Mobilisations Presentation 04.02.17

@Physiocouk #manchesterphysio facebook.com/physiocouk

WelcomeAn introduction to mobilisations and manual therapy for sports and massage therapists

With Katie Emmett & Kate Hindley

3@Physiocouk #manchesterphysio facebook.com/physiocouk

Who are we?Katie’s LinkedIn: www.linkedin.com/katieemmett Twitter: @KatiePhysiocouk

Kate’s LinkedIn: www.linkedin.com/katehindley Twitter: @Katephysiocouk

Let’s connectWebsite: www.physio.co.ukTwitter: @physiocoukFacebook: www.facebook.com/physiocouk

Aims of today

Learn the theory of joint mobilisations

Learn how to assess a joint before mobilisingPractice different joint mobilisations

Learn the evidence and research behind joint mobilisations

Itinerary10.00 - 10.30: Induction/arrival 10.30 – 11.30: Theory: Mobilisations and Manual therapy11.30 – 12.00: Assessment Practical12.00 – 12.30: Lunch 12.30 - 13.30 : Practical: Mobilisations and Manual therapy 13.30 - 14.00: Evidence and recent research 14.00 – 15.00: Case studies and Practical

Theory:Joint Mobilisations and Manual Therapy

Definition of a joint mobilisation

A skilled passive movement of the articular surfaces performed by a physical therapist to decrease pain or increase joint mobility.

Edward P. Mulligan, 2001

Anatomy of a synovial joint

• The synovial joint is the most common type of joint found in the body

• Most evolved and therefore most mobile type of joints

• Articular surfaces are covered with hyaline cartilage

Anatomy of a synovial joint

• Between the articular surfaces there is a joint cavity filled with synovial fluid

• The joint is surrounded by an articular capsule which is fibrous in nature and is lined by synovial membrane

• The synovial membrane lines the entire joint except the articular surfaces covered by hyaline cartilage

Types of synovial joints

• Pivot

• Ball and Socket

• Hinge

• Condyloid

• Saddle

• Gliding

Joint kinematics

Understanding joint movement…• Physiological – “movement you see”

• Accessory – “movement you feel”

Physiological

• Known as Osteokinematic joint movements

• The natural movements that occur in our joints

• Rotation around an axis

• Can be analysed from movement quality and symptom response

Physiological Movement occurs in different

planes…

Accessory

• Known as Arthrokinematic joint movements

• Articular movements between two joint surfaces:• Roll• Glide • Spin

• Occur with all active/passive physiological joint movement.

• Necessary for full, pain-free range of movement

• Movements that we FEEL

Arthrokinematic Roll

• New points of one surface come into contact with the other surface

• This can only occur when the two joint surfaces are incongruent

• Analogy: wheel

Arthrokinematic Glide

• One joint surfaces slides or translates over the other

• Occurs when two surfaces are congruent and flat, or congruent and curved

• Analogy: An ice-skater’s blade (one point) sliding across the ice surface (many points)

Arthrokinematic Spin

• Rotation around a longitudinal axis

• One joint surface rotates around another

• Analogy: a top spinning on the table (if it were to remain upright and in one place)

Joint Morphology

Joint surfaces can be described as either:

1. Convex: Male, Arched, Rounded

2. Concave: Female, Shallow, Hollowed

Knowing that a joint surface is concave or convex is important because shape determines motion

Convex on Concave

• Concave surface is fixed and the convex surface moves over it.

• Physiological and accessory joint movements occur in the opposite direction

• Glide and Roll are in opposite directions

Concave on Convex

• Convex segment is static with the concave surface moving over it

• Physiological and accessory joint motions are in the same direction

• Roll and glide are in the same direction

Assessment

Assessing physiological joint movements

The therapist passively takes joints through their available range.

Used to assess:

1. Available range of movement at a joint2. Presence/absence of a capsular pattern3. End-feel4. Pain

Capsular Patterns – Cyriax (1982)

• A series of limitations of joint movement when the joint capsule is a limiting structure.

• Usually represents pathology/restriction from within the joint or capsule itself.

• Unique pattern to each synovial joint

• Assessed by evaluating the available ROM and ‘end-feel’ in joints passively

Joint Capsular Pattern (in order of most limited)

Cervical Spine Side flexion & rotations equally limited,extension

Thoracic Spine Side flexion & rotation equally limited, extension

Lumbar Spine Extension, Side flexion & rotation equally limited.

Shoulder (Glenohumeral) Lateral rotation, abduction, medial rotation

Elbow (Humeroulnar) Flexion, extension

Wrist Flexion & extension equally limited

Hip Medial rotation, flexion, abduction

Knee Flexion, extension

Ankle (Talocrural) Plantar flexion, dorsi flexion

End-feels

‘The specific sensation imparted through the examiner’s hands at the extreme of passive movement’ (Cyriax, 1982)

Can be categorised as either:

• Normal end-feel• Abnormal end-feel

Normal End-feels

1. HardBone-to-bone approximation E.g. extension of the elbow

2. SoftCharacteristic of a stop to the movement due to approximation of tissueE.g. Knee flexion

3. Elastic Felt when tissues are placed on a passive stretch causing an elastic resistance E.g. Lateral rotation of the hip or shoulder

Abnormal End-feels

1. HardDifferent from that of ‘normal’ hard end-feel Often felt in early OAInvoluntary muscle spasm causes provides a break to movementAlso due to capsular contracture

2. SpringyAssociated with mechanical joint displacement, usually a loose bodyFeels like the joint springs or bounces back just before end range

3. EmptyExaminer does not have the opportunity to appreciate true end-feelDue to pain or apprehension

Practical

Assessment Workshop 1

In pairs assess PROM in the following joints:

• Shoulder• Hip• Knee• Lumbar Spine (AROM)• Ankle• Cervical Spine

Feedback capsular patterns for each joint

Assessment Workshop 2

Assessing the normal end-feel of joints.

• Knee flexion and extension• Elbow extension• Shoulder medial rotation• Cervical side flexion• Hip lateral rotation

Cause of limited motion Identification Intervention

Intra-articular adhesions/capsular stiffness

• Capsular end-feel• Palpation• ROM unaffected by

proximal or distal joint positioning

• Joint mobilisations

Shortened muscle groups/soft tissue restrictions

• Palpation• ROM affected by

proximal or distal joint positioning

• Stretch• Heat• Soft tissue

mobilisation/Myofascial release

Muscle weakness • ROM affected by gravity/resistance

• Strengthen

Pain • Empty end-feel• Reduced willingness to

perform active movements

• Joint mobilisations

Nerve-root irritation • Neural tension tests • Neural mobilisations• Joint mobilisations

Aims of joint mobilisations

Restoring normal range of movement

Pain gate theory

Descending inhibition

Increased local blood flow

Synovial sweep

Restoring normal range of movement

• Reduces pain (PGT)

• Enables normal biomechanics

• Functional movement

• Indication of proper muscle tone and balance around a joint

• Abnormal joint function are secondary to abnormal postures, injury and stress

Pain gate theory (PGT)• Proposed in 1965 by Melzack and Wall

• Commonly used explanation of pain transmission

• 3 types of sensory nerves involved in the transmission:

• A- Beta fibres • A- Delta fibres • C-fibres

Pain gate theory (PGT)

- a-beta fibresResponsible for “sharp” pain, large diameter and myelinated, fast transmission fibre - a-Delta fibres Small diameter and myelinated, responsive to vibration and light touch – fast reactive - C – fibres Small diameter and un-myelinated, throbbing or burning, slow

• Size = bigger a nerve, the quicker its conduction

• Speed = increased with myelin sheath

Pain gate theory (PGT)• All nerves synapse onto projection cells and

travel up the CNS to the brain

• Spinal cord has inhibitory interneurons acts as “gate keeper”

• When there is no sensation from the nerves the inhibitory interneurons stop signals – no need for brain response (“gate closed”)

• When smaller fibres are stimulated the inhibitory interneurons do not act – “gate open”

• Pain is sensed

Descending inhibition• Mobilisations have shown to stimulate areas if the

brain, instrumental in experience of pain

• These areas include:- Anterior cingulate cortex (ACC)- Amygdyla- Periaqueductal Gray (PAG)- Rostral Ventromedial Medualla (RVM)

• The doral area of PAG and RVM, have been shown to selective produce analgesia to cause sympatho-excitation and the release of endorphins

Increased local blood flow

Increased nutrition supply

Remove inflammatory exudate

Produces movement so that blood/fluid can move in and out of articular cartilage within joints

Maintenance of healthy articular cartilage and proper joint function.

Stimulates repair of cellular damage

Enhances the healing process

Synovial sweep • Lubrication of a joint through a 'synovial sweep'

mechanism

Synovial sweep • An oscillation/movement increases

lubrication of cartilage • Provides nutrients to maintain healthy

joints • Elasticity increases range of movement• Synovial fluid is found in the cavities of

synovial joints• Egg white–like consistency, with the

principal role of reducing friction between the articulating surfaces during movement.

• Lack of lubricated synovial fluid causes poor joint dysfunction and secondary injuries

Precautions to joint mobilisations • Excessive pain or swelling • Arthroplasty • Pregnancy • Hypermobility • Spondylolisthesis • Rheumatoid arthritis • Vertebrobasilar insufficiency

ABSOLUTE CONTRAINDICATIONS• Malignancy in area of treatment• Infectious Arthritis• Metabolic Bone Disease • Neoplastic Disease• Fusion or Ankylosis • Osteomyelitis• Osteoporosis • Fracture or Ligament Rupture

Treatment PrinciplesNeed to consider the following:

1. The Desired Effect - what effect of the mobilisation is the therapist wanting? Relieve pain or stretch tissues?

2. The Starting Position - of patient and therapist to make the treatment effective and comfortable.

3. The Direction - AP/PA

4. The Method of Application - The position, grade, amplitude, rhythm and duration of the technique.

5. The Expected Response - Should the patient be pain-free, have an increased range or have reduced soreness?

(Hengeveld and Banks, 2005)

Treatment Principles

1 oscillation per second = 30 oscillations if high SIN factor / 60 if low SIN factor (Donatelli, 2001)

Maitland’s grading system

Small amplitude movement at the beginning of the available ROM

Clinical Reasoning: Donatelli (2001)

• 7-10/10 VAS pain rating• Pain before resistance upon palpation• Acute phase of injury• Inflammatory phase of healing• Aim to reduce pain and neutralise joint

pressures

Grade 1

Grade 2Large amplitude movement at within the available ROM

• 5-7/10 VAS pain rating• Pain and resistance occur simultaneously upon

palpation• Proliferation stage of recovery• Aim to reduce pain and neutralise joint pressures

Grade 3Large amplitude movement that reaches the end ROM

• 3-5/10 VAS pain rating• Resistance before pain• Scar maturation/remodelling phase of healing• Aim to treat stiffness/hypomobility

Grade 4Small amplitude movement at the very end range of motion

• 1-3/10 VAS pain rating• Increase ROM through promotion of capsular

mobility and plastic deformation

Practical and Case studies

Lumbar Spine

Thoracic spine

Lumbar spine: Case study 1

33 year old women who works as a social worker. Reports a lifting and twisting injury 2 days ago. Immediate pain into lumbar spine and referred unilateral leg sensations. Aggravating factors are bending forwards and prolonged sitting. Finds walking and bending backwards easing. She rates her pain score 8/10 on the VAS scale.

• Diagnosis?• What mobilisations would you perform to relieve

symptoms?• What grade would you perform?

55 year old taxi driver involved in a RTC 2 weeks ago. Reports instant pain and reduced range of movement and now struggles to check blind spot during driving. His current VAS score is 7/10.Objective findings of limitation in bilateral side flexion and rotation.

• Diagnosis?• What mobilisations would you perform to relieve

symptoms?• What would you reassess after treatment?

Neck: Case study 2

Hip: Case study 3 60 year old female reports gradual onset of pain into right hip (5/10 VAS). The main aggravating factors are prolonged standing and walking and she also reports morning stiffness. Objective findings of a mild capsular pattern are found. Diagnosis is OA of the R hip.

• What is the capsular pattern of the hip?• What mobilisations would you perform to relieve

symptoms?• What grade would you perform?• What else would you advise to this patient?

Evidence

Upper Extremity Comparison of Supervised Exercise With and Without Manual Physical Therapy for Patients With Shoulder Impingement Syndrome (Bang et al, 2000):

Manual therapy combined with supervised clinical exercise resulted in superior outcomes to exercise alone in patients with shoulder impingement syndrome

The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome (Conroy et al, 1998):

Mobilisation decreased 24-hour pain and pain associated with subacromial compression test in patients with shoulder impingement syndrome

Lower ExtremityA randomised controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains (Green et al, 2001)

Addition of talocrural mobilizations to the RICE protocol in the management of inversion ankle injuries necessitated fewer treatments to achieve pain-free dorsiflexion and to improve stride speed more than RICE alone.

Effect of physical therapy on limited joint mobility in the diabetic foot. A pilot study (Dijs et al, 2001)

Joint mobilization and physical therapy resulted in a significant, although temporary, improvement in the mobility of the ankle and foot in diabetic patients with limited joint mobility and neuropathy

Spinal Mobilisations Manipulation or mobilisation for neck pain: A Cochrane Systematic Review (Gross et al, 2010)

27 trials reviewed by two authorsModerate quality evidence suggested manipulation and mobilisation produced similar effects on pain, function and patient satisfactionLow quality evidence supported thoracic manipulation as an additional therapy for pain reduction and increased function in acute pain Mobilisation for neck pain, low quality evidence for subacute and chronic neck pain indicated that:

1. A combination of Maitland mobilisation techniques was similar to acupuncture for immediate pain relief and increased function

2. There was no difference between mobilisation and acupuncture as additional treatments for immediate pain relief and improved function

3. Neural dynamic mobilisations may produce clinically important reduction of pain immediately post-treatment.

References• Cyriax, J. (1982). Textbook of Orthopaedic Medicine, 8th edn. Bailliere Tindell,

London. • Hengeveld, E. & Banks, K. (2005). Maitland's Peripheral Manipulation. 4th ed.

Elsevier: London.• Donatelli 2001• Bang, M. D., & Deyle, G. D. (2000). Comparison of supervised exercise with and

without manual physical therapy for patients with shoulder impingement syndrome. Journal of Orthopaedic & Sports Physical Therapy, 30(3), 126-137.

• Conroy, D. E., & Hayes, K. W. (1998). The effect of joint mobilization as a component of comprehensive treatment for primary shoulder impingement syndrome. Journal of Orthopaedic & Sports Physical Therapy, 28(1), 3-14.

• Green, T., Refshauge, K., Crosbie, J., & Adams, R. (2001). A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Physical therapy, 81(4), 984-994.

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