Peripheral Joint Mobilization-- Shoulder JointsHuei-Ming Chai, PT PhDSchool of Physical TherapyNational Taiwan University, Taipei, TaiwanJune 23, 2008

Manual TherapyJoint mobilization for restoration of joint alignment or joint mobilityosteokinematics (physiological movement)arthrokinematics (accessory movement)Mulligans techniques: SNAG, MWMSoft tissue mobilization for establishment of muscular balance (neuromuscular therapy)PNF stretchmuscle energy techniqueSweden massagedeep friction massagemyofascial releaseconnective tissue massagenerve mobilizationChinese massage

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

Rationales of joint mobilizationTo 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 areaTo restore accessory movement (joint play)

Concave-Convex Ruleconcave on convexconvex on concave

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

Closed-Packed PositionThe 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 Jointappropriate for the stage of the joint problem and the skill of the therapist:resting position: for an acute problem or an inexperienced therapistother starting position toward motion barrier: for a skilled therapist in non-acute condition

Hand placementfixation handstabilization of the joint component to be fixedmobilizing handplacing as close to the joint as possible

Techniques (I)directiondistractionglidingamplitudedepending on pain, muscle guarding or degree of limitationMaitland's grades

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

No Pain At Allpainmuscle spamvessel constrictionaccumulation of metabolitesnociceptive stimulation

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 adhesionFor gentle mobilization carried out in the pain-free rangesevere painspasm increased after testingpresence of neurological deficitpain disturbing sleepingFor more vigorous mobilizationjoint irritability minimal with muscle guarding on movementmobility testing limited but does not aggravate painlimitation of motion by tension of tissues rather than painno neurological deficit

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

Patient Response to Joint Mobilizationimproved after treatment continue treatment until symptoms are subsideexacerbated for hours after treatment but improved later continue but decrease dosageexacerbated immediately after treatment reassess patients conditiongentle traction of the treated segmentdocumentation of all physical findingsstationary after 3-5 treatments re-evaluate patients condition

Absolute Contraindicationsbacterial infection: cellulitis neoplasm with metastasis to bone: malignancy or benign tumor (cancer) recent fracture: psudoarthrosisbone disease: Osteogenesis Imperfectapotential destruction of ligaments or capsule: RA or dysplasia of odontoid process

transverse ligamentodontoid process

Relative Contraindicationsjoint effusionin the status of acute inflammationdegenerative joint disease in acute stage or bony blockmarked rheumatoid arthritisosteoporosisinternal derangementgeneral debilitationpregnancyhypermobility in mobility testingmoderate to severe deformitiespsychological changesneurosishysteriadepression

Relative Contraindicationsfor spinal mobilizationvertebral artery insufficiencyligament instability

Mobilization to the Shoulder Joint Glenohumeral jointThoracoscapular articulationSternoclavicular jointAcromioclavicular joint

Glenohumeral Joint (GHJ)convex on cave jointproximal component: concave glenoid cavitydistal component: convex humeral headjoint type: ball and socketDOF = 3flexion/ extension: posterior/ anterior glideabduction/ adduction: inferior/ superior glideexternal/ internal rotation: anterior/ posterior glide Note: retroversion of the humeral head about 30 posterior to the frontal axis of the elbow joint (scapular plane)

Glenohumeral Joint (contd)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 Techniquesdistraction: anterolateralinferior glide: inferolateralposterior glide: posterolateralanterior glide: anteromedial

Distraction of GHJ force direction:anterolateral

Inferior Glide of GHJforce direction:inferolateral

Posterior Glide of GHJforce direction:posterolateral

Anterior Glide of GHJforce direction:anteromedial

Advanced Mobilization Techniquesinferior glide with distractioninferior glide with shoulder internal rotationinferior 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 JointGlenohumeral joint Scapulothoracic articulationSternoclavicular jointAcromioclavicular joint

Scapulothoracic Articulation (STA)concave on convexproximal component: convex rib cage distal component: concave anterior surface of the scapula motion: results of motions occurring at STJ and ACJscapular elevation/ depressionscapular abduction/ adduction scapular upward/downward rotationDOF = 3

Elevation of Scapulaforce direction:superior

Depression of Scapulaforce direction:inferior

Protraction/ Retraction of Scapulaforce direction:lateral

Distraction of the Scapula

Mobilization to the Shoulder JointGlenohumeral jointScapulothoracic articulation Sternoclavicular jointAcromioclavicular joint

Characteristics of SC Jointproximal component -- sternumsaddle-shaped sternal manubriumdistal component -- claviclesaddle-shaped medial end of claviclejoint type: saddle jointdegree of freedom = 3motions

Mobilization to the Shoulder JointGlenohumeral jointScapulothoracic articulation Sternoclavicular joint Acromioclavicular joint

Acromioclavicular Jointproximal 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 wingingscapular tippingscapular upward/downward rotationDOF = 3

hmchai@ntu.edu.twhttp://www.taiwanpt.net