What is Joint Mobilization?

Joint Mobilization z “Joint Mobs”

z Manual therapy technique
– Used to modulate pain
– Used to increase ROM
– Used to treat joint dysfunctions that limit ROM by
specifically addressing altered joint mechanics
z Factors that may alter joint mechanics:
Techniques Utilized in Rehabilitation – Pain & Muscle guarding
– Joint hypomobility
– Joint effusion
– Contractures or adhesions in the joint capsules or
supporting ligaments
– Malalignment or subluxation of bony surfaces

Terminology
Pondering Thoughts
z Mobilization – passive joint movement for
z Would you perform joint mobilizations on increasing ROM or decreasing pain
someone who has a hypermobile joint? – Applied to joints & related soft tissues at varying speeds &
amplitudes using physiologic or accessory motions
– Force is light enough that patient’s can stop the movement

z Manipulation – passive joint movement for

increasing joint mobility
– Incorporates a sudden, forceful thrust that is beyond the
patient’s control

Terminology
Terminology z Physiologic Movements – movements done voluntarily
– Osteokinematics – motions of the bones

z Self-Mobilization (Automobilization) – self-

stretching techniques that specifically use joint z Accessory Movements – movements within the joint &
traction or glides that direct the stretch force to the surrounding tissues that are necessary for normal ROM, but
joint capsule
can not be voluntarily performed
– Component motions – motions that accompany active motion,
z Mobilization with Movement (MWM) – but are not under voluntary control
concurrent application of a sustained accessory
z Ex: Upward rotation of scapula & rotation of clavicle that occur with
mobilization applied by a clinician & an active shoulder flexion
physiologic movement to end range applied by the
patient – Joint play – motions that occur within the joint
– Applied in a pain-free direction z Determined by joint capsule’s laxity
z Can be demonstrated passively, but not performed actively
 Terminology
z Arthrokinematics – motions of bone surfaces within the joint
– 5 motions - Roll, Slide, Spin, Compression, Distraction
Terminology
z Muscle energy – use an active contraction of deep muscles
that attach near the joint & whose line of pull can cause the
z Concave – hollowed or rounded inward
desired accessory motion
– Clinician stabilizes segment on which the distal aspect of the muscle
attaches; command for an isometric contraction of the muscle is given, z Convex – curved or rounded outward
which causes the accessory movement of the joint

z Thrust – high-velocity, short-amplitude motion that the patient

can not prevent
– Performed at end of pathologic limit of the joint (snap adhesions,
stimulate joint receptors)
– Techniques that are beyond the scope of our practice!

Relationship Between Physiological & Joint Shapes & Arthrokinematics

Accessory Motion
z Ovoid – one surface is z 5 types of joint
z Biomechanics of joint motion convex, other surface is arthrokinematics
– Physiological motion concave – Roll
– What is an example of an – Slide
z Result of concentric or eccentric active muscle contractions ovoid joint? – Spin
z Bones moving about an axis or through flexion, extension, – Compression
abduction, adduction or rotation z Sellar (saddle) – one surface
– Distraction
is concave in one direction
& convex in the other, with
– Accessory Motion the opposing surface convex z 3 components of joint
z Motion of articular surfaces relative to one another & concave respectively mobilization
– What is an example of a sellar – Roll, Spin, Slide
z Generally associated with physiological movement
joint? – Joint motion usually often
z Necessary for full range of physiological motion to occur involves a combination of
z Ligament & joint capsule involvement in motion
rolling, sliding & spinning

Roll Spin
zA series of points on one articulating z Occurs when one bone rotates around a
surface come into contact with a series stationary longitudinal mechanical axis
z Same point on the moving surface creates an arc of a
of points on another surface circle as the bone spins
– Rocking chair analogy; ball rolling on ground z Example: Radial head at the humeroradial joint
– Example: Femoral condyles rolling on tibial plateau during pronation/supination; shoulder
– Roll occurs in direction of movement flexion/extension; hip flexion/extension
– Occurs on incongruent (unequal) surfaces – Spin does not occur by itself during normal
– Usually occurs in combination with sliding or spinning joint motion
 Slide
z Specific point on one surface comes
into contact with a series of points on z Compression –
another surface
– Decrease in space between two joint surfaces
z Surfaces are congruent – Adds stability to a joint
z When a passive mobilization – Normal reaction of a joint to muscle contraction
technique is applied to produce a
slide in the joint – referred to as a
GLIDE. z Distraction -
z Combined rolling-sliding in a joint – Two surfaces are pulled apart
– The more congruent the surfaces are, the
more sliding there is – Often used in combination with joint
– The more incongruent the joint surfaces mobilizations to increase stretch of capsule.
are, the more rolling there is

Convex-Concave & Concave-Convex Rule

z Basic application of correct mobilization Convex-concave rule: convex joint
techniques - **need to understand this!
surfaces slide in the OPPOSITE
– Relationship of articulating surfaces associated with
sliding/gliding direction of the bone movement
(concave is STABLE)
z One joint surface is MOBILE & one is STABLE If convex surface in moving on
stationary concave surface –
z Concave-convex rule: concave joint surfaces gliding occurs in opposite
slide in the SAME direction as the bone direction to roll
movement (convex is STABLE)
– If concave joint is moving on stationary convex
surface – glide occurs in same direction as roll

Effects of Joint Mobilization Contraindications for Mobilization

z Neurophysiological effects –
– Stimulates mechanoreceptors to ¶ pain z Should not be used haphazardly
– Affect muscle spasm & muscle guarding – nociceptive stimulation
– Increase in awareness of position & motion because of afferent nerve
impulses z Avoid the following:
– Inflammatory arthritis – Neurological involvement
z Nutritional effects –
– Malignancy – Bone fracture
– Distraction or small gliding movements – cause synovial fluid movement
– Movement can improve nutrient exchange due to joint swelling & – Tuberculosis – Congenital bone
immobilization deformities
– Osteoporosis
– Vascular disorders
z Mechanical effects – – Ligamentous rupture
– Herniated disks with nerve – Joint effusion
– Improve mobility of hypomobile joints (adhesions & thickened CT from
immobilization – loosens) compression z May use I & II
– Maintains extensibility & tensile strength of articular tissues – Bone disease mobilizations to relieve
pain
z Cracking noise may sometimes occur
 Maitland Joint Mobilization
Grading Scale
Precautions z Grading based on amplitude of movement & where
within available ROM the force is applied.
z Osteoarthritis
z Grade I
z Pregnancy – Small amplitude rhythmic oscillating movement at the
beginning of range of movement
z Flu
– Manage pain and spasm
z Total joint replacement z Grade II
– Large amplitude rhythmic oscillating movement within
z Severe scoliosis midrange of movement
z Poor general health – Manage pain and spasm

z Patient’s inability to relax z Grades I & II – often used before & after treatment with
grades III & IV

z Grade III
– Large amplitude rhythmic oscillating movement up to point Indications for Mobilization
of limitation (PL) in range of movement
– Used to gain motion within the joint
z Grades I and II - primarily used for pain
– Stretches capsule & CT structures
z Grade IV – Pain must be treated prior to stiffness
– Small amplitude rhythmic oscillating movement at very end – Painful conditions can be treated daily
range of movement
– Used to gain motion within the joint – Small amplitude oscillations stimulate
z Used when resistance limits movement in absence of pain mechanoreceptors - limit pain perception
z Grades III and IV - primarily used to increase
z Grade V – (thrust technique) - Manipulation
– Small amplitude, quick thrust at end of range motion
– Accompanied by popping sound (manipulation) – Stiff or hypomobile joints should be treated 3-4
– Velocity vs. force times per week – alternate with active motion
– Requires training
exercises

ALWAYS Examine PRIOR Joint Positions

to Treatment z Resting position
– Maximum joint play - position in which joint capsule and ligaments are
most relaxed
z If limited or painful ROM, 1) If pain is experienced BEFORE
tissue limitation, gentle pain- – Evaluation and treatment position utilized with hypomobile joints
examine & decide which tissues inhibiting joint techniques may be
are limiting function used z Loose-packed position
z Stretching under these circumstances
is contraindicated – Articulating surfaces are maximally separated
z Determine whether treatment
will be directed primarily – Joint will exhibit greatest amount of joint play
toward relieving pain or 2) If pain is experienced
CONCURRENTLY with tissue – Position used for both traction and joint mobilization
stretching a joint or soft tissue
limitation (e.g. pain & limitation that
limitation occur when damaged tissue begins to
– Quality of pain when testing heal) the limitation is treated z Close-packed position
ROM helps determine stage of cautiously – gentle stretching – Joint surfaces are in maximal contact to each other
recovery & dosage of techniques used
techniques
z General rule: Extremes of joint motion are close-packed, &
3) If pain is experienced AFTER tissue
limitation is met because of midrange positions are loose-packed.
stretching of tight capsular tissue, the
joint can be stretched aggressively
 Joint Mobilization Application Positioning & Stabilization
z All joint mobilizations follow the convex-concave rule z Patient & extremity should be positioned so that the
z Patient should be relaxed patient can RELAX
z Explain purpose of treatment & sensations to expect to
z Initial mobilization is performed in a loose-packed
patient
position
z Evaluate BEFORE & AFTER treatment
– In some cases, the position to use is the one in which the joint
z Stop the treatment if it is too painful for the patient is least painful
z Use proper body mechanics
z Firmly & comfortably stabilize one joint segment,
z Use gravity to assist the mobilization technique if
usually the proximal bone
possible
– Hand, belt, assistant
z Begin & end treatments with Grade I or II oscillations – Prevents unwanted stress & makes the stretch force more
specific & effective

Treatment Force & Direction of

Treatment Direction
Movement
z Treatment force is applied as close to the z Treatment plane lies on
the concave articulating
opposing joint surface as possible surface, perpendicular to
z The larger the contact surface is, the more comfortable the a line from the center of
procedure will be (use flat surface of hand vs. thumb) the convex articulating
surface (Kisner & Colby, p.
226 Fig. 6-11)

z Direction of movement during treatment is

z Joint traction techniques
either PARALLEL or PERENDICULAR to the are applied
treatment plane perpendicular to the
treatment plane
z Entire bone is moved so
that the joint surfaces
are separated

z Gliding techniques are applied parallel to the treatment Speed, Rhythm, & Duration of
plane
z Glide in the direction in which the slide would normally occur for the Movements
desired motion
z Direction of sliding is easily determined by using the convex-concave z Joint mobilization sessions z Vary speed of oscillations
rule usually involve: for different effects
z The entire bone is moved so that there is gliding of one joint surface on
the other – 3-6 sets of oscillations z For painful joints, apply
z When using grade III gliding techniques, a grade I distraction should be – Perform 2-3 oscillations per intermittent distraction for 7-
used second 10 seconds with a few
z If gliding in the restricted direction is too painful, begin gliding – Lasting 20-60 seconds for seconds of rest in between
mobilizations in the painless direction then progress to gliding in
restricted direction when not as painful tightness for several cycles
– Lasting 1-2 minutes for pain z For restricted joints, apply a
z Reevaluate the joint response the next day or have the 2-3 oscillations per second minimum of a 6-second
patient report at the next visit z Apply smooth, regular stretch force, followed by
– If increased pain, reduce amplitude of oscillations oscillations partial release then repeat
– If joint is the same or better, perform either of the following: with slow, intermittent
z Repeat the same maneuver if goal is to maintain joint play
z Progress to sustained grade III traction or glides if the goal is to increase joint
stretches at 3-4 second
play intervals
 Patient Response Joint Traction Techniques
z May cause soreness z Technique involving pulling one articulating surface
z Perform joint mobilizations on alternate days to away from another – creating separation
allow soreness to decrease & tissue healing to z Performed perpendicular to treatment plane
occur z Used to decrease pain or reduce joint hypomobility
z Patient should perform ROM techniques z Kaltenborn classification system
z Patient’s joint & ROM should be reassessed after – Combines traction and mobilization
treatment, & again before the next treatment – Joint looseness = slack
z Pain is always the guide

Kaltenborn Traction Grading z Grade I traction should be used initially to reduce

chance of painful reaction
z Grade I (loosen)
– Neutralizes pressure in joint without actual surface z 10 second intermittent grade I & II traction can be
separation used
– Produce pain relief by reducing compressive forces
z Distracting joint surface up to a grade III & releasing
z Grade II (tighten or take up slack)
allows for return to resting position
– Separates articulating surfaces, taking up slack or
eliminating play within joint capsule
z Grade III traction should be used in conjunction with
– Used initially to determine joint sensitivity
mobilization glides for hypomobile joints
z Grade III (stretch) – Application of grade III traction (loose-pack position)
– Involves stretching of soft tissue surrounding joint – Grade III and IV oscillations within pain limitation to
– Increase mobility in hypomobile joint decrease hypomobility

References
z Houglum, P.A. (2005). Therapeutic exercise for
musculoskeletal injuries, 2nd ed. Human Kinetics:
Champaign, IL
z Kisner, C. & Colby, L.A. (2002). Therapeutic
exercise: Foundations and techniques, 4th ed. F.A.
Davis: Philadelphia.
z http://www.pt.ntu.edu.tw/hmchai/Kinesiology/KI
Nmotion/JointStructionAndFunciton.htm
z www.google.com (images)