Dr. Naveen, PT
Guide to PT Practice-
Mobilization/Manipulation = “A manual therapy technique comprised of a continuum of skilled passive movements to joints and/or related soft tissues that are applied at varying speeds and amplitudes, including a small amplitude/high velocity therapeutic movement”
Manipulation Education Committee, June 2003
Maitland Joint Mobilization Grading Scale
Grading based on amplitude of movement & where within available ROM the force is applied.
l Grade I
– Small amplitude rhythmic oscillating movement at the beginning of range of movement
– Manage pain and spasm
l Grade II
– Large amplitude rhythmic oscillating movement within midrange of movement
– Manage pain and spasm
– Grades I & II – often used before & after treatment with grades III & IV
l Grade III
– Large amplitude rhythmic oscillating movement up to point of limitation (PL) in range of movement
– Used to gain motion within the joint
– Stretches capsule & CT structures
l Grade IV
– Small amplitude rhythmic oscillating movement at very end range of movement
– Used to gain motion within the joint
l Used when resistance limits movement in absence of pain
– Grade V – (thrust technique) - Manipulation
– Small amplitude, quick thrust at end of range
– Accompanied by popping sound (manipulation)
– Velocity vs. force
– Requires training
Indications for Mobilization
l Grades I and II - primarily used for pain
– Pain must be treated prior to stiffness
– Painful conditions can be treated daily
– Small amplitude oscillations stimulate mechanoreceptors - limit pain perception
l Grades III and IV - primarily used to increase motion
– Stiff or hypomobile joints should be treated 3-4 times per week – alternate with active motion exercises
ALWAYS Examine PRIOR to Treatment
l If limited or painful ROM, examine & decide which tissues are limiting function
l Determine whether treatment will be directed primarily toward relieving pain or stretching a joint or soft tissue limitation
– Quality of pain when testing ROM helps determine stage of recovery & dosage of techniques
1) If pain is experienced BEFORE tissue limitation, gentle pain-inhibiting joint techniques may be used
· Stretching under these circumstances is contraindicated
2) If pain is experienced CONCURRENTLY with tissue limitation (e.g. pain & limitation that occur when damaged tissue begins to heal) the limitation is treated cautiously – gentle stretching techniques used
3) If pain is experienced AFTER tissue limitation is met because of stretching of tight capsular tissue, the joint can be stretched aggressively
Joint Positions
l Resting position
– Maximum joint play - position in which joint capsule and ligaments are most relaxed
– Evaluation and treatment position utilized with hypomobile joints
l Loose-packed position
– Articulating surfaces are maximally separated
– Joint will exhibit greatest amount of joint play
– Position used for both traction and joint mobilization
l Close-packed position
– Joint surfaces are in maximal contact to each other
– General rule: Extremes of joint motion are close-packed, & midrange positions are loose-packed.
Joint Mobilization Application
l All joint mobilizations follow the convex-concave rule
l Patient should be relaxed
l Explain purpose of treatment & sensations to expect to patient
l Evaluate BEFORE & AFTER treatment
l Stop the treatment if it is too painful for the patient
l Use proper body mechanics
l Use gravity to assist the mobilization technique if possible
l Begin & end treatments with Grade I or II oscillations
Positioning & Stabilization
l Patient & extremity should be positioned so that the patient can RELAX
l Initial mobilization is performed in a loose-packed position
– In some cases, the position to use is the one in which the joint is least painful
– Firmly & comfortably stabilize one joint segment, usually the proximal bone
– Hand, belt, assistant
– Prevents unwanted stress & makes the stretch force more specific & effective
Treatment Force & Direction of Movement
l Treatment force is applied as close to the opposing joint surface as possible
l The larger the contact surface is, the more comfortable the procedure will be (use flat surface of hand vs. thumb)
l Direction of movement during treatment is either PARALLEL or PERENDICULAR to the treatment plane
Treatment Direction
l Treatment plane lies on the concave articulating surface, perpendicular to a line from the center of the convex articulating surface (Kisner& Colby, p. 226 Fig. 6-11)
l Joint traction techniques are applied perpendicular to the treatment plane
l Entire bone is moved so that the joint surfaces are separated
l Gliding techniques are applied parallel to the treatment plane
– Glide in the direction in which the slide would normally occur for the desired motion
– Direction of sliding is easily determined by using the convex-concave rule
– The entire bone is moved so that there is gliding of one joint surface on the other
– When using grade III gliding techniques, a grade I distraction should be used
– If gliding in the restricted direction is too painful, begin gliding mobilizations in the painless direction then progress to gliding in restricted direction when not as painful
l Reevaluate the joint response the next day or have the patient report at the next visit
– If increased pain, reduce amplitude of oscillations
– If joint is the same or better, perform either of the following:
· Repeat the same maneuver if goal is to maintain joint play
· Progress to sustained grade III traction or glides if the goal is to increase joint play
Speed, Rhythm, & Duration of Movements
l Joint mobilization sessions usually involve:
– 3-6 sets of oscillations
– Perform 2-3 oscillations per second
– Lasting 20-60 seconds for tightness
– Lasting 1-2 minutes for pain 2-3 oscillations per second
l Apply smooth, regular oscillations
l Vary speed of oscillations for different effects
l For painful joints, apply intermittent distraction for 7-10 seconds with a few seconds of rest in between for several cycles
l For restricted joints, apply a minimum of a 6-second stretch force, followed by partial release then repeat with slow, intermittent stretches at 3-4 second intervals
Patient Response
l May cause soreness
l Perform joint mobilizations on alternate days to allow soreness to decrease & tissue healing to occur
l Patient should perform ROM techniques
l Patient’s joint & ROM should be reassessed after treatment, & again before the next treatment
l Pain is always the guide
Joint Traction Techniques
l Technique involving pulling one articulating surface away from another – creating separation
l Performed perpendicular to treatment plane
l Used to decrease pain or reduce joint hypomobility
l Kaltenborn classification system
– Combines traction and mobilization
– Joint looseness = slack
Kaltenborn:
• more gliding---> nearly congruent
• more rolling---> nearly incongruent
• The rolling portion of the combined roll-glide movement always follows the direction of the bone movement
• The gliding portion of the combined roll-glide movement
• whether the moving surface is convex or concave
• If the moving surface is concave---> both the gliding and the bone movement follow the same direction
• If the moving surface is convex---> the gliding follows the opposite direction
Kaltenborn Traction Grading
l Grade I (loosen)
– Neutralizes pressure in joint without actual surface separation
– Produce pain relief by reducing compressive forces
l Grade II (tighten or take up slack)
– Separates articulating surfaces, taking up slack or eliminating play within joint capsule
– Used initially to determine joint sensitivity
l Grade III (stretch)
– Involves stretching of soft tissue surrounding joint
– Increase mobility in hypomobile joint
l Grade I traction should be used initially to reduce chance of painful reaction
l 10 second intermittent grade I & II traction can be used
l Distracting joint surface up to a grade III & releasing allows for return to resting position
l Grade III traction should be used in conjunction with mobilization glides for hypomobile joints
– Application of grade III traction (loose-pack position)
– Grade III and IV oscillations within pain limitation to decrease hypomobility
Indications:
• Joint dysfunction
• Restriction of accessory joint motion
• Capsuloligamentous tightening
• Internal derangement
• Reflex muscle guarding
• bony blockage
Contraindication
• Absolute:
– bacterial infection,
– neoplasm,
– recent fracture
• Relative
– Joint effusion or inflammation
– Arthrosis ( e.g. degenerative joint disease) if acute, or if causing a bony block to movement to be restored)
– Rheumatoid arthritis
– Osteoporosis
– internal derangement
– General delilitation ( e.g. influenza, pregnancy, chronic disease)
