Peripheral Joint Mobilization -- Shoulder Joints Huei-Ming Chai, PT PhD School of Physical Therapy National Taiwan University, Taipei, Taiwan June 23, 2008

Manual Therapy Joint mobilization for restoration of joint alignment or joint mobility osteokinematics (physiological movement) arthrokinematics (accessory movement) Mulligan’s techniques: SNAG, MWM Soft tissue mobilization for establishment of muscular balance (neuromuscular therapy) PNF stretch muscle energy technique Sweden massage deep friction massage myofascial release connective tissue massage nerve mobilization Chinese massage

Mobilization vs. Manipulation mobilization: repetitive passive movement of varying amplitudes of low velocity applied at different parts of the range depending on the effects desired manipulation: a high-velocity thrust of small amplitude performed at the limit of available movement

Rationales of joint mobilization To relieve pain and muscle guarding increasing proprioceptive input to the spinal cord so as to inhibit ongoing nociceptive input to anterior horn cells and central receiving area To restore accessory movement (joint play)

Concave-Convex Rule convex on concave concave on convex

Treatment Plane treatment plane is the plane that parallel to the articular surface of the concave component of the joint to be treated Kaltenborn FM: direction of mobilization define by treatment plane Mulligan B: always parallel or perpendicular to treatment plane only

Closed-Packed Position The joint surface becomes maximally congruent. The joint capsule and major ligaments become twisted, causing joint surface to approximate. The joint become locked so that no further movement is possible in that direction.

Position of Joint appropriate for the stage of the joint problem and the skill of the therapist: resting position: for an acute problem or an inexperienced therapist other starting position toward motion barrier: for a skilled therapist in non-acute condition

Hand placement fixation hand mobilizing hand stabilization of the joint component to be fixed mobilizing hand placing as close to the joint as possible

Techniques (I) direction amplitude distraction gliding depending on pain, muscle guarding or degree of limitation Maitland's grades Range: initial limited full I II III IV V

Techniques (II) velocity slow stretch for capsular or ligamentous tightness or adhesion: application with rhythm, slow speed, and the slack position fast oscillation (rhythm: 2-3 cycles per second) for relieving of pain and muscle guarding in the acute conditions as a treatment chronic conditions to prepare for more vigorous stretching or to promote more relaxation of muscles controlling the joint

No Pain At All pain muscle spam vessel constriction nociceptive stimulation accumulation of metabolites

Indications (I) used in the joints with restriction of joint play that cause pain or restriction of physiological motion, especially in the cases due to capsular or ligamentous tightness or adhesion For gentle mobilization carried out in the pain-free range severe pain spasm increased after testing presence of neurological deficit pain disturbing sleeping For more vigorous mobilization joint irritability minimal with muscle guarding on movement mobility testing limited but does not aggravate pain limitation of motion by tension of tissues rather than pain no neurological deficit

Indications (II) For manipulation used as a progression from vigorous mobilization that has not produced the maximum improvement of signs and symptoms considered possible used as a primary treatment in joints with no articular inflammatory signs and the restricted joint has been identified through mobility testing used in joints with minimal pain that appears only at the end of the range

Patient Response to Joint Mobilization improved after treatment  continue treatment until symptoms are subside exacerbated for hours after treatment but improved later  continue but decrease dosage exacerbated immediately after treatment  reassess patient’s condition gentle traction of the treated segment documentation of all physical findings stationary after 3-5 treatments  re-evaluate patient’s condition

Absolute Contraindications bacterial infection: cellulitis neoplasm with metastasis to bone: malignancy or benign tumor (cancer) recent fracture: psudoarthrosis bone disease: Osteogenesis Imperfecta potential destruction of ligaments or capsule: RA or dysplasia of odontoid process

odontoid process transverse ligament

Relative Contraindications joint effusion in the status of acute inflammation degenerative joint disease in acute stage or bony block marked rheumatoid arthritis osteoporosis internal derangement general debilitation pregnancy hypermobility in mobility testing moderate to severe deformities psychological changes neurosis hysteria depression

Relative Contraindications for spinal mobilization vertebral artery insufficiency ligament instability neutral rotation to left

Mobilization to the Shoulder Joint Glenohumeral joint Thoracoscapular articulation Sternoclavicular joint Acromioclavicular joint

Glenohumeral Joint (GHJ) convex on cave joint proximal component: concave glenoid cavity distal component: convex humeral head joint type: ball and socket DOF = 3 flexion/ extension: posterior/ anterior glide abduction/ adduction: inferior/ superior glide external/ internal rotation: anterior/ posterior glide Note: retroversion of the humeral head about 30º posterior to the frontal axis of the elbow joint (scapular plane)

Glenohumeral Joint (cont’d) neutral position： anatomic position resting position： 70 of shoulder abduction and 30 of flexion (horizontal adduction) closed packed position： 90 of shoulder abduction and full external rotation

Basic Mobilization Techniques distraction: anterolateral inferior glide: inferolateral posterior glide: posterolateral anterior glide: anteromedial

Distraction of GHJ force direction: anterolateral

Inferior Glide of GHJ force direction: inferolateral

Posterior Glide of GHJ force direction: posterolateral

Anterior Glide of GHJ force direction: anteromedial

Advanced Mobilization Techniques inferior glide with distraction inferior glide with shoulder internal rotation inferior glide in sitting position posterior glide in sitting position

Inferior Glide of GHJ with Distraction force direction: inferolateral

Inferior Glide of GHJ with IR force direction: inferolateral

Posterior Glide of GHJ in Sitting force direction: posterolateral

Mobilization to the Shoulder Joint Glenohumeral joint Scapulothoracic articulation Sternoclavicular joint Acromioclavicular joint

Scapulothoracic Articulation (STA) concave on convex proximal component: convex rib cage distal component: concave anterior surface of the scapula motion: results of motions occurring at STJ and ACJ scapular elevation/ depression scapular abduction/ adduction scapular upward/downward rotation DOF = 3

Elevation of Scapula force direction: superior

Depression of Scapula force direction: inferior

Protraction/ Retraction of Scapula force direction: lateral

Distraction of the Scapula

Mobilization to the Shoulder Joint Glenohumeral joint Scapulothoracic articulation Sternoclavicular joint Acromioclavicular joint

Characteristics of SC Joint proximal component -- sternum saddle-shaped sternal manubrium distal component -- clavicle saddle-shaped medial end of clavicle joint type: saddle joint degree of freedom = 3 motions elevation depression posterior rotation A P protraction retraction

Mobilization to the Shoulder Joint Glenohumeral joint Scapulothoracic articulation Sternoclavicular joint Acromioclavicular joint

Acromioclavicular Joint proximal component: convex lateral end of the clavicle distal component: concave acromion process of the scapula joint type: nearly plane joint motion: shoulder girdle motion scapular winging scapular tipping scapular upward/downward rotation DOF = 3

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