Joint Mobilization Techniques

Joint Mobilization Techniques

• Joint mobilization techniques aim to enhance joint mobility or alleviate joint pain by restoring accessory movements, leading to full, unrestricted, pain-free range of motion (ROM).
• These techniques can be applied for mechanical or neurophysiological treatment goals.
• Joint mobilization can help to reduce pain and decrease muscle guarding.
• It can be used to stretch tissue around a joint, especially capsular and ligamentous tissue.
• Joint mobilization has proprioceptive effects that improve postural and kinesthetic awareness.

Effects of Joint Mobilisation

• Joint mobilization stimulates mechanoreceptors to reduce pain.
• Joint mobilization reduces muscle spasm and muscle guarding through nociceptive stimulation.
• It heightens awareness of position and motion through afferent nerve impulses.
• Distraction or small gliding movements introduce synovial fluid movement.
• Mobilization improves nutrient exchange during joint swelling and immobilization

Mechanical Effects

• Mobilizations improve the mobility of hypomobile joints by addressing adhesions and thickened connective tissue resulting from immobilization.
• They maintain the extensibility and tensile strength of articular tissues.
• Cracking noises can sometimes occur during mobilization.

Effects of Joint Motion

• Joint motion encourages biological activity by circulating synovial fluid.
• Synovial fluid delivers nutrients to the avascular articular cartilage of joint surfaces and intra-articular fibrocartilage of the menisci.
• Atrophy of articular cartilage can occur shortly after joint immobilization.
• Joint motion maintains the tensile strength of articular and periarticular tissues.
• Immobilization can lead to fibrofatty proliferation, causing intra-articular adhesions.
• Immobilization also results in biochemical changes in tendon, ligament, and joint capsule tissue, which causes joint contractures and ligamentous weakening.
• Afferent nerve impulses from joint receptors send information to the central nervous system.
• This provides awareness of position and motion.
• Injury or joint degeneration can lead to a reduction in proprioceptive feedback which may affect balance.

Limitations of Joint Mobilization Techniques

• Joint mobilization can not alter disease processes like rheumatoid arthritis or the inflammatory process of an injury.
• Treatment is geared towards reducing pain, preserving available joint play and minimizing mechanical limitations.

Measurements

• Movement during ROM is quantifiable through various measurement techniques.
• Each joint possesses a motion scope with an anatomical limit (AL) dictated by bone structure and enveloping soft tissues.
• Accessory movements can be hypomobile, normal, or hypermobile.
• Hypomobile joint motion ceases at the pathological point of limitation (PL), prior to the anatomical limit, due to pain, spasm, or tissue resistance.
• Hypomobile joints often respond positively to mobilization and traction techniques.
• Hypermobile joints surpass their anatomical limit due to laxity in surrounding structures and should be treated with strengthening and stability exercises and taping, splinting, or bracing if necessary.

Stretching and Adhesions

• Mobilization and traction can stretch tissue and break adhesions.
• Inappropriate application can lead to tissue damage and joint sprains.
• Effective treatment incorporates slow, small amplitude movements.
• Amplitude describes the passive distance a joint moves within its full ROM.
• Mobilization uses small amplitude oscillating motions for gliding or sliding one joint surface in a specific direction within a certain part of the range.
• Maitland described grades of oscillation for joint mobilization.
• Amplitude for oscillations are between a beginning point (BP) and the anatomical limit (AL).

Five Mobilization Grades

• Grading is based on the amplitude of movement and where in the available ROM the force is applied.
• Grade I: Small amplitude, rhythmic oscillation at the start of ROM, for when pain and spasm limit movement, in the early range of motion.
• Grade II: Large amplitude, rhythmic oscillating movement through midrange, for managing pain and spasm.
• Grade III: Large amplitude, rhythmic oscillation up to the point of limitation (PL), to gain motion within the joint and stretch capsule and CT structures.
• Grade IV: Small amplitude at the very end of the range of movement, at the PL, used to gain motion, when resistance limits movement.
• Grade V: Small amplitude, quick thrust at the end of the range of movement (end of physiological limit), often with a popping sound/manipulation, when minimal resistance limits movement. It is most effective with velocity over force and cannot be stopped voluntarily and can be under anesthesia.

Convex-Concave Rule

• The appropriate direction for oscillating glides is determined by the convex-concave rule.
• If the concave joint surface is stationary, gliding the convex segment should be directed opposite to the restriction of joint movement.
• Applying it conversely, with a stationary convex articular surface, gliding the concave segment aligns with the restriction direction of joint movement.

Indications for Joint Mobilization

• Joint mobilization may be indicated for pain, muscle guarding, spasm, reversible joint hypomobility, positional faults/subluxations, progressive limitation, and functional immobility.

Indications for Mobilization Grades

• Grades I and II are primarily used for pain to be treated prior to stiffness; painful conditions can be treated daily.
• Small amplitude oscillations stimulate mechanoreceptors, limiting pain perception.
• Grades III and IV are primarily used to increase motion of stiff or hypomobile joints 3-4 times weekly while alternating with active motion exercises.

Mobilization for Pain, Muscle Guarding, and Spasm

• Neurophysiologic and mechanical effects can address painful joints, reflex muscle guarding, and muscle spasm through gentle joint-play techniques.
• Small-amplitude oscillatory and distraction movements stimulate the mechanoreceptors that may inhibit the transmission of nociceptive stimuli at the spinal cord or brain stem levels.
• Gentle joint-play techniques maintain nutrient exchange, preventing painful and degenerating stasis effects.

Reversible Joint Hypomobility Mobilization

• Reversible joint hypomobility is treated with progressively vigorous joint-play stretching techniques to elongate hypomobile capsular and ligamentous connective tissue.

Positional Fault/Subluxation Mobilization

• A malposition of one bony partner with respect to its opposing surface may result in limited motion or pain after a traumatic injury, periods of immobility, or muscle imbalances.
• Manipulations are used to reposition dislocations like a pulled elbow or capitate lunate subluxation.

Progressive Limitation Mobilization

• Diseases that progressively limit movement can be treated with joint-play techniques, maintaining available motion and slowing down mechanical restrictions.

Functional Immobility Mobilization

• When a patient cannot functionally move a joint for a period of time, it is treated with nonstretch gliding or distraction techniques to maintain joint play and prevent degeneration.

Contraindications for Mobilization

• Contraindications include inflammatory arthritis (such as Ankylosing spondylitis, Lupus, or Gout), malignancy, osteoporosis, ligamentous rupture, and hypermobility due to capsule or ligament laxity.
• Other contraindications include bone disease, recent/unhealed bone fractures, congenital bone deformities (club foot), and acute infective/inflammatory arthritis (septic arthritis).
• Swelling (effusion) from trauma or disease may indicate bleeding within the joint from trauma or diseases such as hemophilia, requiring aspiration to minimize its necrotizing effect.

Mobilization for Joint Effusion

• Avoid stretching a swollen joint with mobilization or passive stretching techniques.
• The capsule is already stretched to accommodate extra fluid, and limited motion is a response to pain rather than shortened fibers.
• Gentle oscillating motions block the transmission of pain stimuli for improved fluid flow and joint play.

Joint Traction Techniques

• Kaltenborn's system uses traction combined with mobilization to ease pain or mobilize hypomobile joints.
• All joints have play or looseness.
• Kaltenborn calls this slack, and it is necessary for normal joint motion.
• The technique is performed perpendicular to the treatment plane and involves pulling one articulating surface away from another and it decreases pain or joint hypomobility.
• Traction should be perpendicular to the treatment plane while glides are parallel to the treatment plane.

Kaltenborn Traction Grading

• Grade I (loosen): Neutralizes pressure in the joint without separation to produce pain relief by reducing the compressive forces, used with all mobilization grades.
  • Small amplitude, small tension on the capsule and supporting structures to decrease pain (slackness).
• Grade II (tighten or take up slack): Separates surfaces, taking up slack within the joint capsule.
• Used to determine joint sensitivity where, after its known, the dosage is either increased (for tissue resistance) or decreased (for pain) accordingly.
• Grade III (stretch): Stretches soft tissue around the joint with large amplitude traction to increase mobility in the hypo-mobile joint.
• Joint Traction Techniques:
  • Sustained: Mobilization continues for 20-30 seconds.
  • Oscillatory: Mobilization continues for 60-90 seconds.