of forces and stresses on a joint Reducing pain Lubricating joint surfaces Providing nutrition to joint structures
joint mobs are most effective when
combined with a comprehensice treatment plan
absolute contraindications (8)
CANCER in the area active inflammation active infections joint fusions (ankylosis) fractures untrained practioner neuro degeneration disease affecting bone integrety arterial insufficieny
relative (yellow flags) contraindications
exessive pain/ swelling in the area arthroplasty hypermobility metabolic bone disease pregnancy spondylolisthesis (vert split)
joint mkobs help biomechanixs how
Motion improvement
Positional improvement
Increase joint capsule extensibility
joint mobs nutritional effects
Synovial fluid movement
Improve nutrient exchange
joint mobs neurophysiological
Stimulates mechanoreceptors to inhibit pain impulses
gate control and descending pain pathway
gate control theory
Gate control theory
Slow pain signals are getting to the brain faster so that the pain signals are unable to get into the brain
brain
Descending pathway inhibition theory
(primarily related to grade V mobilizations/manipulations)
Grade 5 manips: stimulate the periaqueductal gray area for pain modulation
stress strain curve
Toe- taking up the slack
Yield: stretch but come back to normal
Plastic region: good amount of stress to make a permanent stretch
joint play mvm
compression
traction/distraction
gliding
compression joint mobs
approximation of joint surfaces; force perpendicular to joint plane
Improves stability
traction/ distraction joint mob
separation of joint surfaces; force perpendicular to the joint plane
Pulling away from the joint surface perpendicular
People who have rubbing love distraction
gliding
force direction parallel to joint surface
how many grades are there for distraction
3
Distraction
grade I
piccolo (loosen)
Very small amplitude of traction force
Minimal stress on the joint capsule
Reduces compression forces on articular surfaces
Pain reduction
Commonly used with gliding mobilizations
Distraction
Grade II
slack (take up the slack, “tightening”) in elastic
phase
Slack in joint capsule and surrounding tissues is taken up
Can help to determine the sensitivity of the joint
Used to alleviate pain, assess joint play, and/or reduce muscle guarding
Distraction
Grade III
stretch
Designed to stretch joint capsule and soft tissues surrounding the joint to increase mobility
Used to assess end feel or increase movement
how many grades for oscillation grades
5
Oscillation
Grade I
Small amplitude technique performed at beginning of available ROM (first 25%)
Primary goal:
reduce pain and muscle guarding
improve joint lubrication/nutrition
Oscillation
Grade II
Large amplitude technique performed in middle of available ROM (middle 50%; 25-75%)
Primary goal:
reduce pain and muscle guarding
improve joint lubrication/nutrition
oscillations
Grades I and II summery and theory
Pain relief and muscle guarding
No direct mechanical effect on restrictions
Influences mechanical nociception
Often used before and after grade III and IV mobilizations
Theory:
Reduces pain by improving joint lubrication and circulation to tissues related to the joint
Rhythmic oscillations possibly activate articular and skin mechanoreceptors which play role in pain reduction
oscillations
Grade III
Large amplitude technique performed at end of available ROM (last 50%; 50-100%)
Primary goal:
stretching joint capsule and associated structures (ligaments, muscles attaching in the area)
Oscillations
Grade IV
Small amplitude technique performed at end of available ROM (last 25%; 75-100%)
Hovering at end range w/ small mvm
Primary goal:
stretching joint capsule and associated structures (ligaments, muscles attaching in the area)
ONLY ON HYPOMOBILE that is not hypermobile correction
Assess the mvm at all times to make sure they are not normal and assess what grade do they need that day
summery of grade III and IV fxn
Primarily stretching techniques
Mechanical and neurophysiological effect
May activate inhibitory joint and muscle spindle receptors to aid in reducing restriction of movement
Oscillations
Grade V
High velocity thrust of small amplitude at end of available range but within its anatomical range
Movement that exceeds the resistance barrier
Commonly referred to as high velocity thrust technique or joint manipulation
Primary goal:
decrease pain and muscle guarding
Oscillations Grade V summery
Similar to grade IV in terms ofamplitude and position in joint range, but difference in velocity
Applied to barrier or point of joint restriction
Involves application of fast impulse (quick thrust) of small amplitude (short distance)
Joint briefly forced beyond restricted ROM
joint mobs types
Distractions
Oscillation mobilizations
Sustained hold mobilizations
Manipulations
target impairments for oscillation mobs and manips
guarding, pain, joint hypomobility
Address extensibility
Must consider stress-strain curve of
collagen tissue when considering efficacy of joint mobilization for improved joint mobility
sustained hold mobs target impairments
joint mobility, pain
Pain:
beginning range to mid range
Joint mobility:
end range
Address tissue extensibility directly to allow motion (when enough force applied for enough time according to stress-strain curve for collagen)
joint mobs technique
Resting position used for: Assessment Acute stage During grade I and II oscillations Can be used during grades III and IV if this is the only position patient can tolerate
When attempting to improve ROM (grades III and IV) should place joint at
end ROM if tolerable
One half of joint should be stabilized,
while other half is mobilized
technique for mobs the therapist positions should be
Both stabilizing and mobilizing hands should be as
close as possible to the joint line
Clinician’s hands should make
maximum contact with patient’s body
in what direction do you apply a joint mobs
Based on convex concave rule and which part of joint is being mobilized and which is being stabilized
goal time and ocillations per second
1-3/seconds
Typically:
1-5 sets for 15-60 seconds each
goal sustained hold times
Typically:
1-5 sets for 5-30 seconds each
More commonly used to treat ROM
tips for PTs applying mobs
Allow gravity to
assist when possible
Your body and the mobilizing part should act as
one unit as much as possible
Body
mechanics!!!
When possible your forearm should align with the
intended direction of your force
Reassess afterwards
Stop for the day when a large improvement has been
obtained or when improvement ceases
How do I know what direction to push for joint glides?
ARTHROKINEMATICS
CONVEX/CONCAVE RULE
CONCAVE/CONVEX RULE
Grade I and II mobilizations direction is
Direction less important as
not stretching the joint capsule
Trying to stimulate the gate control theory
Perform grade I and II in direction which
initially caused their pain if tolerated
Often done in open pack (resting) position
direction of Grade III and IV
Determine what motion you want to improve and the direction of the osteokinematics (ie hip extension)
Determine what joint you are going to mobilize (ie hip joint)
Determine which part of the joint you are going to mobilize which part is going to be stationary (ie femur=mobilizing, acetabulum=stationary)
Determine if bone mobilizing is convex or concave (femur=convex)
Convex on concave=mobilize opposite direction as osteokinematics; if concave on convex=mobilize in same direction as osteokinematics
If tolerated should mobilize at the end range (where restriction likely is)
most often therapist mobilize
distal part of the joint and stabilize the proximal portion
Mulligan’s Mobilization with Movement (MWMs) type
combined sustained joint mobilization applied by therapist while patient performs active movement to end range
mulligans golden rule
Golden rule of MWMs should be painless,
if pain occurs either need to change direction of force, correct pressure, or not use MWMs
MWM’s theory
bony positional faults contribute to painful joint restrictions
MWM’s guidelines
Should be
pain free when performing
Apply
10 times before reassessing joint motion
Overpressure
should be applied at end range of AROM
