Joint Mobilization

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Joint motion is often lost due to injury
Contracture of inert connective tissue Resistance of contractile tissue to stretch

May result in joint hypomobility To regain motion
Joint mobilization

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved

Relationship Between Physiological and Accessory Motion
Biomechanics of joint motion
Page 174 Therapeutic Exercise (White book)

Physiological motion
Result of concentric or eccentric active muscle contractions Also referred to as osteokinetic motion Bones moving about an axis or through flexion, extension, abduction, adduction or rotation

Accessory Motion
Motion of articular surfaces relative to one another Generally associated with physiological movement Necessary for full range of physiological motion to occur Ligament and joint capsule involvement in motion
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Stretching techniques must be utilized in order to correct physiological motion deficits
Most effective at end of physiological range of motion Utilizes long lever arms to apply stretch of muscles

To improve accessory motion mobilization techniques are required
Used to correct tight inert tissues Multidirectional activity that can be effective at any point in range Utilize short lever arms, resulting in less stress being applied to ligamentous structures
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Joint Arthrokinematics
Involves 3 components
Spin
Motion that occurs about some stationary longitudinal mechanical axis Radial head at the humeroradial joint

Roll
A series of points on one articulating surface come into contact with a series of points on another surface Rocking chair analogy Femoral condyles rolling on tibial plateau Occurs in direction of movement
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Glide (translation)
Specific point on one articulating surface comes into contact with a series of points on another articulating surface Occurs when performing an anterior drawer of knee (tibial plateau sliding anteriorly relative to femoral condyles) Pure gliding requires congruent surfaces Direction of movement determined by shape of articulating surface (convex/concave)

Joint motion will often involve a combination of these components
Rolling and gliding generally occur together
Not always proportional or in same direction

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Convex-Concave Rule
Relationship of articulating surfaces associated with gliding If concave joint is moving on stationary convex surface ± glide occurs in same direction as roll If convex surface is moving on stationary concave surface ± gliding occurs in opposite direction to roll Necessary to understand in order to determine appropriate treatment direction
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Joint Positions
Resting position
Maximum joint play- position in which joint capsule and ligaments are most relaxed Evaluation and treatment position utilized with hypomobile joints

Loose-packed position
Articulating surfaces are maximally separated Joint will exhibit greatest amount of joint play Position used for both traction and joint mobilization

Close-packed position
Maximal contact of articulating surfaces

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Mobilization and traction utilize translation movements of joint surfaces relative to one another Treatment occur perpendicular or parallel to treatment plane Mobilization techniques involve glides that translate along the treatment plane Traction ± moves perpendicular to treatment plane

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Joint Mobilization Techniques
Used to improve joint mobility or decrease joint pain by restoring accessory motion Used to attain mechanical or neurophysiological treatment goals
Pain reduction Decrease muscle guarding Stretching or lengthening tissue surrounding a joint Reflexogenic effects
Facilitate muscle tone or stretch reflex

Proprioceptive effects

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Accessory motion can be hypo-, normal, or hypermobile Joints have range with anatomical limits (bony and soft tissue) With hypomobile joints motion stops at point short of anatomical limits
Pathological point of limitation

Hypermobile joint move beyond anatomical limits
Due to laxity Treat with strengthening and stability exercises, bracing, taping, or splinting
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To restore motion in hypomobile joints tissue deformation occurs Tissue stretch within elastic range does not produce permanent structural change Stretching in plastic range cause permanent structural changes Traction and joint mobilization can be used to stretch tissue and break tissue adhesions
Treatments generally involve slow, small amplitude movements
Joint mobilizations involve small amplitude oscillations

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Maitland Joint Mobilization Grading Scale
Grade I
Small amplitude movement at the beginning of the range of movement Used to manage pain and spasm

Grade II
Large amplitude movement within midrange of movement Utilize when quick oscillation induces spasm or when slowly increasing pain restricts movement halfway into range

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Grade III
Large amplitude movement up to point of limitation (PL) in the range of movement Used when pain and resistance from spasm, inert tissue tension or tissue compression limit movement near end of range

Grade IV
Small amplitude movement at very end of range Used when resistance limits movement in absence of pain

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Grades of Movement

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All joint mobilizations follow the convexconcave rule If mobilization in the appropriate direction exacerbates pain or stiffness the technique should be applied in the opposite direction until tolerance to the appropriate direction is achieved Joint mobilization sessions usually involve 3-6 sets of oscillations lasting 20-60 seconds, 1-3 oscillations per second

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Indications for Mobilization
Grades I and II are used primarily for pain Grades III and IV can be utilized for stiffness Pain must be treated prior to stiffness Small amplitude oscillations are utilized to stimulate mechanoreceptors, limiting pain perception Painful conditions can be treated daily Stiff or hypomobile joints should be treated 34 times per week ± alternate with active motion exercises
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Pain prior to resistance being applied
Avoid mobilization techniques

Pain elicited upon resistance to motion applied
Grade I and II mobilizations

Resistance application prior to indication of pain
Grade III and IV

Athlete and athletic trainer must utilize appropriate positioning to ensure safe and effective treatment

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Pain and Resistance

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Contraindications for Mobilization
Should not be used haphazardly Avoid the following
Inflammatory arthritis Malignancy Bone disease Neurological involvement Bone fracture Congenital bone deformities Vascular disorders
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Joint Traction Techniques
Technique involving pulling one articulating surface away from another ± creating separation Performed perpendicular to treatment plane Used to decrease pain or reduce joint hypomobility Kaltenborn classification system
Combines traction and mobilization Joint looseness = slack
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Kaltenborn Traction Grading
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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Grade I traction should be used initially to reduce chance of painful reaction 10 second intermittent grade I and II traction can be used Distracting joint surface up to a grade III and releasing allows for return to resting position Grade III traction should be used in conjunction with mobilization glides for hypomobile joints
Application of grade III traction (loose-pack position) Grade III and IV oscillations within pain limitation to decrease hypomobility
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