JOINT MOBILIZATION
PREPARED BY: DR RAHUL CHHATLANI
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MOBILIZAION
CONTENT
• introduction • grades or dosages of
• terminology movement
• • positioning and stabilization
physiological & accessory motion
• basic concepts of joint motion • Treatment force and
• difference between passive direction of movement
stretching and joint • Initiation and progression of
mobilization(glide) treatment
• indications • Speed, Rhythm and
• Contraindications Duration of Movements
• precautions • MWM
• examination and evaluation
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INTRODUCTION
• Joint Mobilization…
- Manual therapy technique
- Used to modulate pain
- Used to increase ROM
- Used to treat joint dysfunctions that
limit range of motion (ROM).
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INTRODUCTION
• Factors that may alter joint mechanics:
- Pain & Muscle guarding
- Joint hypomobility
- Contractures or adhesions in the joint
capsules or supporting ligaments
- Malalignment or subluxation of bony
surfaces
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INTRODUCTION
• How it differs from stretching?
- Mobilization: specifically address
restricted capsular tissue by replicating
normal joint mechanics while
minimizing abnormal compressive
stresses on the articular cartilage in the
joint
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TERMINOLOGY
• 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
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TERMINOLOGY
• Mobilization/Manipulation (cont)
- The varying speeds and amplitudes
could range from a small-amplitude
force applied at high velocity to a large-
amplitude force applied at slow velocity
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TERMINOLOGY
• Self-Mobilization(Auto-mobilization)
- It refers to self-stretching techniques
that specifically use joint traction or
glides that direct the stretch force to
the joint capsule.
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TERMINOLOGY
• Mobilization with Movement
- It is concurrent application of sustained
accessory mobilization applied by a
therapist and an active physiological
movement to end range applied by the
patient.
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Physiological & Accessory Motion
Physiological Motion Accessory Motion
Movements the Movements in the joint
patient can do and surrounding
voluntarily. tissues that are
Traditional necessary for normal
movements. ROM.
Also called Also called
osteokinematics. arthrokinematics.
can not be actively
performed by the
patient.
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ACCESSORY
MOTION
COMPONENT
JOINT PLAY
MOTION
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• Motions that accompany
active motion, but are not
COMPONENT under voluntary control
• Ex:
MOTION Upward rotation of
scapula & rotation of clavicle
that occur with shoulder
flexion.
• Motions that occur between
the joint surfaces
• Determined by joint
JOINT PLAY capsule’s laxity
• Can be demonstrated
passively, but not performed
actively.
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Basic concepts of joint motion :
Arthrokinematics
• JOINT SHAPES:
- Ovoid – one surface is convex, other
surface is concave.
eg. Radio carpal joint.
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Basic concepts of joint motion :
Arthrokinematics
• Sellar (saddle) – one surface is concave in
one direction & convex in the other, with
the opposing surface convex & concave
respectively.
• Ex. First carpo metacarpal joint.
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Basic concepts of joint motion :
Arthrokinematics
• Types of joint motion
• 5 types of joint arthrokinematics
Roll
Slide
Spin
Compression
Distraction
• Joint motion usually often involves a
combination of rolling, sliding & spinning
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Roll
• Surfaces are incongruent
• New points on one surface meet new
points on the opposing surface
• Rolling results in angular motion of
bone
• Rolling is always in same direction
• It causes compression of the surfaces on
the side to which the bone is swinging
and separation on other side
• Normally pure rolling does not occur
alone
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Roll
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Spin
• Rotation about stationary mechanical axis
• Same point on the moving surface creates
an arc of a circle
• Occurs in combination with rolling and
sliding.
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Spin
• E.g. humerus flexion/extension, hip
flexion/extension, radio-humeral
pronation/supination
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Slide
• Surfaces must be congruent for pure
slide
• Same point on one surface meet new
points on opposing surface
• Sliding does not occur alone
• Direction of sliding depends on the
shape of moving surface
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convex-concave rule
• A) Sliding is in opposite
direction of the angular
movement of the bone if
the moving joint surface
is convex.
• B) Sliding is in same
direction of the angular
movement of the bone if
the moving surface is
concave.
• ‘
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Combined roll- slide in a joint
• If surfaces are more congruent- more of
sliding
• If joint surfaces are more of incongruent-
more of rolling
• When muscles actively contract to move a
bone, some of the muscles may cause or
control the sliding movement of the joint
surfaces. For example, the caudal sliding
motion of the humeral head during
shoulder abduction is caused by the rotator
cuff muscles.
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• When a passive mobilization technique
is applied to produce a slide in the joint
– referred to as a GLIDE
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What is the difference
between passive stretching
and joint mobilization(glide)
stretching?
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Passive Angular Stretching Joint Mobilization(glide)
Stretching
when the bony lever is
used to stretch a tight
joint capsule, may cause
increased pain or joint safer and more selective
trauma because: because
• Lever significantly • Close to joint surface with
increase the force at joint controlled intensity
• Excessive joint • Replicate sliding
compression in rolling component and does not
direction compress the cartilage
• Roll without slide does • Force can be selectively
not replicate normal joint applied to the desired
mechanics tissues only
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Other accessory motions
• Compression – decrease in joint space between
bones
• Normally occurs in the weight bearing joints
• Provide stability to joint
• Compression occur on the side in which the
bone is angulating
• Move synovial fluid and maintain cartilage
health
• Abnormal compressive load may damage the
cartilages.
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Other accessory motions
Traction ≠ Distraction
A longitudinal pull Separation or pulling apart
• Traction does not always turns into distraction. E.g.
glenohumeral joint, pull at right angle to glenoid fossa
is required.
• For clarity, whenever there is pulling on the long axis
of a bone, the term long-axis traction is used.
Whenever the surfaces are to be pulled apart, the term
distraction, joint traction, or joint separation is
used.
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INDICATIONS FOR JOINT
MOBILIZATION
• Pain, Muscle Guarding, and Spasm
- Painful joints, reflex muscle guarding,
and muscle spasm can be treated with
gentle joint-play techniques to stimulate
neurophysiological and mechanical effects
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Neurophysiological effects
Small amplitude oscillatory mov
stimulates mechanoreceptors
↓ transmission of nociceptive
stimuli at spinal cord & brain
stem levels.
Pain
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Nutritional effects :–
Distraction or small gliding
movements
Synovial fluid motion
Bring nutrients to the avascular
portions of articular cartilage.
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INDICATIONS FOR JOINT
MOBILIZATION
Reversible Joint Hypomobility
Positional Faults
Progressive Limitation
Functional Immobility
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CONTRAINDICATI PRECAUTIONS
ONS
• Malignancy
• Hypermobility • Bone disease
• Joint effusion’ • Unhealed fractures
• Excessive pain
rapid swelling ( bleeding)
• Joint replacement surgery
slow swelling (serous
effusion) • Newly formed or weak
• Inflammation connective tissues
• Systemic connective tissue
disease
• Elderly persons
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PROCEDURE FOR
APPLYING PASIVE
JOINT MOBILIZATION
TECHNIQUES
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Examination and evaluation
• Quality of pain
• Pain experienced before tissue
limitation-acute
• Pain experienced concurrently with
tissue limitation-healing
• Pain experienced after tissue limitation
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Examination and evaluation
(cont)
• Capsular restriction
• ROM is limited in a capsular pattern
• Firm end feel
• Decreased joint-play movement
• Subluxation or dislocation
• may require thrust technique
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Grades or Dosages of Movement
• Graded Oscillation Techniques
• Sustained Translatory Joint-Play
Techniques
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Graded Oscillation Techniques
• Dosages
• Grade I: Small-amplitude rhythmic
oscillations are performed at the beginning
of the range.
• Grade II: Large-amplitude rhythmic
oscillations are performed within the range,
not reaching the limit.
• Grade III: Large-amplitude rhythmic
oscillations are performed up to the limit of
the available motion and are stressed into the
tissue resistance.
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Graded Oscillation Techniques
(cont)
• Grade IV: Small-amplitude rhythmic
oscillations are performed at the limit
of the available motion and stressed
into the tissue resistance.
• Grade V: A small-amplitude, high-
velocity thrust technique.
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Graded Oscillation Techniques
(cont)
• Uses
• Grades I & II
– Pain
• Grades III & IV
–Stretching
maneuvers
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Graded Oscillation Techniques
(cot)
• Techniques
• May be performed using physiological
motions or joint-play techniques
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Sustained Translatory Joint-Play
Techniques
• Dosages
• Grade I (loosen): Small-amplitude
distraction is applied where no stress is
placed on the capsule. It equalizes
cohesive forces, muscle tension, and
atmospheric pressure acting on the joint.
• Grade II (tighten): Enough distraction or
glide is applied to tighten the tissues
around the joint. “Taking up the slack.”
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Sustained Translatory Joint-Play
Techniques (cont)
• Grade III (stretch): A distraction or
glide is applied with an amplitude large
enough to place stretch on the joint
capsule and surrounding periarticular
structures.
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Sustained Translatory Joint-Play
Techniques (cont)
• Uses
• Grade I – with all gliding
movt. & relief Pain
• Grade II – to inhibit pain
• Grade III – to stretch the
joint structures.
•
• Techniques
• Performed only using
joint-play techniques.
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Comparison
• In both the systems Grade I and II are Low
intensity and do not stretch capsule so usually
indicated for pain relief
• Grade III and IV oscillations and Grade III
sustained stretch generate a stretch force to
capsule, so used to improve ROM
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Positioning and Stabilization
• Patient should be comfortable
• The muscles surrounding a joint should be
relaxed
• First treatment in the resting position of joint
• With progression of treatment the joint is
positioned at or near the end of available
ROM
• Stabilize the part, usually the proximal bone
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Treatment force and direction
of movement
• Force applied close to the joint surface
• Whenever possible use larger contact
• Direction of movement is either parallel
or perpendicular to the treatment plane
(T.P.)
• Distraction perpendicular to T.P.
• Gliding parallel to T.P. (convex-
concave rule)
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Treatment force and direction
of movement (cont)
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Initiation and progression of
treatment
• Sustained grade-2 distraction of the
joint surface
• Joint held in resting position or in
relaxed position
• Next day…
• Pain is increased then reduce
amplitude to G-I oscillations
• Joint is same then repeat the same
maneuver and then progress to
stretching techniques
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Initiation and progression of
treatment
• To maintain joint play sustained G II
or G II oscillation techniques
• To progress – move the bone to end of
available ROM and apply G III
distraction or glide
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Speed, Rhythm and Duration
of Movements
• Oscillations
• Grades I and IV are rapid oscillations like manual
vibrations
• Grades II and III are smooth, regular oscillations
at 2 or 3 per second for 1 to 2 minutes
• Sustained
• For painful joints distraction for 7-10 sec with
few seconds rest in between
• For restricted joints minimum of 6 sec stretch
followed by partial release then repeat with
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Mobilization with movement
• MULLIGAN concept- “comfort and
capabilities restored instantly in a pain-
free way”.
• Developed by BRAIN R.MULLIGAN
in 1984.
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Mobilization with Movement
Principles
• While the therapist sustains the pain-free
accessory mobilization, the patient is
requested to perform the comparable sign.
The comparable sign should now be
significantly improved; that is, there
should be increased ROM, and the motion
should be free of the original pain.
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Mobilization with Movement
• Comparable sign include loss of joint
play movement, loss of ROM, or pain
associated with movement during
specific functional activities such as
lateral elbow pain with resisted wrist
extension or pain with overhead
reaching.
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Mobilization with Movement
• Failure to improve the comparable
sign would indicate that the therapist
has not found the correct direction of
accessory mobilization or the grade
of movement
• Repeated 6 to 10 times
• Further gain can be expected by pain-
free passive overpressure.
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References
• Therapeutic exercise (Kisner Colby)
• Manual of mulligan concept (Dr.Dipak
Kumar)
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