Basic Introduction about Joint Mobilisation and Manipulation, This article gives clear notes for the students to understand the Mobilisation techniques.

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DEFINITION
• Mobilizations: these are passive movements
performed by therapist at a slow speed enough
that the patient can stop the movement.
• Manipulations: these are sudden movements
performed with a high velocity, short amplitude
motion such that the patient cannot prevent the
B.ARUN.,MPT,CMPT,COHS motion.
ORTHOPEDIC PHYSIOTHERAPY
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Terminology Terminology
• Mobilization – passive joint movement for
increasing ROM or decreasing pain • Self-Mobilization (Automobilization) –
– Applied to joints & related soft tissues at varying self-stretching techniques that specifically use
speeds & amplitudes using physiologic or accessory joint traction or glides that direct the stretch
motions force to the joint capsule
– Force is light enough that patient’s can stop the
movement • Mobilization with Movement (MWM) –
concurrent application of a sustained
accessory mobilization applied by a clinician
• Manipulation – passive joint movement for & an active physiologic movement to end
increasing joint mobility range applied by the patient
– Applied in a pain-free direction
– Incorporates a sudden, forceful thrust that is beyond
the patient’s control
Terminology Terminology
• Physiologic Movements – movements done • Arthrokinematics – motions of bone surfaces within the
voluntarily joint
– 5 motions - Roll, Slide, Spin, Compression, Distraction
– Osteokinematics – motions of the bones
• Muscle energy – use an active contraction of deep
muscles that attach near the joint & whose line of pull can
• Accessory Movements – movements within the cause the desired accessory motion
joint & surrounding tissues that are necessary for – Clinician stabilizes segment on which the distal aspect of the
normal ROM, but can not be voluntarily performed muscle attaches; command for an isometric contraction of the
muscle is given, which causes the accessory movement of the joint
– Component motions – motions that accompany active
motion, but are not under voluntary control • Thrust – high-velocity, short-amplitude motion that the
• Ex: Upward rotation of scapula & rotation of clavicle that occur patient can not prevent
with shoulder flexion – Performed at end of pathologic limit of the joint (snap adhesions,
stimulate joint receptors)
– Joint play – motions that occur within the joint – Techniques that are beyond the scope of our practice!
• Determined by joint capsule’s laxity
• Can be demonstrated passively, but not performed actively
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Joint Surfaces of Ovoid
and Sellar Joints KINEMATICS
• Physiological Movements & Accessory
movements.
• Also called as
• Osteokinematics (Physiological
movements)
• Arthrokinematics. (Accessory movements
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Osteokinematics ARTHROKINEMATICS
• Deals about the movement present in the joint • Also termed as Accessory movements
• Helps to find out the amount of Motion • Movements occurs inside the joint.
available in particular joint
• Responsible for improving Physiological
• Can be visualized
movements.
• Can be measured
• Restriction in accessory motion results in
• Also called as Physiological movements
decrease of physiological movements.
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Arthrokinematics Roll
• Roll
• Glide / Slide
• Spin
• Compression
• Distraction
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Slide Spin
Compression Distraction
CONCAVE AND CONVEX
RULE
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Maitland Joint Mobilization
Grades of Movement in a
Grading Scale
Normal and a Restricted Joint • Grading based on amplitude of movement &
where within available ROM the force is applied.
• Grade I
– Small amplitude rhythmic oscillating movement at the
beginning of range of movement
– Manage pain and spasm
• Grade II
– Large amplitude rhythmic oscillating movement within
midrange of movement
– Manage pain and spasm
• Grades I & II – often used before & after treatment
Adapted by permission from G. Maitland 1991.
with grades III & IV
• Grade III
– Large amplitude rhythmic oscillating movement up to OSCILLATION MOBILIZATION
point of limitation (PL) in range of movement
– Used to gain motion within the joint
– Stretches capsule & CT structures
• Grade IV
– Small amplitude rhythmic oscillating movement at very
end range of movement
– Used to gain motion within the joint
• Used when resistance limits movement in absence of pain
• Grade V – (thrust technique) - Manipulation
– Small amplitude, quick thrust at end of range
– Accompanied by popping sound (manipulation) Beginning Pathologic Normal
– Velocity vs. force range of al limit of limit of
– Requires training movement movement movement
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Kaltenborn Traction
Grading SUSTAINED MOBILIZATION
• Grade I (loosen)
– Neutralizes pressure in joint without actual surface
separation
– Produce pain relief by reducing compressive forces
• Grade II (tighten or take up slack)
– Separates articulating surfaces, taking up slack or
eliminating play within joint capsule
– Used initially to determine joint sensitivity
• Grade III (stretch)
– Involves stretching of soft tissue surrounding joint
– Increase mobility in hypomobile joint
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CONTRAINDICATION
INDICATIONS • Inflammatory arthritis ( RA, AKS)
• Pain • Malignancy
• Muscle spasm • Bone disease
• Decreased ROM • Bone Fracture
• Hypomobile Joints • Vascular disorder
• Reduce Functionally Mobility. • Unskilled manipulator
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• Joint effusion 26
• Pregnancy • Rubbery end feel of the CAUSES FOR COMPLICATIONS
• TKR, THR joint.
• Practioner — Related complications
• Closed pack position • Evidence of involvement
of 2 adjacent nerve root
Diagnostic error
• Cauda equina lesion.
• Undiagnosed pain
in lumbar spine Lack of skill
• Lower limb neurological Lack of interprofessional consultation
• Protective muscle
symptoms due to
spasm
cervical or thoracic
• Inability of the patient
dysfunction.
to relax. 27 26-11-2008 28
Patient — Related complications • Patient in whom uncomplicated sciatica
becomes a unilateral radiculopathy with distal
Patient with psychological intolerance of pain.
paralysis of limb, sensory loss.
Patient involved in litigation
• These patients usually doesn’t respond to
Patient recently undergone treatment to any
manipulation & should be considered as
practioners.
surgical emergency.
Patient develop psychological dependence on
manipulation.
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JOINT POSITIONS RESISTING POSITION:
• The position in which the joint capsule &
JOINT PLAY
ligaments are relaxed.
• Each joint in the body has positioned to
• Helps in evaluation of the joint
make maximum amount of motion.
• Treatment done for hypomobile joints
• Joint should be positioned in a Relaxed
position. • Placing the joint in resting position allows the
joint to assumes a Loose pack position
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TREATMENT PLANES
Closed pack position:
• Direction of movement is either parallel or
• Here maximal contact of articular surface of
Perpendicular to the treatment planes.
bones with capsule & ligaments are tense or
• Joint traction – Perpendicular to the
tight.
treatment plane
• No movement is seen.
• Glides — Parallel to the
treatment planes.
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TREATMENT FORCE SPEED
OSCILLATIONS:
• It should be close to the opposing joint surface,
• Grade I & IV are usually rapid oscillations
• Either Gentle or Strong.
• Grades II & III are smooth, regular oscillations at
• Large contact area will be more comfortable than
two or three per second for 1 to 2 minutes.
small surfaces..
• Vary the speed of oscillation for different effects
• Like use of Hand is advised than Thumb for
such as low amplitude and high speed to inhibit
mobilizing larger joint or Surface.
pain or slow speed to relax muscle guarding.
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Sustained: LIMITATION
• Painful joints : Apply intermittent distraction 7—10 sec
• Few seconds of Rest in-between. 1. Can’t change the disease process of Disorders.
• If no response Repeat correctly or Discontinue. 2. Like OA,RA manual therapy helps in Reducing
• Resisted Joints : pain & mobilize joints.
• Apply for 6 sec stretch force 3. Skill of therapist affects outcome.
• Followed by partial release
• Repeat with intermittent stretches for 3—4 sec intervals.
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PRINCIPLES OF MANUAL 5. All pain arise from lesion, so treatment should
THERAPY focus on the lesion.
• The principles are summarize by clinicians such as
6. Constant reassess to determine the effect of the
Grieves, Maitland, Cyriax ect..
technique being used.
1. Remember the contraindications & conditions
7. Progress is governed by the response to previous
require extra care.
treatment.
2. Don’t harm the patient or yourself
8. Discontinue technique that are not productive
3. A through examination is necessary
9. Make the patient to relax, reduce anxiety & fear.
4. Make an accurate diagnosis as possible based on
10.Don’t force the protective muscle spasm.
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solid knowledge of anatomy.
Causes of Limited Range of
11. A slight alteration of joint position or angle of
thrust often allows a technique much more
Motion
effective. • Loss of Extensibility of periarticular connective
12. Warm up patients of the potential for post tissue structures, ligaments, capsule & fascia.
treatment soreness. • Deposition of Fibrofatty infiltrates acting as
13.Don’t over treat. intraarticular “Glue”.
14.Aim for restoration of normal , painless • Adaptive shortening of Muscles.
technique.
• Breakdown of articular cartilages.
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EFFECTS
Pain & Muscle guarding
• Mobilization showed that it helps in break down of
Muscle shortening and reduce the fibroblastic • Wyke’s explained that Receptors nerve
proliferations inside the joints. endings present in various periarticular
• Forceful passive movements has shown to structures.
rupture of intra-articular adhesion that forms
during immobilization.
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• Type I (postural) & Type II (dynamic)
mechanoreceptors are located in joint capsule. • Type IV, (Pain receptors), are found in capsule,
ligaments, Fat pads and Blood vessel walls.
• They have low threshold and excited by repetitive
movements including oscillations. • These receptors are fired by noxious stimuli as
in trauma and have a relatively high threshold.
• Type III mechanoreceptors are found in joint
capsules and extracapsular ligaments. • Type IV are Slow conducting fibers,
• They are excited in stretching & thrust • Type I & II are Fast conducting fibers.
maneuvers.
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EFFECT OF MANUAL EFFECTS OF MANUAL
THERAPY THERAPY
PAIN REDUCTION Pain Reduction
• During Oscillatory glides, faster impulses Small amplitude
Stimulate
distraction,
Oscillatory mechanorece
overwhelm the slower impulses. movement ptors
• It helps in closing of gate at spinal level.
• Release of Endorphins from CNS.
Inhibit
Transmission
Melzack R, Torgerson WS: On the language of pain, Anesthesiology, of Nociceptive
stimuli
1971
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Wyke B: Articular neurology—a review, physiotherapy, 1958
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Small
Amplitude
Muscle Relaxation
Distractions
& Glides
• Type III receptors in joint & golgi tendon organ
Stimulates
Gentle Joint Synovial fire by stretching or thrusting of a joint result in
play helps in Fluid
maintain motion temporary inhibition or relaxation of muscle.
Nutrient
exchange
• This itself cause an increase Range of motion
Brings nutrition
to Avascular and helps prepare the joint for further
Articular
cartilage stretching & mobilization.
Prevent
Painful
Degenerati Paris SV: extremity dysfunction and mobilization . Institute Press, Atlanta
49 1980
on Wyke B: Articular neurology—a review, physiotherapy, 1958
IMPORTANT RULES FOR 3) Protect neighboring hypermobilities. If patient
MOBILIZATION is having shoulder dislocation, following a
Described by Stanley. V. Paris. anterior laxity, mobilization focused on
1. Identify the location and direction of the improving abduction and rotation.
limitation. for e.g Ankle stiffness, posterior glide
4) Communicate with the surgeon, find out which
of talus is restricted.
tissue have been cut or scarified, and what
2. Prepare the soft tissue, (i.e) first reduce the
motions should be avoided initially.
swelling, pain, muscle guarding or tightness.
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WHAT IS THE NAME OF A
CROSS BREED BETWEEN
THIS
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