TherEx1 - Week 2 - Stretching for Impaired Mobility
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Questions and Answers

What is the main reason for avoiding passive stretching of a swollen joint during joint mobilization?

  • Swollen joints are less responsive to treatment.
  • It can lead to muscle atrophy.
  • It is always harmful regardless of condition.
  • The capsule is already on stretch. (correct)

    • Which of the following conditions requires extreme caution during joint mobilization?

  • Mild joint stiffness
  • Unhealed fractures (correct)
  • Transient pain relief
  • Normal joint mobility

    • What is a significant risk associated with performing forceful mobilization techniques on individuals with systemic connective tissue diseases?

  • Improved joint flexibility
  • Ruptured tissue and instability (correct)
  • Enhanced muscle strength
  • Increased range of motion

    • In what situation is joint mobilization indicated despite the presence of pain?

    <p>When pain is manageable with gentle techniques</p> Signup and view all the answers

    What is the primary concern when mobilizing joints in elderly individuals?

    <p>Diminished circulation and weakened connective tissue</p> Signup and view all the answers

    When is mobilization after surgery particularly discouraged?

    <p>Immediately following surgery if the tissue is not healed.</p> Signup and view all the answers

    What type of diseases may complicate the joint mobilization process leading to potential injuries?

    <p>Systemic connective tissue diseases</p> Signup and view all the answers

    What does the stress-strain curve illustrate regarding connective tissue?

    <p>The mechanical strength and energy storage properties of connective tissue under stress loads</p> Signup and view all the answers

    Which of the following best summarizes the term 'strain' in a clinical context?

    <p>The total deformation or lengthening resulting from applied stress</p> Signup and view all the answers

    What factors should be considered as contraindications for stretching?

    <p>Joint instability and recent fractures</p> Signup and view all the answers

    Which statement accurately describes mechanical stress in the context of soft tissue?

    <p>It refers to the internal resistance that soft tissue provides against external loading</p> Signup and view all the answers

    What are the determinants of stretching that contribute to effective stretching techniques?

    <p>Duration, intensity, and frequency of the stretch applied</p> Signup and view all the answers

    What is the clinical significance of understanding collagen tissue changes in relation to the stress-strain curve?

    <p>To predict the mechanical properties and adaptive responses of connective tissue</p> Signup and view all the answers

    What is the primary purpose of adjuncts to stretching?

    <p>To enhance the effectiveness of stretching protocols</p> Signup and view all the answers

    When should stretching techniques ideally be incorporated into a rehabilitation session?

    <p>During the cool-down phase to enhance relaxation</p> Signup and view all the answers

    Which of the following represents a common precaution for implementing stretching techniques?

    <p>Maintain controlled movement to avoid injury</p> Signup and view all the answers

    Which statement accurately describes the joint glide/mobilization technique?

    <p>Force is applied close to the joint surface at an intensity compatible with the pathology.</p> Signup and view all the answers

    What occurs during joint compression in the context of joint mechanics?

    <p>It typically involves weight bearing in extremities and spinal joints.</p> Signup and view all the answers

    In arthrokinematics, which motion must occur alongside roll and spin for normal movement?

    <p>Glide</p> Signup and view all the answers

    What is the effect of long axis traction on joints?

    <p>It assists in reducing joint stiffness and improves range of motion.</p> Signup and view all the answers

    Which best describes the approach to joint mobilization techniques?

    <p>They aim for specific small amplitudes targeting restricted portions.</p> Signup and view all the answers

    What is a contraindication to stretching related to joint stability?

    <p>Shortened soft tissues</p> Signup and view all the answers

    Which statement is correct regarding the effectiveness of stretching?

    <p>Stretching does not prevent injuries and isn't optimal before vigorous exercise.</p> Signup and view all the answers

    Which of the following is NOT a condition that contraindicates stretching?

    <p>Previous stretching experience</p> Signup and view all the answers

    What is the recommended direction to stretch the glenohumeral external rotators?

    <p>Move into external rotation</p> Signup and view all the answers

    Shortened soft tissues can allow individuals with which condition to perform special functional skills?

    <p>Severe muscle weakness or paralysis</p> Signup and view all the answers

    What is an outcome of stretching that may not be beneficial for all individuals?

    <p>Increased muscle strength</p> Signup and view all the answers

    Which of the following is true about performing a stretch to increase flexibility?

    <p>It should involve moving in the opposite direction of the muscle's action.</p> Signup and view all the answers

    What type of intervention is considered an adjunct to stretching?

    <p>Heat application</p> Signup and view all the answers

    Which of these muscles is NOT typically associated with external rotation of the shoulder?

    <p>Subscapularis</p> Signup and view all the answers

    What should be avoided if a patient has an incomplete bony union?

    <p>Stretching</p> Signup and view all the answers

    What is the primary characteristic of static progressive stretching?

    <p>It progressively increases the stretch force over time.</p> Signup and view all the answers

    Which type of stretching is defined by short bursts of force that are applied and released repeatedly?

    <p>Cyclic stretching</p> Signup and view all the answers

    What factor should NOT be considered when determining the frequency of stretching?

    <p>Personal fitness level</p> Signup and view all the answers

    What defines ballistic stretching and makes it potentially unsafe for the average individual?

    <p>It applies fast and forceful intermittent stretch.</p> Signup and view all the answers

    What best describes active stretching?

    <p>It incorporates repeated end range contractions of the opposing muscle.</p> Signup and view all the answers

    Which mode of stretching is performed by a therapist or caregiver?

    <p>Manual stretching</p> Signup and view all the answers

    Why is the speed of stretch significant during stretching exercises?

    <p>Slow and controlled stretches minimize the risk of injury.</p> Signup and view all the answers

    What is an essential consideration for determining stretch frequency?

    <p>Age and tissue response.</p> Signup and view all the answers

    What distinguishes cyclic stretching from ballistic stretching?

    <p>Cyclic stretching is safer and less intense.</p> Signup and view all the answers

    Which statement about the muscle spindle's sensitivity is correct?

    <p>It is sensitive to the velocity of muscle length changes.</p> Signup and view all the answers

    Study Notes

    Introduction to Therapeutic Exercise

    • The presentation covers PTA Therapeutic Exercise, specifically stretching for impaired mobility, part 2.
    • The course is offered by Stanbridge University in 2022.

    Road Map

    • Students should understand the stress-strain curve and its clinical relevance by the end of this section.
    • Students should be able to summarize the properties of soft tissue and their response to stretch.
    • They should comprehend how changes in collagen tissue affect the stress-strain curve.
    • Additionally, students must know indications, precautions, and contraindications of stretching.
    • Students should be able to describe determinants of stretching.
    • They should be able to explain proper stretching technique timing within a session.
    • Students should be able to state the adjuncts to stretching.
    • Students should be proficient in applying or teaching assigned stretches in the lab.

    Outline

    • The outline covers properties of soft tissue, response to immobilization and stretch, stretching indications and contraindications, determinants and types of stretching exercises, precautions for stretching, procedural guidelines for application of stretching interventions, and adjuncts to stretching.

    Stress-Strain Curve: What Is It?

    • The stress-strain curve illustrates the mechanical strength of structures.
    • It is used to understand how connective tissue responds to stress.
    • Application of a tensile force causes a structure to elongate.
    • The curve reveals strength properties, stiffness, and the energy storage capacity before failure.

    Stress and Strain

    • Stress is defined as force per unit area.
    • Mechanical stress represents internal resistance to external loads.
    • Strain is the deformation or lengthening that occurs when a load or stretch force is applied.

    Kinds of Stress

    • Tension: Force applied perpendicular to the cross-sectional area of tissue, moving away from the tissue (stretching, muscle contraction).
    • Compression: Force applied perpendicular to the cross-sectional area of tissue, moving toward the tissue (pushing two ends of a joint together, wrapping a bandage).
    • Shear: Force applied parallel to the cross-sectional area of tissue (rubbing across skin).

    Stress-Strain Curve Definitions

    • Elasticity: The ability of soft tissue to return to its pre-stretch resting length after a short stretch.
    • Viscoelasticity: A time-dependent property of soft tissue that initially resists deformation.
    • Plasticity: The tendency of soft tissue to assume a new and greater length after a stretch.

    Stress-Strain Curve Definitions: Toe Region

    • The toe region shows considerable deformation without much force.
    • Collagen fibers align and straighten in this region.
    • Most functional activity occurs in this region.

    Stress-Strain Curve Definitions: Elastic Range

    • Tissue returns to its original size when the load is released if stress is not maintained, within the elastic range.
    • This is like an elastic band.

    Stress-Strain Curve Definitions: Elastic Limit

    • Point beyond which the tissue does not return to its original shape and size.

    Stress-Strain Curve Definitions: Plastic Range

    • Area where there is permanent deformation when stress is released.
    • Represents micro-failure of bonds between collagen fibers, ultimately leading to whole fiber rupture and increased length.
    • This is what typically happens during a stretching procedure.

    Stress-Strain Curve Definitions: Ultimate Strength

    • Greatest load (stress) a tissue can sustain before necking
    • Necking is the weakening of the tissue leading to rapid failure.
    • Structural stiffness: The slope of the linear part of the curve (elastic range), where stiffer tissues have steeper slopes.

    Stress-Strain Curve: Clinical Relevance

    • Awareness of tissue feel is critical when manually stretching to avoid injuries.
    • Stretching should be performed slowly, and the patient should be asked about the intensity of the stretch (light, medium, strong).
    • The goal is a moderate stretch sensation.

    Stress-Strain Curve: Clinical Relevance: Grading of Ligament Injuries (Sprains)

    • Grade I: Micro-failure of a few fibers in the lower portion of the plastic range.
    • Grade II: Macro-failure, greater rupture of fibers, partial tear, identifiable on imaging.
    • Grade III: Complete rupture or tissue failure.

    Connective Tissue Response to Load: Creep

    • When a load is applied for an extended period, the tissue elongates and does not return to its original length.

    Connective Tissue Response to Load: Stress Relaxation

    • The underlying mechanism of prolonged passive stretching.
    • When a stress is applied to stretch a tissue and the length is kept constant, after initial creep, a decrease in force is needed to maintain that length and the tension in the tissue decreases.

    How Are the Two Different?

    • Creep: Constant stress results in increased strain (plastic strain).
    • Stress Relaxation: Constant strain results in decreased stress.

    Review

    • Key components of the stress-strain curve.
    • Locations on the stress-strain curve where permanent changes occur.

    Connective Tissue: Response to Load

    • Cycle loading and connective tissue fatigue: repetitive loading increases heat production and can cause failure below the yield point.
    • Greater load applied, fewer cycles are needed for failure (stress fractures, overuse syndromes).
    • Stretching should apply repetitive or cyclical loads at a submaximal level on successive days or alternate days for recovery.

    Changes in Collagen Affecting Stress-Strain Response

    • Factors affecting collagen properties include immobilization, inactivity/decreased activity, age, medications (corticosteroids), and injury.

    Changes in Collagen: Immobilization

    • Tissue weakening due to collagen turnover and weak bonding between newly formed, non-stressed fibers.
    • Adhesion formation (greater crosslinking, reduced ground substance effectiveness between disorganized collagen fibers, and lubrication).

    Changes in Collagen: Inactivity/Decreased Activity

    • Tissue weakening due to reduced collagen fiber size and amount (atrophy, fatty infiltrates).
    • Physical activity increases connective tissue strength (hypertrophy).
    • Recovery may take up to 5 months with regular cyclic loading without re-injury.

    Changes in Collagen: Age

    • Maximum tensile strength and elastic modulus decrease, rate of adaptation to stress is slower.
    • Increased tendency for overuse syndromes, fatigue failure, and tears with stretching.

    Changes in Collagen: Corticosteroids

    • Decreased tensile strength of collagen.
    • Fibrocyte death near injection site up to 15 weeks after injection.
    • Increased risk of injury.
    • Patient education on reduced loading, and slower progression of therapeutic interventions.

    Changes in Collagen: Injury

    • Excessive tensile loading can lead to ligament and tendon rupture.
    • Initial healing involves type III collagen, which is structurally weaker than type I collagen.
    • Prior injury decreases structural stiffness of tissue.
    • Recovery to stronger type I collagen takes 3 weeks to 1 year.

    Stretching Indications

    • Lost extensibility of soft tissues.
    • Restricted motion leading to structural deformities.
    • Muscle weakness and shortening of opposing tissues limiting ROM.
    • Prevention of future injuries during training or wellness programs.
    • Before and after vigorous exercise to reduce muscle soreness and improve performance.
    • Stretching does not always prevent injury, and may not be best performed before vigorous exercise.

    Contraindications to Stretching

    • Bony block/end feel
    • Incomplete bony union (fracture)
    • Acute inflammation
    • Infection
    • Hematoma/tissue trauma
    • Hypermobility
    • Shortened soft tissues providing joint stability in lieu of neuromuscular or structural stability
    • Shortened soft tissues for individuals with paralysis or severe muscle weakness to perform special functional skills.

    Motion vs Stretching

    • Perform a stretch to increase a motion, move in same direction as the motion stated.
    • Perform a stretch to increase the flexibility of a muscle, move in the opposite direction of the muscle's action.

    Activity

    • Identify motion performed/increased in a given photograph.
    • Recognize the muscle group being stretched.
    • Identify 2 muscles within the stretched muscle group.
    • Review the origin and insertion of the identified muscles.

    Determinants, Types, and Effectiveness of Stretching Interventions

    • Alignment and stabilization.
    • Intensity of stretch.
    • Duration of stretch.
    • Speed of stretch.
    • Mode of stretch.
    • PNF stretching techniques.
    • Dynamic stretching.
    • Integration of function into stretching.

    Alignment & Stabilization

    • Alignment of segment being stretched: consider position of trunk and adjacent joints.
    • Stabilization of one segment: fixate proximal or distal attachment site of tissue being stretched.
    • Stabilization influences stress on soft tissues and affects available ROM in the joints.

    Alignment & Stabilization: Example Rectus Femoris Stretch

    • Avoid anterior pelvic tilt, excessive lumbar extension, and hip abduction.
    • Keep belly button pulled in to avoid excessive lumbar extension (recruit TrA).

    Duration of Stretch

    • Traditional manual and self-static stretches: 3 x 30 seconds (program standard).
    • Cumulative minimum total stretch time should add up to 60 seconds.
    • Hold time may need adjustment based on patient response.
    • Low load, long duration stretch (LLLD) or prolonged passive stretch (PPS): build up time slowly to a total of 6 hours per day.
    • Begin with 6 x 5 minutes at 30 minutes and gradually increase to 60 minutes.
    • Goal: 6 sessions/day x 10 minutes/session = 60 minutes.
    • Mechanical stretch- Performed with weights, positioning, bands.
    • Dynamic splint: device with springs to increase stretch load to 8-10 hours/day.

    Intensity of Stretch

    • Traditional static stretches: moderate discomfort, more comfortable, minimizes muscle guarding, and decreases muscle spindle activity.
    • Mode: manual or self-stretch.
    • LLD stretching: Little to no discomfort; may have soreness for up to 10 minutes after removing stretch.

    What Kind of End Feel Might You Experience If the Joint Capsule Is Limiting the Motion?

    Duration of Stretch

    • Static: Soft tissues are elongated just past the resistance point and held for a period. Static progressive: increased stretch force over time.
    • Cyclic: Short duration force is applied, released, and reapplied (5-10 seconds at a time). Not synonymous with ballistic stretching

    Speed of Stretch

    • Goal: slow and controlled; gradually increase force.
    • Muscle spindles are sensitive to velocity of muscle length changes
    • Ballistic Stretching: fast, forceful intermittent stretch, not safe for the average individual.

    Frequency of Stretch

    • 2x-5x/week (program standard) based on underlying cause of impaired mobility, quality and level of healing tissue, chronicity and severity of contracture, age, tissue response to corticosteroids, and previous use of corticosteroids.

    Mode of Stretch

    • Therapist = manual
    • Caregiver = manual
    • Mechanical: weight, serial cast, splint
    • Self: static vs. active stretching.
    • Active stretching: repeated short duration end range active muscle contractions of the muscle opposite the shortened muscle.
      • Example: supine hamstring stretch

    Mode of Stretch: Self-Stretch

    • Patient uses body weight to stretch.

    Mode of Stretch: Mechanical Stretch

    • Cuff weight is used to provide the stretching force.

    Mode of Stretch: Mechanical Stretch (JAS Orthosis)

    • Static progressive stretch provided by adjustable springs in the brace.

    Integration With Function

    • After the stretch, ensure the patient uses new ROM.
    • Emphasize development of neuromuscular control and strength of agonists.
    • Low load resistance exercises or functional AROM into new range x 10 reps.

    Review

    • Direction to increase wrist flexion.
    • Direction to increase wrist flexor flexibility.
    • Various determinants of stretching.

    Proprioceptive Neuromuscular Facilitation Stretching Techniques

    • Active stretching or facilitative stretching: keep the stretched muscle as relaxed as possible.
    • Utilizes reflexive relaxation due to autogenic or reciprocal inhibition.
    • Self-induced, inhibitory, negative feedback lengthening reaction (Golgi tendon activation) is protective in nature.

    Proprioceptive Neuromuscular Facilitation Stretching Techniques (cont.)

    • Contract Relax (CR), slow reversal, neuro class
    • Agonist Contraction (AC)
    • Hold Relax (HR)
    • Hold Relax with Agonist Contraction (HR-AC) or Hold Relax Active
    • These techniques aren't suitable for spasticity or paralysis.
    • Useful when contractile tissue limits motion.

    What Kind of Abnormal End Feel Might You Experience If the Contractile Tissue Is Limiting the Motion?

    PNF Stretching Techniques: Agonist Contraction

    • "Agonist" = muscle opposite the range limiting target muscle.
    • "Antagonist" = range limiting (tight) muscle.
      • Examples:
        • Short hip flexors: contract hip extensors
        • Short elbow flexors: contract elbow extensors
        • Short hamstrings: contract quadriceps

    Another Way to Say It (Agonist vs. Antagonist)

    • AGONIST: Muscle assisting in the movement being increased.
    • ANTAGONIST: Muscle that, when tight, limits the desired movement.

    PNF Stretching Techniques: Multiple Joint Muscles

    • Maximally move one joint first, then the next joint.
    • Example: Biceps brachii
      • extend elbow
      • pronate forearm
      • extend glenohumeral joint

    Dynamic Stretching

    • Defined as controlled movement through the AROM for each joint.
    • Proposed to enhance performance; effects increase with stretches longer than 90 seconds.
    • Best used as a warm-up.

    Chronic Effects of Static & Dynamic Stretching

    • 45 active men were randomly allocated with dynamic, static, and control groups.
    • There was a large decrease in eccentric peak torque (-15.4 ± 10.4%) and reduction in triple hop test distance (-3.7 ± 4.1%) after static stretching training.
    • Dynamic stretching didn't negatively affect strength or performance.

    ACSM Guidelines for Stretching

    • Mode: active or passive stretching, PNF 20-75% max contraction for 3-6 second hold.
    • Duration: 10-30 seconds; older populations 30-60 seconds.
    • Reps: reach 60 seconds per flexibility exercise (e.g., 2 x 30 seconds, or 4 x 15 seconds).
    • Frequency: ≥ 2–3 days/week.
    • Timing: when muscle temp is elevated after light to moderate cardiovascular activity.

    Outline

    • Properties of soft tissue, response to immobilization, stretching indications/contraindications/outcomes, precautions for stretching, determinants/types of stretching exercises, and procedural guidelines for stretching interventions.

    Procedural Guidelines: Application of Stretching

    • Examination and evaluation of the patient.
    • Preparation for stretching, including obtaining consent, selecting appropriate technique, warming up tissue, positioning appropriately, and clearing the area from restrictions.
    • Apply manual stretching procedures.
    • Actively utilize new functional ROM after stretching.

    Stretching Interventions: Guidelines/Application

    • Exam/evaluation factors: cause of ROM limitations, involved structures, tissue irritability, healing stage, muscle strength, and treatment goals.

    Stretching Interventions: Guidelines/Application (cont.)

    • Preparation for Stretching: Obtaining consent, Selecting appropriate technique, Warming up tissue, Positioning appropriately, Clearing the area from restrictions, Explaining/educating/demonstrating.
    • Double check for contraindications to stretching.

    Stretching Interventions: Guidelines/Application (cont.)

    • Manual Stretching: Firm grasp, appropriate stabilization, single joint stretches first, Grade I distraction to avoid compression, slow movement to point of tissue resistance, low intensity, slow, controlled, sustained stretch x 30 seconds.

    Stretching Interventions: Guidelines/Application (cont.)

    • Manual Stretching (cont.): Hold until tissue tension decreases (allow for creep and stress relaxation), stretch further, gradually release tension, assess response/tolerance: repeat/change

    Stretching Interventions: Guidelines/Application (cont.)

    • Manual stretching (cont.): Observe for signs that the patient is relaxed (decreased muscle tension, lowered heart/respiration rates, constricted pupils, little-no body movement, flat affect, relaxed jaws/hands).

    Stretching Interventions: Guidelines/Application (cont.)

    • Post-stretching: Perform AROM, strengthen, and use functional movement patterns. Ice in elongated position if appropriate.

    Outline (page 68)

    • Properties of soft tissue/response, Stretching indications, contraindications/outcomes, and precautions, Determinants of stretching techniques, and Procedural guidelines.

    General Stretching Precautions

    • Do not force a joint beyond its normal ROM.
    • Use caution with patients with suspected or known osteoporosis.
    • Avoid vigorous stretching of recently immobilized tissue.
    • Progress dosage gradually and be mindful of edematous/swollen tissue.
    • Avoid overstretching weak tissue.

    Special Precautions for Mass-Market Flexibility Programs

    • Nonselective or poorly balanced stretching activities.
    • Insufficient warm-up.
    • Ineffective stabilization.
    • Ballistic stretching.
    • Excessive intensity (no pain, no gain).
    • Abnormal biomechanics.
    • Limited attention to age-related differences (elderly, growth spurts).
    • Educate your patients on current exercise trends.

    Outline (page 71)

    • The outline covers properties of soft tissue, response to immobilization/stretch, stretching indications/contraindications/outcomes, precautions for stretching, determinants/types of stretching exercises, and procedural guidelines for stretching interventions.

    Adjuncts to Stretching

    • Heat: increases tissue extensibility, lessens guarding (HP, paraffin, US, active exercise, shortwave diathermy). Decreases the amount of intensity of stretch required to make a plastic change.
    • Cold: used to decrease muscle tone (spasticity) and icing tissue in a lengthened position.
    • Massage: increases circulation, decreases spasms, breaks up adhesions, improves scar mobility, causes creep and stress relaxation.
    • Relaxation training.

    Adjuncts to Stretching (cont.)

    • Biofeedback (visual, auditory): monitoring and learning to reduce tension in muscles, heart rate, blood pressure, decreasing muscle tension, reducing pain, and increasing flexibility.
    • Joint traction or oscillation: helps inhibit joint pain and muscle spasm surrounding a joint. Example: pendulums.

    Review

    • Stages of tissue healing during stretching, what to do after stretching, what tissue is being stretched, and appropriate times for stretching within a treatment session.

    References

    • Various research articles on muscle extensibility, acute effects of muscle stretching on physical performance, and the quantity and quality of exercise for healthy adults.

    Therapeutic Exercise: PTA 1005 Peripheral Joint Mobilization

    • PTA 1005 course offered by Stanbridge University in 2022 specifically regarding Peripheral Joint Mobilization

    Road Map (page 77)

    • State/define basic mobilization/movement terms.
    • Describe basic concepts of joint motion (types of motion, passive angular stretching vs. joint glide stretching, and accessory motions).
    • Describe indications/precautions/contraindications for joint mobilization.
    • Describe the grade of joint mobilization and appropriate grade for each stage.

    Joint Mobilization

    • Manual therapy techniques to modulate pain and treat joint dysfunction limiting ROM.
    • Specifically addresses altered joint mechanics.

    Joint Mobilizations

    • Technique to deal with capsular restrictions while minimizing abnormal compressive stresses on articular cartilage.
    • Best performed in the open pack position.

    Definition of Terms

    • Mobilization/Manipulation: Manual therapy technique on joints/related tissues at different speeds and amplitudes using physiological/accessory motions.
    • High Velocity Thrust: Grade V, short amplitude manipulation technique to change relationships, stimulate joint receptors, performed at the end of ROM.
    • Self-mobilization/auto-mobilization: Using joint traction/glides to direct stretch force to the joint capsule.
    • Mobilization with Movement (MWM): Therapist applies sustained accessory mobilization with patient performing AROM and overpressure to treat without pain.
    • Physiologic movements: Movements patients can do voluntarily, examples are flexion, abduction, and rotation.
    • Accessory Movements: Joint/surrounding tissue movements necessary for movement but not actively performed by a patient.
    • Manipulation under Anesthesia (MUA): Procedure to restore full ROM by breaking adhesions while patient is anesthetized, and is used when conservative care doesn't restore ROM.
    • Muscle Energy Technique: Active contraction of deep muscles near a joint utilizing therapist stabilization, isometric contraction, sacroiiliac joint MET, cervical spine(C/S), and lumbar spine(L/S)

    Mobilization/Manipulation (page 81)

    • Skilled manual therapy to modulate pain and treat joint dysfunction that limits ROM.
    • Varying speeds and amplitudes using physiological/accessory motions.
    • Can be performed at different intensities and speeds (e.g., small amplitude force at fast velocity, large amplitude force at slow velocity).
    • Grade I-V exist.

    Definitions (Page 82)

    • Physiologic Movements (voluntary): Examples - flexion, abduction, rotation
    • Accessory Movements (involuntary): Necessary for overall range of motion (ROM).

    High Velocity Thrust (Page 83)

    • High-velocity, short amplitude technique (Grade V).
    • Goal: alter positional relationships, reduce adhesions, and stimulate joint receptors.
    • Performed at end of available range of motion (ROM).

    Self Mobilization (Page 84)

    • Self-stretching techniques using joint traction or glides.
    • Direct stretch force to the joint capsule.

    Mobilization with Movement (MWM)

    • Therapist applies sustained accessory mobilization with patient performing AROM (active range of motion) to end range.
    • Overpressure is delivered without pain as a barrier.
    • Corrects joint tracking if positional fault occurs.

    Mobilization with Movement: Goal (Pill)

    • Pain-free (P).
    • Instant result (I).
    • Long-lasting (LL).

    Mobilization with Movement

    • YouTube video demonstrating MWM.

    Manipulation Under Anesthesia (MUA)

    • Procedure to restore full ROM by breaking adhesions around a joint while anesthetized.
    • Technique: rapid thrust or passive stretch using physiological or accessory movements.
    • Used when conservative care doesn't restore ROM.
    • Common joints: Knee and shoulders.

    Manipulation Under Anesthesia: Video

    • YouTube video demonstrating MUA.

    Muscle Energy Technique

    • Use active contraction of deep muscles attaching near a joint with line of pull causing desired accessory motion.
    • Therapist stabilizes a segment, commands isometric contraction of muscles.
    • Examples include sacroiliac joint MET, cervical, and lumbar spine.

    Muscle Energy Technique: Video

    • YouTube video demonstrating the technique.

    Physiological Movements (page 92)

    • Voluntary movements like flexion, abduction, and rotation, based on osteokinematics.

    Accessory Motions

    • Arthrokinematics = rolling, sliding, and spinning motions in the joint.
    • Necessary movements in the joint and surrounding tissue for normal ROM, but are not actively performed by the patient.
    • Other accessory motions include compression and distraction.

    Accessory Movements (page 94)

    • Joint play: Movement between the two joint surfaces.
    • Necessary for normal joint function.
    • Assessing joint play determines whether there's a tight capsule and the need for joint mobilization.

    Types of Arthrokinematic Motion: Glide

    • Direction of glide depends on whether the joint surface is concave or convex.
    • Convex surface: glide in the opposite direction of bone's angular movement. Example: Femur gliding on the acetabulum
    • Concave surface: glide in the same direction as bone's angular movement. Example: Acetabulum gliding on the Femur.

    Types of Arthrokinematic Motion: Combined Rolling/Sliding

    • Joint mobilization uses gliding component to restore joint play.

    Concave-Convex Rule

    • Theoretical basis for mobilizing force direction when joint gliding is used.
    • Concave: same direction as physiological motion.
    • Convex: opposite direction of physiological motion.

    Review (page 99)

    • Types of mobilization/manipulation techniques.
    • Difference between osteo and arthrokinematics.
    • Joint motions combining to create normal osteokinematics.

    Clinical Application

    • Arthrokinematics and osteokinematics are used in joint mobilization and stretching treatments.

    Passive Static Stretching vs. Joint Mobilization (page 101)

    • Osteokinematic stretching of a joint with a tight joint capsule can cause increased pain and joint trauma.
    • Lever effect magnifies force at the joint.
    • Force causes compression of joint surfaces in the direction of rolling bone.

    Stretching vs. Joint Mobilization (page 102)

    • Joint glide/mobilization is safer and more selective than osteokinematic stretching (osteo vs. arthrokinematic motions).
    • Force applied near the joint surface, controlled by therapist, and compatible with pathology.
    • Glide replication replicates the gliding component of the joint's mechanics.
    • Small yet specific amplitude of motion to restricted or adherent portion of capsule/ligaments.

    Other Accessory Motions (page 103)

    • Compression: Decrease in joint space between two bony partners, occurs in extremities/spinal joints during weight bearing, and happens when muscles contract.
    • Long Axis Traction: Pulling along the long axis of the bone.
    • Joint Distraction: Separation/pulling apart of joint surfaces.

    Arthrokinematics Kinesiology Review

    • Rolling, spinning, and gliding occur together for normal movement.

    Compression (page 105)

    • Decrease in joint space between two bony partners.
    • Occurs in extremities/spinal joints during weight bearing.
    • Occurs when muscles contract to provide stability to the joints.

    Compression During Arthrokinematics

    • One bone rolling over the other. (same side as spin)

    Compression (page 107)

    • Normal intermittent compressive loads help maintain cartilage health through synovial fluid movement
    • Abnormally high compressive loads cause articular cartilage changes and deterioration.

    Traction & Distraction (page 108)

    • Distraction: Separation or pulling apart of joint surfaces (also called joint traction or joint separation).
    • Traction: Pulling along the long axis of the bone.

    Traction & Distraction (page 109)

    • Traction (Long axis): Caudal gliding of the joint surface
    • Distraction: Separation of the GH joint at a right angle to the glenoid fossa.

    Why Is Proper Joint Mobility Necessary?

    • Loss of joint mobility: decreases synovial fluid movement, decreases extensibility/tensile strength of the articular and peri-articular tissues, affects afferent nerve impulses from joint receptors, decreasing proprioceptive feedback, affecting balance/muscle response

    Indications for Joint Mobilization (page 111)

    • Pain, muscle guarding, spasm
    • Reversible joint hypomobility
    • Positional faults/subluxations
    • Progressive limitation
    • Functional immobility

    Indications for Joint Mobilization (Pain, Muscle Guarding, Spasm)

    • Use small amplitude oscillatory and distraction movements to stimulate mechanoreceptors, inhibit the transmission of nociceptive stimuli, and maintain normal nutrient exchange to prevent painful and degenerating effects of fluid stasis in swollen/painful joints.

    Indications for Joint Mobilization: Reversible Joint Hypomobility (page 113)

    • Sustained or oscillatory stretch forces are used to distend the shortened tissue mechanically.
    • Elongation of hypomobile capsular or ligamentous connective tissue through progressively vigorous joint play stretching techniques.

    Indications for Joint Mobilization: Positional Faults/Subluxations

    • Faulty tracking of joint surfaces.
    • Causes: trauma, immobility, muscle imbalances.
      • Can use MWM techniques and high velocity thrusts.

    Indications for Joint Mobilization: Progressive Limitation

    • Diseases progressively limiting movement.
    • Used for maintaining available ROM and retarding progressive mechanical restrictions.

    Indications for Joint Mobilization: Functional Immobility

    • Patient cannot functionally move a joint for a period.
    • Treated using non-stretch gliding or distraction techniques (Grade I or II).
    • Maintain available joint play and prevent degenerative/restricting effects of immobility.

    Self Treatments

    • Seated knee joint traction
    • Elbow joint distraction

    Contraindications to Joint Mobilization (page 118)

    • Hypermobility: no stretching/mobilization techniques (e.g., necrosis of ligaments, capsule, hypermobility syndromes).
    • Joint effusion: avoid stretching/mobilization on a swollen joint as the capsule is already stretched.
    • Gentle oscillations may decrease pain and improve fluid flow while maintaining joint play.

    Contraindications to Joint Mobilization (page 119)

    • Presence of inflammation: stretching usually increases pain/muscle guarding (further tissue damage).

    Precautions to Joint Mobilization: Use Extreme Care With...

    • Malignancy
    • Bone disease
    • Unhealed fracture (depends on fracture site/stabilization)
    • Excessive pain
    • Hypermobility (in associated joints, proper stabilization).

    Precautions to Joint Mobilization: Use Extreme Care With... page 121

    • Total joint replacements: consult implant design/ROM, avoid inappropriate mobilization techniques.
    • Newly formed/weakened connective tissue: avoid forceful techniques after injury, surgery, or disuse/certain medications.

    Precautions to Joint Mobilization: Use Extreme Care With... page 122

    • Systemic connective tissue diseases (e.g., rheumatoid arthritis): avoid forceful techniques to prevent ruptured tissue and instability.
    • Elderly individuals with weakened connective tissue/diminished circulation: use gentle techniques.

    Review (page 123)

    • Reasons for normal joint mobility
    • Key characteristics differentiating joint mobilization and osteokinematic stretching.
    • Indications, precautions, and contraindications for joint mobilization.

    Procedures for Applying Joint Mobilization Techniques (page 124)

    • Examination/evaluation: determines the plan of care and factors include quality of pain, capsular restriction, and subluxation/dislocation.

    Procedures for Applying Joint Mobilization Techniques (page 125)

    • Examination and evaluation, determine quality of pain:
      • Pain before tissue limitation : no stretch, pain-limiting techniques
      • Pain at same time as tissue limitation: gentle stretch
      • Pain after tissue limitation: more aggressive stretch

    Procedures for Applying Joint Mobilization Techniques (page 126)

    • Look for capsular restriction in evaluation:
      • Passive ROM limited in a capsular pattern
      • Firm capsular end feel when applying overpressure to tissue limiting motion
      • Decreased joint play documented by mobility tests

    Procedures for Applying Passive Joint Techniques (page 127)

    • Examination for subluxation/dislocation history
    • Proceed with caution (Grade I and II okay), avoid stretching in hypermobile direction.
    • High-thrust techniques, not in PTAs scope of practice

    Grades and Dosages of Mobilizations (page 128)

    • Maitland (non-thrust oscillation) Grades I-IV and Kaltenborn (non-thrust sustained) Grades I-III

    Sustained vs. Oscillatory (page 129)

    • Grades I and II (Maitland/Kaltenborn): low intensity, do not create a stretch
    • Grades III and IV (oscillations): similar intensity, create a stretch

    Procedures for Applying Joint Mobilization Techniques: Oscillations (page 130)

    • Grade I: small amplitude, rhythmic oscillations at beginning of range, rapid.
    • Grade II: large amplitude, rhythmic oscillations within range (not reaching the limit); 2-3/second, 1-2 minutes.
    • Grades I and II: stimulate mechanoreceptors that block pain pathways, and increase synovial fluid movement.

    Joint Mobilization Grades I-IV (page 131)

    • Illustrates the concept of available joint play, tissue resistance, and anatomic limit for each grade.

    Procedures for Applying Joint Mobilization Techniques: Oscillations (page 132)

    • Grade III: large amplitude rhythmic oscillations up to the limit of available motion; with emphasis on tissue resistance, 2-3/second for 1-2 minutes
    • Grade IV: small amplitude rhythmic oscillations at the limit of motion, with emphasis on tissue resistance, rapid, and manual vibration-like oscillations.
    • Grade III and IV are stretching maneuvers

    Procedures for Applying Joint Mobilization Techniques: Sustained (page 133)

    • Kaltenborn- sustained technique: slow, sustained separation/glide for several seconds with partial relaxation then repeated.
    • Joint surfaces are separated (distracted) or glided/translated (slided)

    Procedures for Applying Joint Mobilization Techniques (page 134)

    • Grade I (Loosen): small amplitude distraction, no stress on the capsule (within slack zone)
    • Grade II (Tighten): enough distraction/glide to tighten tissues around the joint (slack zone to transition zone)
    • Grade III (Stretch): sufficient distraction/glide to stretch the joint capsule and periarticular tissues (push through transition zone)

    Kaltenborn Sustained Grades (page 135)

    • Illustrates slack, transition, and stretching zones in relation to grades I, II, and III.

    Oscillating & Sustained Prescription (page 136)

    • Grade I or II (oscillation or sustained) for managing pain (acute/subacute healing).
    • Grade II-IV oscillations, Grade III sustained, or Grade III MWM are considered for decreased functional range due to loss of joint play (subacute/chronic phases of healing).
    • Grade II oscillating or sustained techniques are useful for any phase of tissue healing to maintain available range.

    Procedures for Applying Joint Mobilization Techniques - Positioning and Stabilization (page 137)

    • Position Patient for relaxation
    • Stabilize one joint partner (usually proximal)
    • Assess joint play & apply treatment at resting position (maximizing capsular laxity)
    • Progression for Grades III/IV: bringing the joint near the end of available ROM before applying.

    Procedures for Applying Joint Mobilization Techniques - Treatment Force and Direction (page 138)

    • Applied as close/parallel to opposing joint surface, utilize a large enough surface area possible.
    • Treatment plane is perpendicular to the line from the axis of rotation to the middle of the concave part of the bony partner.

    Joint Mobilization Techniques: Glide and Distraction Direction (page 139)

    • Glides are parallel to the treatment plane (TP)
    • Distractions are perpendicular to the treatment plane (TP)
    • Illustrates the relationship of the treatment plane (TP) with the concave bony surface and the axis of rotation (AOR).

    Procedures for Applying Joint Mobilization Techniques- Direction of Movement (page 140)

    • Direction of force/movement is either parallel to treatment plane (glide), perpendicular to treatment plane (distraction), or a combination.

    Suggested Sequence of Treatment (page 141)

    • Warm the tissues (active warm-up, hot packs)
    • Relax the muscles (hold-relax inhibition technique).
    • Joint mobilization stretches to address faulty arthrokinematics.
    • Passive stretching to address faulty osteokinematics.
    • Patient actively uses the new range (functional activity).
    • Maintain the new range with HEP (home exercise program)-incorporating self-stretches, self-mobilization techniques, and active resistive ROM, and functional use of body segments.

    Peripheral Joint Mobilization Techniques

    • These will be taught and practiced within the PTA 1008 Orthopedic interventions course.

    Joint Mobilization: Supportive Evidence (page 143)

    • C/S leans to specific mobilization and L/S to general mobilization.
    • Thrust vs. non-thrust outcomes for spinal manipulation.
    • Clinicians should consider thrust procedures for L/S spine mobility deficits and acute low back pain (back related buttock/thigh pain)

    Joint Mobilization: Supportive Evidence (page 144)

    • Clinicians consider using cervical manipulation/mobilization with exercise to address neck pain and headache.
    • Related to various types of pain (shoulder, heel, hip) as well as mobilization/manipulation approaches.

    Review (page 145)

    • Varieties of non-thrust oscillations and sustained grades and definitions
    • Appropriate stages of tissue healing for each mobilization grade.

    Review (page 146)

    • Basic mobilization/movement terms
    • Basic joint motion concepts including types of motion, passive angular/glide stretching, and accessory motions
    • Indications, precautions, and contraindications for joint mobilization techniques.
    • Grade of joint mobilization, along with appropriate grades for each stage.

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    Description

    Test your knowledge on the best practices and precautions in joint mobilization. This quiz covers essential concepts such as contraindications, risks, and techniques related to joint and soft tissue mobilization. Key topics include effects of swelling, pain management, and considerations for elderly patients.

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