MANUAL THERAPY &

PERIPHERAL JOINT
MOBILIZATION

SALONI SHETTY
 LEARNING OBJECTIVE

 Principles

 Grades

 Indications

 Contraindications

 Effects and uses

 NON- THRUST SUSTAINED JOINT PLAY
TECHNIQUES (KALTENBORN)

DOSAGES

 GRADE I (Loosen)- Small-amplitude distraction is applied

where no stress is placed on the capsule.

 GRADE II (Tighten)- Enough distraction or glide is applied to

tighten the tissues around the joint.

 GRADE III (Stretch)- A distraction or glide is applied with an

amplitude large enough to place stretch on the joint capsule and

surrounding periarticular structures.
 INDICATIONS

 Grade I- Pain relief

 Grade II- Initial treatment to determine how sensitive the joint is

 Gentle grade II distraction applied intermittently may be used to

inhibit pain.
 Grade II glides may be used to maintain joint play when ROM is
not allowed.
 Grade III distractions or glides are used to stretch the joint
structures and thus increase joint play
 The Kaltenborn Treatment Plane

 The direction of movement during treatment is either parallel or

perpendicular to the treatment plane. It was described by

Kaltenborn as a plane perpendicular to a line running from the
axis of rotation to the middle of the concave articular surface.
 Distraction techniques are applied perpendicular to the treatment

plane. The entire bone is moved so the joint surfaces are

separated.

 Gliding techniques are parallel to the treatment plane.

Translatory Joint Play Movements

 Traction

 Compression

 Gliding
 Mobilization with Movement (Mulligan)

 The concept of Mobilizations with movement (MWM) of

the extremities and SNAGS (sustained natural apophyseal

glides) of the spine were first coined by Brian R. Mulligan.

 It is concurrent application of pain free accessory mobilization

with active and/ or passive physiological movement.

 Passive end range stretching or overpressure is applied without

pain as barrier.
 Concept of Positional Fault
 Mulligan proposed that injuries or sprains might result in a minor
"positional fault" to a joint causing restrictions in physiological
movement.
 Normal joints have been designed in such a way that the shape of
the articular surfaces, the thickness of the cartilage, the
orientation of the fibers, ligaments and capsule, the direction of
pull of muscles and tendons, facilitate free but controlled
movement while simultaneously minimizing the compressive
forces generated by that movement.
 Alteration in any or all of the above factors would alter the joint
position or tracking during movement and would provoke
symptoms of pain, stiffness or weakness in the patient.
 NAGS- Natural Apophyseal Glides.

 SNAGS - Sustained Natural Apophyseal Glides.

 MWMS- Mobilization with Movements.

 NAGs

 Natural Apophyseal Glides

 NAGs are used for the cervical and upper thoracic spine.

 They consist of oscillatory mobilizations

 Mid-range to end range facet joint mobilizations applied antero-

superiorly along the treatment planes of the joint selected.

 Useful for grossly restricted spinal movement.

 SNAGs

 Sustained Natural Apophyseal Glides.

 SNAGs can be applied to all the spinal joints, the rib cage and the
sacroiliac joint.
 The therapist applies the appropriate accessory zygoepiphyseal
glide while the patient performs the symptomatic movement.
 This must result in full range pain free movement.

 SNAGs are most successful when symptoms are provoked by a

movement and are not multilevel.
 Peripheral MWM

 Once the aggravating movement has been identified, an appropriate

glide is chosen.

 Once the glide has been chosen it must be sustained throughout the

physiological movement until the joint returns to its original starting

position

 Mobilizations performed are always into resistance but without pain.

 Immediate relief of pain and improvement in ROM are expected.

 If this is not achieved, vary the glide parameters

 Principles and Applications

 Comparable sign

 Passive techniques

 Accessory glide with active comparable sign

 No pain

 Repetitions
 REFERENCES

 Therapeutic Exercise- Carolyn Kisner

THANK YOU