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Peripheral Joint Mobilization

Joint mobilization refers to manual therapy techniques that are used to modulate pain and treat joint dysfunctions that limit range of motion (ROM) by specifically addressing the altered mechanics of the joint.

Peripheral Joint Mobilization

The altered joint mechanics may be due to 1. Pain 2. Joint effusion, 3. Contractures or adhesions in the joint capsules or supporting ligaments, 4. Malalignment or subluxation of the bony surfaces.

Contractures and adhesions

Subluxation of joint

Terminology
Mobilization It is a passive joint movement for decreasing pain and increasing range of motion. Applied to joints and related soft tissues at varying speeds and amplitudes using physiological or accessory motions. Force is light enough that patients can stop the movements.

Terminology

Manipulation

It is a Passive joint movement for increasing joint mobility. Incorporates a sudden forceful thrust that is beyond the patients control.

Terminology
Physiological Movements Physiological movements are movements the patient can do voluntarily (e.g., the classic or traditional movements, such as flexion, abduction, and rotation). The term osteokinematics is used when these motions of the bones are described.

Terminology
Accessory Movements Accessory movements are movements in the joint and surrounding tissues that are necessary for normal ROM but that cannot be actively performed by the patient.

Terms that relate to accessory movements are component motions and joint play.

Terminology
Component motions Component motions are those motions that accompany active motion but are not under voluntary control. The term is often used synonymously with accessory movement. For example, motions such as upward rotation of the scapula and rotation of the clavicle, which occur with shoulder flexion.

Terminology
Joint play Joint play describes the motions that occur between the joint surfaces which allows the bones to move.

The movements are necessary for normal joint functioning through the ROM and can be demonstrated passively, but they cannot be performed actively by the patient.

Terminology
The movements include Rolling, sliding, spinning compression, and distraction, The term arthrokinematics is used when these motions of the bone surfaces within the joint are described.

Terminology
Roll Characteristics of one bone rolling on another are as follows. The surfaces are incongruent. New points on one surface meet new points on the opposing surface. Rolling is always in the same direction as the swinging bone motion whether the surface is convex or concave

Rolling

Terminology
Slide/Translation Characteristics of one bone sliding (translating) across another include the following. For a pure slide, the surfaces must be congruent, either flat or curved. The same point on one surface comes into contact with the new points on the opposing surface.

Terminology
The direction in which sliding occurs depends on whether the moving surface is concave or convex. Sliding is in the opposite direction of the angular movement of the bone if the moving joint surface is convex. Sliding is in the same direction as the angular movement of the bone if the moving surface is concave.

Sliding

Terminology
Spin Characteristics of one bone spinning on another include the following. There is rotation of a segment about a stationary mechanical axis. The same point on the moving surface creates an arc of a circle as the bone spins.

Terminology
Spinning rarely occurs alone in joints but in combination with rolling and sliding. Examples of spin occurring in joints of the body are the radiohumeral joint with pronation or supination

Terminology
Compression Compression is the decrease in the joint space between bony partners. Compression normally occurs in the extremity and spinal joints when weight bearing.

Terminology
Traction/Distraction Traction is a longitudinal pull. Distraction is a separation, or pulling apart. Whenever the surfaces are to be pulled apart, the term distraction, joint traction, or joint separation is used.

INDICATIONS FOR JOINT MOBILIZATION


Pain, and Spasm Joint Hypomobility Progressive Limitation Post traumatic joint stiffness

LIMITATIONS OF JOINT MOBILIZATION TECHNIQUES

Mobilization techniques cannot change the disease process of disorders such as rheumatoid arthritis or the inflammatory process of injury. In these cases, treatment is directed toward minimizing pain, maintaining available joint play, and reducing the effects of any mechanical limitations

CONTRAINDICATIONS AND PRECAUTIONS


The only true contraindications to mobilization techniques are Hyper mobility, Joint effusion, and Inflammation. Tumors

Maitland's Mobilization Technique


Graded Oscillation Techniques Dosages Grade I: Small-amplitude rhythmic oscillations are performed at the beginning of the range. Grade II: Large-amplitude rhythmic oscillations are performed within the range, not reaching the limit. Grade III: Large-amplitude rhythmic oscillations are performed up to the limit of the available motion and are stressed into the tissue resistance.

Maitland's Mobilization Technique


Grade IV: Small-amplitude rhythmic oscillations are performed at the limit of the available motion and stressed into the tissue resistance. Grade V: A small-amplitude, highvelocity thrust technique is performed to snap adhesions at the limit of the available motion.

Grades of Maitland's Mobilization

Maitland's Mobilization Technique


Uses

Grades I and II are primarily used for treating joints limited by pain. Grades III and IV are primarily used to improve the range of motion.

Kaltenborns Mobilization technique


Sustained Translatory Joint-Play Techniques 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. Kaltenborn called this taking up the slack.

Kaltenborns Mobilization technique

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.

Kaltenborns Mobilization technique


Uses Grade I distraction is used with all gliding motions and may be used for relief of pain. 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

Positioning and Stabilization


The patient and the extremity to be treated should be positioned so the patient can relax. Examination of joint play and the first treatment are initially performed in the resting position for that joint. Firmly and comfortably stabilize the proximal bone. Appropriate stabilization prevents unwanted stress to surrounding tissues and joints and makes the stretch force more specific and effective.

Treatment Force and Direction of Movement

The treatment force (either gentle or strong) is applied as close to the opposing joint surface as possible. The larger the contact surface, the more comfortable is the patient with the procedure. For example, instead of forcing with your thumb, use the flat surface of your hand.

The direction of movement during treatment is either parallel or perpendicular to the treatment plane.

Treatment Force and Direction of Movement


Distraction techniques are applied perpendicular to the treatment plane. The entire bone is moved so the joint surfaces are separated. Gliding techniques are applied parallel to the treatment plane.

Treatment Force and Direction of Movement

The direction of gliding is easily determined by using the CONVEX-CONCAVE RULE. If the surface of the moving bony partner is convex, the treatment glide should be opposite to the direction in which the bone swings. If the surface of the moving bony partner is concave, the treatment glide should be in the same direction

Concave - Convex Rule

Speed, Rhythm, and Duration of Movements Oscillations

Grades I and IV are usually rapid oscillations, like manual vibrations. Grades II and III are smooth, regular oscillations at 2 or 3 per second for 1 to 2 minutes. Vary the speed of oscillations for different effects such as low amplitude and high speed to inhibit pain or slow speed to relax muscle guarding.

Speed, Rhythm, and Duration of Movements Oscillations


Sustained For painful joints, apply intermittent distraction for 7 to 10 seconds with a few seconds of rest in between for several cycles. Note the response and either repeat or discontinue. For restricted joints, apply a minimum of a 6-second stretch force followed by partial release (to grade I or II), then repeat with slow, intermittent stretches at 3- to 4second intervals.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Shoulder Girdle Complex Glenohumeral Joint The concave glenoid fossa receives the convex humeral head. Stabilization Fixate the scapula with a belt or have an assistant help.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Glenohumeral Distraction Patient Position Supine, with arm in the resting position. Support the forearm between your trunk and elbow.

Hand Placement Use the hand nearer the part being treated (e.g., left hand if treating the patients left shoulder) and place it in the patients axilla with your thumb just distal to the joint margin anteriorly and fingers posteriorly.

Your other hand supports the humerus from the lateral surface.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Mobilizing Force With the hand in the axilla, move the humerus laterally.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Glenohumeral Caudal Glide, Indications To increase abduction (sustained grade III) Patient Position Same as for distraction.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Hand Placement Place one hand in the patients axilla to provide a grade I distraction. The web space of your other hand is placed just distal to the acromion process. Mobilizing Force With the superiorly placed hand, glide the humerus in an inferior direction.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Glenohumeral Caudal Glide Progression Indication To increase abduction. Patient Position Supine or sitting, with the arm abducted to the end of its available range. External rotation of the humerus should be added to the end-range position as the arm approaches and goes beyond 90.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Therapist Position and Hand Placement

With the patient supine, stand facing the patients feet and stabilize the patients arm against your trunk with the hand farthest from the patient. Slight lateral motion of your trunk provides grade I distraction. With the patient sitting, face the patient and cradle the distal humerus with the hand closest to the patient; this hand provides a grade I distraction. Place the web space of your other hand just distal to the acromion process on the proximal humerus.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Mobilizing Force With the hand on the proximal humerus, glide the humerus in an inferior direction.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Glenohumeral Posterior Glide, Indications To increase flexion; to increase internal rotation. Patient Position Supine, with the arm in resting position.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Therapist Position and Hand Placement Stand with your back to the patient, between the patients trunk and arm. Support the arm against your trunk, grasping the distal humerus with your lateral hand. This position provides grade I distraction to the joint. Place the lateral border of your top hand just distal to the anterior margin of the joint, with your fingers pointing superiorly. This hand gives the mobilizing force.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Mobilizing Force Glide the humeral head posteriorly by moving the entire arm as you bend your knees. Glenohumeral Posterior Glide Progression Indications To increase posterior gliding when flexion approaches 90; to increase horizontal adduction.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Patient Position Supine, with the arm flexed to 90 and internally rotated and with the elbow flexed. The arm may also be placed in horizontal adduction. Hand Placement Place padding under the scapula for stabilization. Place one hand across the proximal surface of the humerus to apply a grade I distraction. Place your other hand over the patients elbow. Mobilizing Force Glide the humerus posteriorly by pushing down at the elbow through the long axis of the humerus.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Glenohumeral Anterior Glide Indications To increase extension; to increase external rotation. Patient Position Prone, with the arm in resting position over the edge of the treatment table, supported on your thigh. Stabilize the acromion with padding. Supine position may also be used.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Therapist Position and Hand Placement Stand facing the top of the table with the leg closer to the table in a forward stride position. Support the patients arm against your thigh with your outside hand; the arm positioned on your thigh provides a grade I distraction. Place the ulnar border of your other hand just distal to the posterior angle of the acromion process, with your fingers pointing superiorly; this hand gives the mobilizing force.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Mobilizing Force Glide the humeral head in an anterior and slightly medial direction.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Glenohumeral External Rotation Progressions Indication To increase external rotation.

Techniques Because of the danger of subluxation when applying an anterior glide with the humerus externally rotated, use a distraction progression or elevation progression to gain range.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES

Distraction progression: Begin with the shoulder in resting position; externally rotate the humerus to end range and then apply a grade III distraction perpendicular to the treatment plane in the glenoid fossa. Elevation progression. This technique incorporates end-range external rotation.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Scapulothoracic Mobilization The scapulo thoracic articulation is not a true joint, but the soft tissue is stretched to obtain normal shoulder girdle mobility.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Indications To increase scapular motions of elevation, depression, protraction, retraction, rotation, upward and downward rotations, and winging. Patient Position If there is considerable restriction in mobility, begin prone and progress to side-lying, with the patient facing you. Support the weight of the patients arm by draping it over your inferior arm and allowing it to hang so the scapular muscles are relaxed.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Hand Placement Place your superior hand across the acromion process to control the direction of motion. With the fingers of your inferior hand, scoop under the medial border and inferior angle of the scapula. Mobilizing Force Move the scapula in the desired direction by lifting from the inferior angle or by pushing on the acromion process.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Elbow and Forearm Complex The elbow and forearm complex consists of four joints: humeroulnar, humeroradial, proximal radioulnar and distal radioulnar.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Humeroulnar Articulation The convex trochlea articulates with the concave olecranon fossa. Resting Position Elbow is flexed 70, and forearm is supinated 10.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Stabilization Fixate the humerus against the treatment table with a belt or use an assistant to hold it. The patient may roll onto his or her side and fixate the humerus with the contralateral hand if muscle relaxation can be maintained around the elbow joint being mobilized.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Humeroulnar Distraction and Progression Indications Pain control (grade I or II oscillation); To increase flexion or extension (grade III or IV).

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Patient Position Supine, with the elbow over the edge of the treatment table or supported with padding just proximal to the olecranon process. Rest the patients wrist against your shoulder, allowing the elbow to be in resting position for the initial treatment.

Hand Placement When in the resting position or at end-range flexion, place the fingers of your medial hand over the proximal ulna on the volar surface; reinforce it with your other hand.

When at end-range extension, stand and place the base of your proximal hand over the proximal portion of the ulna and support the distal forearm with your other hand.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Mobilizing Force Force against the proximal ulna at a 45 angle to the shaft of the bone. Humeroulnar Distal Glide (Fig. 5.28B) Indication To increase flexion.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Humeroradial Articulation The convex capitulum articulates with the concave radial head. Resting Position Elbow is extended, and forearm is supinated to the end of the available range. Stabilization Fixate the humerus with one of your hands.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Humeroradial Distraction Indications To increase mobility of the humeroradial joint; to manipulate a pushed elbow (proximal displacement of the radius). Patient Position Supine or sitting, with the arm resting on the treatment table.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Therapist Position and Hand Placement Position yourself on the ulnar side of the patients forearm so you are between the patients hip and upper extremity. Stabilize the patients humerus with your superior hand. Grasp around the distal radius with the fingers and thenar eminence of your inferior hand. Be sure your are not grasping around the distal ulna.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Mobilizing Force Pull the radius distally (long-axis traction causes joint traction).

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Humeroradial Dorsal/Volar Glides Indications Dorsal glide head of the radius to increase elbow extension; volar glide to increase flexion. Patient Position Supine or sitting with the elbow extended and supinated to the end of the available range.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Hand Placement Stabilize the humerus with your hand that is on the medial side of the patients arm. Place the palmar surface of your lateral hand on the volar aspect and your fingers on the dorsal aspect of the radial head.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Mobilizing Force Move the radial head dorsally with the palm of your hand or volarly with your fingers. If a stronger force is needed for the volar glide, realign your body and push with the base of your hand against the dorsal surface in a volar direction.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Proximal Radioulnar Joint, Dorsal/Volar Glides The convex rim of the radial head articulates with the concave radial notch on the ulna Resting Position The elbow is flexed 70 and the forearm supinated 35.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Stabilization Proximal ulna is stabilized. Indications Dorsal glide to increase pronation; volar glide to increase supination.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Patient Position Sitting or supine, with the elbow and forearm in resting position. Progress by placing the forearm at the limit of the range of pronation prior to administering the dorsal glide or at the limit of the range of supination prior to administering the volar glide.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Hand Placement Fixate the ulna with your medial hand around the medial aspect of the forearm. Place your other hand around the head of the radius with the fingers on the volar surface and the palm on the dorsal surface.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Mobilizing Force Force the radial head volarly by pushing with your palm or dorsally by pulling with your fingers.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Distal Radioulnar Joint, Dorsal/Volar Glides The concave ulnar notch of the radius articulates with the convex head of the ulna. Resting Position The resting position is with the forearm supinated 10. Stabilization Distal ulna.

Indications Dorsal glide to increase supination; volar glide to increase pronation.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Patient Position Sitting, with the forearm on the treatment table. Begin in the resting position and progress to end-range pronation or supination. Hand Placement Stabilize the distal ulna by placing the fingers of one hand on the dorsal surface and the thenar eminence and thumb on the volar surface. Place your other hand in the same manner around the distal radius.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Mobilizing Force Glide the distal radius dorsally or volarly parallel to the ulna.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Wrist Complex Radiocarpal Joint The concave distal radius articulates with the convex proximal row of carpals, which is composed of the scaphoid, lunate, and triquetrum. Resting Position The resting position is a straight line through the radius and third metacarpal with slight ulnar deviation. Stabilization Distal radius and ulna.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Radiocarpal Distraction Indications Testing; initial treatment; pain control; general mobility of the wrist.

Patient Position Sitting, with the forearm supported on the treatment table, wrist over the edge of the table.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Hand Placement With the hand closest to the patient, grasp around the styloid processes and fixate the radius and ulna against the table. Grasp around the distal row of carpals with your other hand. Mobilizing Force Pull in a distal direction with respect to the arm.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Radiocarpal Joint, General Glides, and Progression Indications Dorsal glide to increase flexion, Volar glide to increase extension, Radial glide to increase ulnar deviation, Ulnar glide to increase radial deviation.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Patient Position and Hand Placement Sitting with forearm resting on the table in pronation for the dorsal and volar techniques and in mid-range position for the radial and ulnar techniques. Mobilizing Force The mobilizing force comes from the hand around the distal row of carpals.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Patient and Therapist Positions The patient sits You stand and grasp the patients hand so the elbow hangs unsupported. The weight of the arm provides slight distraction to the joint (grade I), so you then need only to apply the glides.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Hand Placement Identify the specific articulation to be mobilized and place your index fingers on the volar surface of the bone to be stabilized. Place the overlapping thumbs on the dorsal surface of the bone to be mobilized. The rest of your fingers hold the patients hand so it is relaxed. To increase extension, the stabilizing index fingers are placed under the bone that is concave (on the volar surface), and the mobilizing thumbs are overlapped on the dorsal surface of the bone that is convex. To increase flexion, the stabilizing index fingers are placed under the bone that is convex (on the volar surface), and the mobilizing thumbs are overlapped on the dorsal surface of the bone that is concave.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Hand and Finger Joints Carpometacarpal and Intermetacarpal Joints of Digits IIV: Distraction Indication To increase mobility of the hand. Stabilization and Hand Placement Stabilize the respective carpal with thumb and index finger of one hand. With your other hand, grasp around the proximal portion of a metacarpal.

Mobilizing Force Apply long-axis traction to the metacarpal to separate the joint surfaces.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Carpometacarpal and Intermetacarpal: Volar Glide Indication To increase mobility of the arch of the hand. Stabilization and Hand Placement Stabilize the carpals with the thumb and index finger of one hand; place the thenar eminence of your other hand along the dorsal aspect of the metacarpals to provide the mobilization force. Mobilizing Force Glide the proximal portion of the metacarpal volar ward.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Carpometacarpal Joint of the Thumb The CMC of the thumb is a saddle joint. The trapezium is concave, and the proximal metacarpal is convex for abduction/ adduction. The trapezium is convex, and the proximal metacarpal is concave for flexion/extension.

Resting Position The resting position is midway between flexion and extension and between abduction and adduction.
Stabilization Fixate the trapezium with the hand that is closer to the patient.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Carpometacarpal Distraction (Thumb) Indications Testing; initial treatment; pain control; general mobility. Patient Position The patient is positioned with forearm and hand resting on the treatment table. Hand Placement Fixate the trapezium with the hand that is closer to the patient. Grasp the patients metacarpal by wrapping your fingers around it. Mobilizing Force Apply long-axis traction to separate the joint surfaces.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Carpometacarpal Glides (Thumb) Indications Ulnar glide to increase flexion; radial glide to increase extension; dorsal glide to increase abduction; volar glide to increase adduction.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Patient Position and Hand Placement The trapezium is stabilized by grasping it directly or by wrapping your fingers around the distal row of carpals. Place the thenar eminence of your other hand against the base of the patients first metacarpal on the side opposite the desired glide. Mobilizing Force The force comes from your thenar eminence against the base of the metacarpal.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Metacarpophalangeal and Interphalangeal Joints of the Fingers In all cases, the distal end of the proximal articulating surface is convex, and the proximal end of the distal articulating surface is concave.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Resting Position The resting position is in light flexion for all joints. Stabilization Rest the forearm and hand on the treatment table, fixate the proximal articulating surface with the fingers of one hand.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES


Metacarpophalangeal and Interphalangeal Glides and Progression Indications Volar glide to increase flexion dorsal glide to increase extension radial or ulnar glide (depending on finger) to increase abduction or adduction.

PERIPHERAL JOINT MOBILIZATION TECHNIQUES

Mobilizing Force The glide force is applied by the thumb against the proximal end of the bone to be moved. Progress by taking the joint to the end of its available range and applying slight distraction and the glide force.

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