Definition

Peripheral joint mobilization (PJM) is the use of skilled graded forces

• toto mobilize joints mobilize joints • toto improve motion improve motion • & to & to normalize joint function.normalize joint function.

Mobilization Techniques are used to

1)1) Improve jt. nutrition. Improve jt. nutrition.

2)2) Improve m. spasm & tensionImprove m. spasm & tension

3)3) Reduce pain.Reduce pain.

4)4) Reverse jt. hypomobility.Reverse jt. hypomobility.

5)5) Improve or restore motion. Improve or restore motion.

6)6) Treat jt. dysfunction as stiffness.Treat jt. dysfunction as stiffness.

A. Joint Mobilization

• Is a type of passive movement performed by the PT Is a type of passive movement performed by the PT at a speed slow enough that the patient at a speed slow enough that the patient can can stop the stop the movement.movement.

• The tech. may be applied with:The tech. may be applied with: 1. 1. Oscillatory motion or Oscillatory motion or 2. Sustained stretch2. Sustained stretch

toto 1.1.↓↓PainPain or or 2.2.↑↑mobility.mobility.

• The tech. may use:1.1. Physiologic orPhysiologic or2.2. Accessory movsAccessory movs..

Indications of Joint MobilizationIndications of Joint Mobilization

1. Pain, m. guarding & spasm All can be treated with gentle joint play technique to All can be treated with gentle joint play technique to stimulate stimulate

neurophysiological & mechanical effectsneurophysiological & mechanical effects..

a. Neurophysiological effect: Small amplitude oscillatory mov → stim mechanoreceptors

→ ↓ transmission of nociceptive stimuli at spinal cord & brain stem levels.

b. Mechanical effects: Small-amplitude distraction Small-amplitude distraction or or gliding mov gliding mov →→ synovial fluid

motion→ bring nutrients to the avascular portions of articular cartilage. (↓ pain of ischemia)

Gentle jt-play → maintain nutrient exchange → prevent painful effects of stasis when a jt is painful or swollen & can’t move through a ROM. (but not in acute or massive swelling)

Precautions

• In most cases jt mobilization is safer than passive angular In most cases jt mobilization is safer than passive angular stretching.stretching.

But • Sometimes Jt mobilization can be used with extreme care in:Sometimes Jt mobilization can be used with extreme care in:

1.1. MalignancyMalignancy --»» spread & growthspread & growth..2.2. Excessive painExcessive pain -»-» m. guarding, prevent mov.m. guarding, prevent mov.3.3. Total jt. replacement Total jt. replacement

-» -» disl. or loosen internal fixation.disl. or loosen internal fixation.4.4. Bone diseaseBone disease (Osteoporosis, TB, Rickets).(Osteoporosis, TB, Rickets).5.5. Unhealed #Unhealed # (site & stabilization)(site & stabilization)

-» -» re-fracture.re-fracture.6.6. HypomobilityHypomobility (in associated jts & m. weak) (in associated jts & m. weak)

-» -»↑↑ capsule laxity, lig. Weakness & jt capsule laxity, lig. Weakness & jt disl.disl.

Procedure for Applying Jt Mobilization Techniques

Possibilities for pain

While moving or mobilizing & found!1.1. Before Before tissue limitationtissue limitation (after acute injury or active stage of a

disease), useuse pain inhibiting jt. tech to relieve pain pain inhibiting jt. tech to relieve pain & & maintain jt. play.maintain jt. play.

1.1. WithWith tissue limitation tissue limitation as damaged tissue begins to heal) (subacute), useuse gradual gentle stretching tech to tight tissue, but gradual gentle stretching tech to tight tissue, but Don’t exacerbate pain by injuring the tissues.Don’t exacerbate pain by injuring the tissues.

2.2. After After tissue limitations tissue limitations (as stretching a tight capsule or a (as stretching a tight capsule or a peri-articular tissue ofperi-articular tissue of chronic stiff joints),chronic stiff joints),

use ↓ force of the stretching techniques. ↓ force of the stretching techniques.

Grades of mov. (Dosage, Amplitude))

systems of techniques:systems of techniques:

1. Graded oscillation.1. Graded oscillation.

2. Sustained translatory joint Play2. Sustained translatory joint Play..

11 . .Graded Oscillation Tech. DosageGraded Oscillation Tech. Dosage

GradeGrade II

SmallSmall amplitudeamplitude rhythmic oscillations rhythmic oscillations at the beginning of at the beginning of ROM.ROM.

GradeGrade IIII

LargeLarge amplitudeamplitude rhythmic oscillations rhythmic oscillations within within the ROM, the ROM, butbut not reaching the limitation.not reaching the limitation.

GradeGrade IIIIII

LargeLarge amplitudeamplitude rhythmic oscillations up to the limit of rhythmic oscillations up to the limit of available motion available motion && stressed into stressed into tissue resistance.tissue resistance.

GradeGrade IVIV

SmallSmall amplitudeamplitude rhythmic oscillations, up to the limit of the rhythmic oscillations, up to the limit of the available motion available motion & & stressed into stressed into tissue resistancetissue resistance..

GradeGrade VV

SmallSmall amplitudeamplitude, high velocity, , high velocity, thrust thrust technique.. technique.. Performed to break adhesions Performed to break adhesions at the level of available motion at the level of available motion (manipulation or chiropractic). ((StretchStretch))

Graded oscillation technique

Techniques

• Oscillations may be done using:Oscillations may be done using:

1- 1- Physiologic Physiologic (osteokinematic) motions(osteokinematic) motions. .

2- 2- Joint play Joint play ((arthrokinematic) techniques.arthrokinematic) techniques.

Sustained Translatory joint Play Technique

• Grade IGrade I (Loosen): (Loosen):

Small amplitude distraction, applied where no stress is placed on the capsule.

. . 1.1. Equalizes cohesive force, Equalizes cohesive force, 2. M. tension 2. M. tension 3. Atmospheric pressure acting on the jt.3. Atmospheric pressure acting on the jt.

• Grade IIGrade II ((Till tightness): Till tightness):

Distraction or glide applied to tightend tissues around jt.

• Grade III:Grade III:

Distraction or glide with large enough amplitude to place a stretch on jt. capsule & surrounding peri-articular structures.

Sustained translatory joint-play technique

Uses

• Grade I: Used with gliding motions to relieve pain..

• Grade II: Used to determine how sensitive the jt is.

• Grade III: Used to stretch jt. structures & ↑ jt play.

• Technique:Technique:

This grading system describes jt. play techniques that This grading system describes jt. play techniques that separate or glide (slide) jt surfaces.separate or glide (slide) jt surfaces.

N.B.

• The consistency between the dosage of the two grading systems isThe consistency between the dosage of the two grading systems is grade I grade I (no tension on the jt capsule or surroundings).(no tension on the jt capsule or surroundings).

• Grade III Grade III (sustained stretch)(sustained stretch) & & IVIV (oscillation)(oscillation) are similar in dosage as they are similar in dosage as they are applied with a stretch force at the limit of the motion.are applied with a stretch force at the limit of the motion.

• Using oscillating or sustained tech., depends on the pt’s response.Using oscillating or sustained tech., depends on the pt’s response.

• Pain management: use oscillating tech.Pain management: use oscillating tech.

• Loss of jt. playLoss of jt. play && ↓↓ functionfunction: use sustained stretch.: use sustained stretch.

• To maintain available RTo maintain available R.:.:

Use either grade II! oscillatingUse either grade II! oscillating oror II sustained technique. II sustained technique.

Patient Position

Patient PositionPatient Position The pt. & treated extremity should The pt. & treated extremity should be carefully positioned & relaxed.be carefully positioned & relaxed.

The jt. is positioned so that the capsule has greatest laxity.

Stabilization

• Firm & comfortable stabilization for proximal Firm & comfortable stabilization for proximal parts by using:parts by using:

1.1. Belt.Belt.2.2. PT hand. PT hand. 3.3. External assistance.External assistance.

Force

• Treatment forceTreatment force (gentle or strong) is applied as close to the is applied as close to the opposing jt. surfaces as possible.opposing jt. surfaces as possible.

• The larger the contact surface of PT handThe larger the contact surface of PT hand → the more → the more comfortable procedure will be.comfortable procedure will be. e.g.e.g. use flat surface of the hand instead of forcing with the thumb. use flat surface of the hand instead of forcing with the thumb.

Direction of Movement

• Either parallel to, or perpendicular to treatment plane.Either parallel to, or perpendicular to treatment plane.

• Joint tractionJoint traction:: Perpendicular to ttt plane. Perpendicular to ttt plane. The entire bone is moved → jt surfaces are separated.The entire bone is moved → jt surfaces are separated.

• Gliding techniqueGliding technique: : Parallel to the ttt plane.Parallel to the ttt plane. This is determined by using the convex-concave rule. This is determined by using the convex-concave rule. • If the surface of moving bone is convex -→ opposite direction glideIf the surface of moving bone is convex -→ opposite direction glide• If the surface of moving bone is concave → glide in the same direction.If the surface of moving bone is concave → glide in the same direction.

The entire bone is moved, so there’s gliding of one jt. surface on the The entire bone is moved, so there’s gliding of one jt. surface on the other.other.

No swing of the bone that causes rolling & compression of the jt. No swing of the bone that causes rolling & compression of the jt. surfacessurfaces