Lecture No

02
Basics Of Manual
Therapy “B”
 IN THIS
LECTURE
 Kaltenborn’s Approach to Joint Play
Testing
 Normal grades of translatoric movement
 Pathological grades of
translatoric movement
 Maitland grading scale
 Manual grading of rotatory
movement
 End Feels
Associate Dean
Academics
 Kaltenborn’s Approach to Joint Play
Testing
 Kaltenborn developed his joint play
testing with an emphasis on straight line,
translatoric, movement within a joint.
 This testing is not truly oscillatory although
it is often repeated several times using
different speeds of movement.
 The examiner feels for abnormal resistance
to motion with a particular emphasis on
end- feel testing.
 GRADES OF TRANSLATORIC
MOVEMENT

 The translatoric movements of

traction and gliding are divided into
three grades.
 These grades are determined by
the amount of joint slack
(looseness and resistance).
The
"slack"
 The
 All joints have"slack"
a characteristic amount of
joint play movement before tissues
crossing the joint tighten.
 This looseness or slack in the capsule
and ligaments is necessary for normal
joint function.
 When gliding is performed, the slack is
taken up in the direction of joint gliding;
 when traction is performed, the slack
is taken up in the direction of
 The
"slack"
 Many factors influence the feel of joint slack
being taken up, including the ;
1. Particular anatomy of the joint being moved,
2. The size of the joint,
3. The amount of soft tissues crossing the joint,
4. The speed and smoothness of
movement
5. The skill with which you perform the
movement.
Grade I
(loosen)
 Kaltenborn’s
Grades
Grade I (loosen)
 Extremely small traction
force which produces no
appreciable increase in
joint separation
 Nullifying intra
articular pressure
 Reduce Friction b/w
joint surface during
gliding
Grade II (tighten or take
up slack)
 Kaltenborn’s
Grades
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
II
» Relieve pain. (Treatment takes place in the Slack
Zone)
» Increase or maintain movement. (Relaxation
mobilization can be applied within the entire Grade
range, including the Transition Zone.)
Grade III
(stretch)
 Kaltenborn’s
Grades
Grade III (stretch)
 Involves stretching of soft
tissue surrounding joint
 Increase mobility in hypomobile
joint
 Kaltenborn’s
Grades
Grade III (stretch)
» Grade lll stretching force applied
over a sufficient period of time.
» Resistance to movement
increases rapidly within the Grade
III range.
 PALPATING RESISTANCE TO NORMAL
MOVEMENT

As the therapist takes up the slack in the

tissues they will feel an increased resistance
to movement as they reach near the first
stop.
This resistance may develop quicker or slower,
and may be firmer or softer depending on the
specific anatomy of the joint and pathology it
may be experiencing.
 IDENTIFYING PATHOLOGICAL
MOVEMENT

 When abnormal movement is

present the first and final
stops to the movement will
change
 For the hypomobile joint
the stop will occur sooner
 For the hypermobile joint
the stop will occur later
IDENTIFYING PATHOLOGICAL
MOVEMENT
 USING TRANSLATORIC GRADES OF
MOVEMENT

 Grade I
 To relieve pain
 Grade II
 To test joint play traction & glide
movements
 To relieve pain
 To increase or maintain movement
 Grade III
 Test joint play end-feel
 To increase mobility
 MAITLAND GRADING
SCALE

 Grading based on amplitude of movement &

where within available ROM the force is applied.
 Grade I
 A small amplitude movement performed at the
beginning of range of movement
 Grade II
 A large amplitude movement performed within
resistance-free part of the available range
 MAITLAND GRADING
SCALE
 Grade III
 A large amplitude movement performed into resistance
or up to the limit of the available range
 Grade IV
 A small amplitude movement performed into
resistance or up to the limit of the available range
 Grade V – (thrust technique) - Manipulation
 A small amplitude high velocity thrust performed
usually, but not always, at the end of the available
range
Grades of Oscillations
(Maitland)
IS EVERY ABNORMAL JOINT
RANGE NEED
MOBILIZATION

Hypomobility or hypermobility are only

pathological findings if they are
associated with symptoms and a
pathological end- feel.
In joints with little range of
motion such as the carpal joints
or
single spinal segments, it may
be impossible or impractical to
measure range of motion with
a goniometer. ???

MANUAL GRADING OF ROTATORIC

MOVEMENT
MANUAL GRADING OF ROTATORIC
MOVEMENT (0-TO-6 SCALE)

o Ankylosed
1 Markedly hypomobile
2 Slightly hypomobile
3 Normal
4 Slightly Hypermobile
5 Markedly Hypermobile
6 unstable
 MANUAL GRADING OF ROTATORIC
MOVEMENT (0-TO-6 SCALE)

 The O-to-6 scale for manual grading of

rotatoric movement was originally based
on Stoddard's 1-to-4 scale and was later
revised and expanded by Paris.
Paris's expanded concept was first
presented at the 1977 IFOMT meeting
(Vail, CO) as part of the Kaltenborn-
Evjenth sessions.
A joint can be both hypomobile
in one direction and
hypermobile
in another .
 Passive range of movement
with overpressure is normally
greater than the
corresponding active
movement.
 NORMAL LIMITING FACTORS & END
FEELS

Unique anatomical structure of a joint

determines the direction & magnitude of
the joints ROM

37 19-Mar-19 RHS 221

 End-
feel
Quality of movement after
the first stop

STAR FIRST FINAL

T STOP STOP
 End
Feel

 The feeling experienced by an examiner as

a barrier to further motion, at the end of
passive ROM

 The ability to distinguish among the

various end feels helps the examiner to
identify the type of limiting structures
 End
Feel
QUALITY TEST
 Test end-feel with a slight additional
stretch after the first significant stop of a
passive movement .
QUANTITY TEST
• Overpressure applied after an
active movement .
 Normal End
Feels
End-Feel Structure Example

Soft Soft tissue Knee flex.

approximatio
n

Firm Muscular stretch Hip flex. with knee straight

Capsular stretch Ext. of MCP joints
Ligamentous stretch Forearm supination

Hard Bone contacting bone Elbow ext.

 Normal End
Feels

 Each joint movement has a characteristic

end- feel, depending on the anatomy of the
joint and the direction of movement tested

Normal end feels are pain free.

 Abnormal End
Feel

Decrease or increase in the ROM or

normal ROM exists but other structures
other than the normal anatomy stop joint
movement
 Abnormal (Pathologic) End
Feels
1. Hard
 An abrupt hard stop to movement when bone
contacts bone, when rough articular surfaces
pass over each other. Loose bodies,
degenerative joint disease, dislocations, or a
fracture.
2. Soft
 Boggy sensation that indicates the presence
of synovitis or soft tissue edema.
44 19-Mar-19 RHS 221
 Abnormal (Pathologic) End
Feels
3. Firm
 A elastic sensation or a hard arrest to
movements with some give,
indicating muscular, capsular or
ligamentous shortening.
4. Springy Block
 A reboundis seen or felt and indicates the
presences of an internal derangement.
45
e.g. knee with a torn men i s c us.
19-M a r-1 9 RHS 221
 Abnormal (Pathologic) End
Feels

5. Empty
 No sensation (end feel) before the end
of passive ROM due to pain. This may
be caused by:
 Extra-articular abscess
 a neoplasm (abnormal growth of tissue)
 acute bursitis
 joint inflammation
 fracture
 Abnormal (Pathologic) End
Feels

More examples:
a) Scar tissue imparts a firmer,
less elastic end-feel;
b) Muscle spasm produces a
more elastic and less soft
end-feel;
 With out measuring the
joint ROM you can say the
most restricted movement
axis is ?
 CAPSULAR
PATTERN
 The capsular pattern manifests itself as a
characteristic pattern of decreased movements at
a joint.
• When expressing the capsular pattern, a series of
three or four movements are listed in sequence:
the first movement listed is proportionally most
decreased, the second movement listed is next
decreased, and so on.
• For example:
Shoulder = external rotation-abduction-
 CAPSULAR
CAPSULAR
PATTERN

PATTERN