Joint Mobilization Concepts

• DPT 5900 is Musculoskeletal I, Spring 2025.

Course Objectives

• Define manual therapy.
• Define common biomechanical terms used in manual therapy like mobilization, manipulation, and soft tissue mobilization.
• Describe the forms and types of manual therapy.
• Identify figures that influenced the development of orthopedic manual therapy.
• Describe referred pain, contractile vs. non-contractile structures, and end feel.
• Discuss the convex-concave rule relative to joint mobilization.
• Use examination information to develop a plan of care.
• Define "comparable sign" and apply it within a clinical case scenario.
• Apply SINS (Severity, Irritability, Nature, Stage) to patient cases.
• Differentiate between "centralization" and "peripheralization."

Course Description

• This course is the first in a series of three focusing on the management of patients with musculoskeletal dysfunction.
• It includes the study of physical therapy, musculoskeletal examination, and evaluation within orthopedic manual physical therapy.
• Students integrate concepts of physical therapy management.
• Clinical applications and case-based learning emphasize patient management within a biopsychosocial spectrum.
• Students will learn reflections on action, and reflection in action, within the clinic and their musculoskeletal physical therapy interactions.
• The course prepares students to use the WHO's International Classification of Function model to identify, assess, and apply musculoskeletal physical therapy concepts in clinical scenarios and case-based learning.

Teaching Strategies

• Course content is delivered via a hybrid classroom model.
• Students gain first exposure to new material outside of class through reading assignments and lecture reviews.
• Active participation is expected in the learning process.
• Students should be prepared for learning activities to foster higher-level learning.

Integrity of Self

• Realize that personal growth and success is your own responsibility and choice

Professional Behaviors for the 21st Century

• Develop and implement solutions, and evaluate outcomes via Problem Solving.
• Effectively communicate vocally as well as non-verbally, read, write, and listen.
• Identify facts and differentiate them from inferences, assumptions, and irrelevant information using Critical Thinking.
• Work respectfully with colleagues, patients, and other healthcare professionals.
• Meet commitments in your professional actions and be accountable and responsible

Professional Behaviors for the 21st Century (Continued)

• Represent the profession effectively while promoting the growth/development of the Physical Therapy profession.
• Seek and provide constructive feedback.
• Maximize effectiveness by optimally managing time and resources.
• Manage stress using effective coping for self, patients/clients, and colleagues.
• Self-direct the learning process, incorporating new knowledge and skills.

Strategies for Success in DPT 5900

• Be responsible to yourself, peers, and the class.
• Discover your "WHY" to assist with motivation, "He who has a 'why' can bear any 'how'".
• Engage and participate consistently.
• Engage in computer use.
• Take notes and read daily.
• Appropriately ask questions.
• Practice new skills.
• Focus on your future.
• Develop and Implement daily, weekly, and monthly goals.

ICF: International Classification of Function

• Created by the World Health Organization (WHO).
• Describes health as components of biological, psychological, and contextual (spiritual, social, financial) factors that influence the health of the individual.

Disablement Concepts

• Nagi: Active pathology interrupts normal processes.
• Impairment includes anatomical, physiological, or psychological abnormalities.
• Functional Limitation is a limitation in performance at the individual level.
• Disability limits performance of social roles.
• ICF: Health Conditions are diseases, disorders, and injuries.
• Body Functions are physiological functions of body systems.
• Body Structures are anatomical parts of the body.
• Impairments are problems in body function or structure.
• Activity is the execution of a task or action by an individual.
• Activity Limitation contains difficulties an individual may have in executing activities.
• Participation consists of involvement in a life situation.
• Participation Restriction has problems an individual may experience in involvement in life situations.

Patient Perspective

• Every patient has a unique story and potential beyond their diagnosis.

History of OMPT/OMT

• History of manual therapy required reading from Dutton, and Cookson & Kent.

Background of Orthopedic Manual Therapy

• OMT is the study of anatomy, mechanics, and pathology, including evaluation and treatment techniques for the neuromusculoskeletal system.
• Challenges to OMT involve vocabulary differences, novice clinicians facing significant challenges and focus on techniques rather than clinical reasoning.

The Role of Touch in OMPT

• Touch facilitates a primary healing modality.
• Tactile analgesia can adjust pain levels.
• Flesh-to-flesh contact cannot be compensated for.

Definition of Orthopedic Manual Therapy (OMT)

• OMT is the study of anatomy, mechanics and pathology, and the use of evaluative/treatment techniques for neuromusculoskeletal system dysfunction.
• An excellent orthopedic clinician demonstrates excellent technical skills, combined with excellent people (interpersonal) skills.

Historical Perspective

• In ancient Egypt and Asia, "bone setters" practiced without training, resetting bone fractures and dislocations.
• In 1656, Friar Thomas published "The Complete Bone-Setter."
• In the 19th-century, Pehr Ling used movement as treatment.
• First official mention of "physical therapy."
• Gustav Zander was a Swedish physician in the 19th/20th century.

Manual Intervention Historical Leaders

• Cyriax
• Mennell
• Osteopathic medicine.
• Maitland
• Kaltenborn
• McKenzie
• Paris
• O'Sullivan and Butler
• Janda
• Grimsby
• Mulligan
• Sahrmann
• Others

James Cyriax

• James Cyriax was a British MD was born in the 1940s and popularized in the 1960’s founded on a philosophical basis.
• All pain has an anatomical source arising from a lesion.

Cyriax: all treatment

• Must reach the pain source.
• Must benefit the pain source if the diagnosis is correct.
• Identify the lesion, Symptoms will decrease.
• Consider the pitfall of referred pain.

Referred Pain vs MS Disorders (Cyriax)

• Spinal cord or dura matter compression causes injury.
• Evaluation must identify the site of the lesion.
• Biggest obstacle in the evaluation are MS (Musculoskeletal) disorders.

Evaluation Framework of soft tissue dysfunctions (Cyriax)

• **
• Contractile vs. non-contractile tissues.
• Assess Active & Passive movement.
• Perform resisted physiologic tests in addition to a neurological exam and palpation.
• During inspection a posture assessment can be performed.
• Cyriax believed that back and neck pain result from faulty posterior and lateral disc protrusion

Evaluation Framework : Active & Passive Movements (Cyriax)

• Active Movement: Assesses ROM and muscle power, involving both contractile and non-contractile elements.
• Passive Movement: Assesses non-contractile elements.
• It is best if patient is relaxed, and provides information on both assessment and assessment
• Two challenges: The patient has to relax and the clinician has to achieve / find end-range

Evaluation Framework : End Feel

• Normal End Feels
• Bone to bone or a hard, abrupt stop
• Soft tissue approximation is soft restriction of movement
• Tissues stretch with a springy and stretchy restriction.
• Abnormal End Feels
• Less stretchy in the expected end of the range motion.
• Boggy Produced by a viscous fluid that created a squishy sensation
• There is no resistance with an empty bone. (Often Stopped at patient's request)
• Restriction in the short range of movement.
• Bone to bone (normal limits)

Resisted Testing (Cyriax)

• Used for contractile structures only.
• It is important that the patient is stabilized if NO movement has been done. (Isometric exercise) Stress must be eliminated on surrounding tissues.
• You should not cross multiply joints.
• Identifies pain and/or weakness.
• Resisted isometrics is not equivalent to manual muscle testing.

Isometrics Interpretation

• Tests: resistive isometrics
• Strong & painful • Minimal/minor tendon/muscle damage
• Weak & painful • Partial tear
• Strong & painless Multiple options
• No lesion
• Lesion not involving contractile structures Lesion not involving MSK system • – multiple options – multiple options
• Lesion not involving MSK system
• Referred pain
• Weak & painless
• Complete tear &/or entrapment of nerve

Interpretation of Limited ROM

• Capsular pattern • Limitations in ROM occur in predictable proportions (Cyriax) Specific to each joint • Limitations in capsular pattern = arthritis (typically)
• Non-capsular Pattern
• Limitations in the other proportions • • •
• Ligamentous
• Capsular adhesion
• Bursitis/ internal derangement

Evaluation of The Atlanto-Occipital

Extension and Side flexion are both equally limited

Evaluation of the Hip

The most limited movements in this region are flexion, abducted and medial rotation is most limited

Intervention : Historical View

• Historical View point interventions focused on
• Traction
• Manual
• Mobilization, and manipulation
• Friction Massage
• Injection
• Patient Education

John Mennell

• His work in the 1960s and 1970s supported Physical therapy and was based on a philosophical basis.
• He believed that Joint dysfunction is sign of both pathology and the source of the disease.
• Joint manipulation can restore normal joint play of joints.

Mennell Evaluation Frameworks

• Include Inspection and Observation as well as palpation.
• Include observation of active movements.
• Muscle exam and special tests for both
• Interpretation of findings is based joint dysfunction

Evaluation framework- Mennell

• Patient has to be be both relaxed and completely supported.
• It is important to relax through examination to maintain a comfortable grasp
• Test only one join at a time and avoid rushing.
• Test the safe side first.
• Movements must be normal
• Movements shouldn’t cause discomfort.

Mennell's Intervention Framework

• Used Manipulation and mobilization in PT settings
• Focus of exercise training.
• Patient Education should also be used in this setting.

Freddy Kaltenborn

• Norwegian trained with Alan stoddard.
• Worked extensively with Siriax

Kalternborn Philosophy

• Ovoid VS Sellar which are both used Interchangeably.
• Bone movement and glide are on the same direction of same bones.
• Bone movement and glide are on the the same direction of opposite bones.
• Used closed pack and lose positions.

5x5 Framework

• To effectively treat joint pain the following criteria.
• History
• Patients current
• Previous history of joint problems
• Social background
• Medical. (Surgical)
• Patient
• Family
• Current history

5x5 Framework (Physical Exams)

• Inspection for the same movement of bones
• Resisted exercises
• Palpation (Sensation of joints)
• Neurological test to test muscles. & Sensation
• Special test to test for pain and inflammation.

Evalauation Frameworks Kaltenborn

• It’s important to assess soft tissue changes as will.
• Restrictions as well as assessing restrictions.
• Is the patient comfortable during the exam.

Kalternborn Intervention Frameworks

• Exercises. PNF
• Traction Distraction
• Soft tissue Mobilization
• Manipulation
• Patient Education to maintain.

Geoffery Maitland : Historical Background

• Geofrey Maitlen was an Australian born Physical therapist in the 1970s founded for Manipulative Physiology.
• His main focus was a non- pathological orientation to the treatment with the intention to minmize symptoms in mind.
• He was known for Clinical Reasonings.

Philosophical Approach

• The patient provides both commitment and understanding.
• Theory can become a critical and clinical thinker.
• THE pain will lead to the reproduction of this pain
• Continual Assessment can lead to the prove of differential asessment

How to Evaluate Framework

• Observation.
• Functional tests.
• Muscle Isometric Strength
• Assess Accessory of Bones
• Palpation
• Nero Exams
• SINS can be a test to measure problems.

Evaluation Framework : Behaviour

• How severe to evaluate framework to test a person
• How Irritable is a person
• How can u provoke a person
• what makes them worse

This quiz assesses understanding of joint mobilization, including concave-convex rules, roll and glide relationships, and proper technique. It covers glenohumeral flexion, hip extension, ankle plantarflexion, and the use of muscle energy techniques. It also tests knowledge of the therapist's role during joint mobilization.