1. Peripheral joint mobilization
Made by Sajida Mazhar

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

3. The altered joint mechanics may be due to
pain
muscle guarding
joint effusion
Contractures
adhesions in the joint capsules
Adhesions in supporting ligaments
Malalignment
subluxation of the bony surfaces

4. Joint mobilization
It differ from stretching in that they
specifically address restricted capsular tissue by replicating normal joint mechanics
minimizing abnormal compressive stresses on the articular cartilage in the joint.
practitioner must know
anatomy
arthrokinematics and
pathology of the neuromusculoskeletal system
recognize when the techniques are indicated
when other techniques would be more effective for regaining lost motion.
False use of may lead to potential harm to the patient’s joints.

5. Mobilization/Manipulation
They are passive skilled manual therapy techniques
applied to joints and related soft tissues
at varying speeds and amplitudes using physiological or accessory motions for therapeutic purposes.
speeds and amplitudes could range from
a small-amplitude force applied at high velocity
to a large-amplitude force applied at slow velocity

6. Self-Mobilization (Auto-mobilization)
Self-mobilization refers to self-stretching techniques
specifically use joint traction or glides that direct
the stretch force to the joint capsule.

7. Mobilization with Movement
Mobilization with movement (MWM) is
accessory mobilization Applied by a therapist
an active physiological movement to end range applied by the patient
The techniques are always applied in
a pain-free direction and
described as correcting joint tracking from a positional fault

8. Physiological Movements
Physiological movements are movements the patient can do voluntarily
(e.g., the classic or traditional movements,
such as flexion, abduction, and rotation)
term osteokinematics is used for these

9. Accessory Movements
Accessory movements are movements in the joint and surrounding tissues
that are necessary for normal ROM
cannot be actively performed by the patient.
Component motions
Accompany active motion
but are not under voluntary control.
E.g. motions such as upward rotation of the scapula and rotation of the clavicle, which occur with shoulder flexion, ext rotation of the tibia in knee extension.

10. Accessory Movements joint play.
the motions that occur between the joint surfaces
the distensibility or “give” in the joint capsule
necessary for normal joint functioning through the ROM
Demonstrated passively
but they cannot be performed actively
The movements include
distraction,
Sliding,
compression,
rolling,
spinning of the joint surfaces.
The term arthrokinematics is used for these motions

11. Thrust Thrust is a high-velocity, Is alter positional relationships
short-amplitude motion
that the patient cannot prevent the motion.
The motion is performed at the end of the pathological limit (end of the available ROM when there is restriction.)
Is alter positional relationships
snap adhesions,
stimulate joint receptors.

12. Manipulation Under Anesthesia
is a medical procedure
used to restore full ROM
by breaking adhesions around a joint
while the patient is anesthetized.
The technique may be a rapid thrust or a passive stretch
using physiological or accessory movements

13. Muscle Energy Muscle energy techniques use
active contraction of deep muscles that attach near the joint and
whose line of pull can cause the desired accessory motion.
The therapist stabilize the segment on which the distal aspect of the muscle attaches.
A command for an isometric contraction of the muscle, that causes accessory movement of the joint

14. BASIC CONCEPTS OF JOINT MOTION: ARTHROKINEMATICS
Joint Shapes
The type of motion occurring between bony partners in a joint
is influenced by the shape of the joint surfaces.

15. Joint Shapes In ovoid joints In sellar joints,
one surface is convex, the
other is concave
In sellar joints,
one surface is concave in one direction
and convex in the other,
with the opposing surface convex and concave

16. Types of Motion As a bony lever moves about an axis of motion,
also movement of the bone surface on the opposing bone surface in the joint.
The movement of the bony lever is called swing
as flexion, extension, abduction, adduction, and rotation.
measured in degrees with a goniometer and is called ROM.
Motion of the bone surfaces in the joint is a combination of rolling and sliding, or spinning.
These accessory motions allow greater angulations of the bone as it swings.
For the rolling, sliding, or spinning
There must adequate capsule laxity or joint play.

17. Types of Motion
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 results in angular motion of the bone (swing).
Rolling is always in the same direction as the swinging bone motion whether the surface is convex or concave.

18. Rolling Rolling, if it occurs alone, causes
compression of the surfaces on the side to which the bone is swinging
separation on the other side.
Passive stretching using
bone angulations alone may cause stressful compressive forces to portions of the joint surface,
potentially leading to joint damage.
In normally functioning joints, pure rolling does not occur alone but in combination with joint sliding and spinning

19. Slide/Translation 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.

20. Slide/Translation Pure sliding does not occur in joints
because the surfaces are not completely congruent.
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.

21. Combined Roll-Sliding in a Joint
The more congruent the joint surfaces are, the more sliding
The more incongruent the joint surfaces are, the more rolling

22. Spin
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

23. Spinning rarely occurs alone in joints but
in combination
with rolling and sliding.
Three examples of spin occurring in joints of the body
are the shoulder with flexion/extension, the hip with
flexion/extension, and the radiohumeral joint with
pronation/supination

24. Other Accessory Motions
Compression
Compression is the decrease in the joint space between
bony partners.
weight bearing jts
With muscle contration (stabilization)
With rolling
help move synovial fluid and thus help maintain cartilage health.
Abnormally high loads may lead
articular cartilage changes and deterioration

25. Traction/Distraction
Traction isa longitudinal pull.
Distraction is a separation, or pulling apart
if traction is applied
to the shaft of the humerus, it results in a glide of the joint surface Distraction of the glenohumeral
joint requires a pull at right angles to the glenoid fossa
whenever there is pulling on the long axis of a bone, the term long-axis traction
the surfaces are to be pulled apart, the term distraction, joint traction, or joint separation is used.

26. Open and close pack position
Position patient in a relaxed, distracted, supported position so the joint capsule is lax (loose(open)-packed position).
Close-packed position is one in which there is maximal contact of the articulating surfaces.

27. Closed-packed Position Open-packed Position
Joint
Closed-packed Position
Open-packed Position
Glenohumeral
90o ABD & Full ER combo
55o flexion w/ 20-30o HABD
Elbow
Humeroulnar
Humeroradial
Raduioulnar
Full Extension
90o flex w/ mid-pronation
Full pronation or supination
70o Flex w/ 10o supination
Full ext w/ full supination
70o flex w/ 35o supination
Distal Radiocarpal Joint
Full extension & radial deviation or full flex
Neutral position
MCP joints
2-5 1
Full flexion
Full opposition
20o flexion
IP joints
Hip
Full IR, Ext & ABD
55o flex w20-30o HABD
Knee (tibiofemoral)
Full Ext & ER
20-25o flexion
Ankle Mortise
Full DF
10o PF
Subtalor
Full EV or INV
Midrange PF & DF
Forefoot
1 MTP = 20o DF
2-5 MTP = 20o PF
IP’s = 20o PF

29. 10 simple steps Evaluation and Assessment Determine grades and dosage
Patient position
Joint position
Stabilization
Treatment force
Direction of movement
Speed and rhythm
Initiation of treatment
Reassessment

30. Grades of Oscillations (Maitland)
Grade I - small amplitude movement at the beginning of the range (pain and spasm)
Grade II - large amplitude movement within the midrange of the movement (pain and spasm)
Grade III - large amplitude movement at the end of the range (into restriction)
Grade IV - small amplitude movement at end range when tissue resistance (not pain) is limiting
Grade V - small amplitude, quick thrust manipulation at end range-

31. Normal motion

32. Grades of Oscillations (Maitland)

33. INDICATIONS FOR JOINT MOBILIZATION
Pain, Muscle Guarding, and Spasm
Painful joints, reflex muscle guarding, and muscle spasm treated gentle joint-play techniques to stimulate neurophysiological and mechanical effects
neurophysiological and mechanical effects
stimulate the mechanoreceptors
Inhibit nociceptive stimuli
mechanical effects
Synovial fluid motion provide neutrients to jts

34. The small-amplitude joint techniques used to
treat pain, muscle guarding, or muscle spasm should not
place stretch on the reactive tissues

35. Reversible Joint Hypomobility
joint-play stretching techniques to elongate
hypomobile capsular and ligamentous connective tissue
Positional Faults/Subluxations
Malposition / regain ROM
realign the bony partners
Progressive Limitation
Diseases that progressively limit movement can be treated with joint-play
Functional Immobility
Patient functionaly imobile

36. CONTRAINDICATIONS AND PRECAUTIONS
Hypermobility
Joint Effusion
Inflammation

37. Conditions Requiring Special Precautions for Stretching
Malignancy
Bone disease detectable on radiographs
Unhealed fracture
Excessive pain
Hypermobility in associated joints
Total joint replacements
Newly formed or weakened connective tissue
Systemic connective tissue diseases such as rheumatoid
Elderly individuals