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B.ARUNB.ARUNB.ARUNB.ARUN.,MPT,CMPT,COHS.,MPT,CMPT,COHS.,MPT,CMPT,COHS.,MPT,CMPT,COHS

ORTHOPEDIC PHYSIOTHERAPYORTHOPEDIC PHYSIOTHERAPYORTHOPEDIC PHYSIOTHERAPYORTHOPEDIC PHYSIOTHERAPY

DEFINITION

• Mobilizations: these are passive movements

performed by therapist at a slow speed enough

that the patient can stop the movement.

• Manipulations: these are sudden movements

performed with a high velocity, short amplitude

motion such that the patient cannot prevent the

motion.

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Terminology

• Mobilization – passive joint movement for

increasing ROM or decreasing pain

– Applied to joints & related soft tissues at varying

speeds & amplitudes using physiologic or accessory motions

– Force is light enough that patient’s can stop the movement

• Manipulation – passive joint movement for

increasing joint mobility

– Incorporates a sudden, forceful thrust that is beyond the patient’s control

Terminology

• Self-Mobilization (Automobilization) –self-stretching techniques that specifically use joint traction or glides that direct the stretch force to the joint capsule

• Mobilization with Movement (MWM) –concurrent application of a sustained accessory mobilization applied by a clinician & an active physiologic movement to end range applied by the patient– Applied in a pain-free direction

Terminology• Physiologic Movements – movements done

voluntarily

– Osteokinematics – motions of the bones

• Accessory Movements – movements within the

joint & surrounding tissues that are necessary for

normal ROM, but can not be voluntarily performed

– Component motions – motions that accompany active

motion, but are not under voluntary control

• Ex: Upward rotation of scapula & rotation of clavicle that occur with shoulder flexion

– Joint play – motions that occur within the joint

• Determined by joint capsule’s laxity

• Can be demonstrated passively, but not performed actively

Terminology• Arthrokinematics – motions of bone surfaces within the

joint– 5 motions - Roll, Slide, Spin, Compression, Distraction

• Muscle energy – use an active contraction of deep muscles that attach near the joint & whose line of pull can cause the desired accessory motion– Clinician stabilizes segment on which the distal aspect of the

muscle attaches; command for an isometric contraction of the muscle is given, which causes the accessory movement of the joint

• Thrust – high-velocity, short-amplitude motion that the patient can not prevent– Performed at end of pathologic limit of the joint (snap adhesions,

stimulate joint receptors)

– Techniques that are beyond the scope of our practice!

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Joint Surfaces of Ovoid

and Sellar Joints KINEMATICS • Physiological Movements & Accessory

movements.

• Also called as

• Osteokinematics (Physiological

movements)

• Arthrokinematics. (Accessory movements

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Osteokinematics

• Deals about the movement present in the joint

• Helps to find out the amount of Motion

available in particular joint

• Can be visualized

• Can be measured

• Also called as Physiological movements

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ARTHROKINEMATICS

• Also termed as Accessory movements

• Movements occurs inside the joint.

• Responsible for improving Physiological

movements.

• Restriction in accessory motion results in

decrease of physiological movements.

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Arthrokinematics

• Roll

• Glide / Slide

• Spin

• Compression

• Distraction26-11-2008 11

Roll

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Slide Spin

Compression Distraction

CONCAVE AND CONVEX

RULE

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Grades of Movement in a

Normal and a Restricted Joint

Adapted by permission from G. Maitland 1991.

Maitland Joint Mobilization

Grading Scale• Grading based on amplitude of movement &

where within available ROM the force is applied.

• Grade I– Small amplitude rhythmic oscillating movement at the

beginning of range of movement– Manage pain and spasm

• Grade II– Large amplitude rhythmic oscillating movement within

midrange of movement– Manage pain and spasm

• Grades I & II – often used before & after treatment with grades III & IV

• Grade III– Large amplitude rhythmic oscillating movement up to

point of limitation (PL) in range of movement

– Used to gain motion within the joint– Stretches capsule & CT structures

• Grade IV– Small amplitude rhythmic oscillating movement at very

end range of movement– Used to gain motion within the joint

• Used when resistance limits movement in absence of pain

• Grade V – (thrust technique) - Manipulation– Small amplitude, quick thrust at end of range– Accompanied by popping sound (manipulation)

– Velocity vs. force– Requires training

OSCILLATION MOBILIZATION

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Beginning range of

movement

Pathological limit of

movement

Normallimit of

movement

Kaltenborn Traction

Grading• Grade I (loosen)

– Neutralizes pressure in joint without actual surface

separation

– Produce pain relief by reducing compressive forces

• Grade II (tighten or take up slack)

– Separates articulating surfaces, taking up slack or eliminating play within joint capsule

– Used initially to determine joint sensitivity

• Grade III (stretch)

– Involves stretching of soft tissue surrounding joint

– Increase mobility in hypomobile joint

SUSTAINED MOBILIZATION

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INDICATIONS

• Pain

• Muscle spasm

• Decreased ROM

• Hypomobile Joints

• Reduce Functionally Mobility.

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CONTRAINDICATION • Inflammatory arthritis ( RA, AKS)

• Malignancy

• Bone disease

• Bone Fracture

• Vascular disorder

• Unskilled manipulator

• Joint effusion26

• Pregnancy

• TKR, THR

• Closed pack position

• Cauda equina lesion.

• Undiagnosed pain

• Protective muscle

spasm

• Inability of the patient

to relax.

• Rubbery end feel of the

joint.

• Evidence of involvement

of 2 adjacent nerve root

in lumbar spine

• Lower limb neurological

symptoms due to

cervical or thoracic

dysfunction.27

CAUSES FOR COMPLICATIONS

• Practioner — Related complications

� Diagnostic error

� Lack of skill

� Lack of interprofessional consultation

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Patient — Related complications

� Patient with psychological intolerance of pain.

� Patient involved in litigation

� Patient recently undergone treatment to any

practioners.

� Patient develop psychological dependence on

manipulation.

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• Patient in whom uncomplicated sciatica

becomes a unilateral radiculopathy with distal

paralysis of limb, sensory loss.

• These patients usually doesn’t respond to

manipulation & should be considered as

surgical emergency.

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JOINT POSITIONSJOINT PLAY

• Each joint in the body has positioned to

make maximum amount of motion.

• Joint should be positioned in a Relaxed

position.

RESISTING POSITION:

• The position in which the joint capsule &

ligaments are relaxed.

• Helps in evaluation of the joint

• Treatment done for hypomobile joints

• Placing the joint in resting position allows the

joint to assumes a Loose pack position

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Closed pack position:

• Here maximal contact of articular surface of

bones with capsule & ligaments are tense or

tight.

• No movement is seen.

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TREATMENT PLANES

• Direction of movement is either parallel or

Perpendicular to the treatment planes.

• Joint traction – Perpendicular to the

treatment plane

• Glides — Parallel to the

treatment planes.

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TREATMENT FORCE

• It should be close to the opposing joint surface,

• Either Gentle or Strong.

• Large contact area will be more comfortable than

small surfaces..

• Like use of Hand is advised than Thumb for

mobilizing larger joint or Surface.

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SPEEDOSCILLATIONS:

• Grade I & IV are usually rapid oscillations

• Grades II & III are smooth, regular oscillations at

two or three per second for 1 to 2 minutes.

• Vary the speed of oscillation for different effects

such as low amplitude and high speed to inhibit

pain or slow speed to relax muscle guarding.

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Sustained:

• Painful joints : Apply intermittent distraction 7—10 sec

• Few seconds of Rest in-between.

• If no response Repeat correctly or Discontinue.

• Resisted Joints :

• Apply for 6 sec stretch force

• Followed by partial release

• Repeat with intermittent stretches for 3—4 sec intervals.

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LIMITATION

1. Can’t change the disease process of Disorders.

2. Like OA,RA manual therapy helps in Reducing

pain & mobilize joints.

3. Skill of therapist affects outcome.

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PRINCIPLES OF MANUAL THERAPY

• The principles are summarize by clinicians such as

Grieves, Maitland, Cyriax ect..

1. Remember the contraindications & conditions

require extra care.

2. Don’t harm the patient or yourself

3. A through examination is necessary

4. Make an accurate diagnosis as possible based on

solid knowledge of anatomy. 39

5. All pain arise from lesion, so treatment should

focus on the lesion.

6. Constant reassess to determine the effect of the

technique being used.

7. Progress is governed by the response to previous

treatment.

8. Discontinue technique that are not productive

9. Make the patient to relax, reduce anxiety & fear.

10.Don’t force the protective muscle spasm.40

11. A slight alteration of joint position or angle of

thrust often allows a technique much more

effective.

12. Warm up patients of the potential for post

treatment soreness.

13.Don’t over treat.

14.Aim for restoration of normal , painless

technique.

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Causes of Limited Range of

Motion

• Loss of Extensibility of periarticular connective

tissue structures, ligaments, capsule & fascia.

• Deposition of Fibrofatty infiltrates acting as

intraarticular “Glue”.

• Adaptive shortening of Muscles.

• Breakdown of articular cartilages.

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EFFECTS

• Mobilization showed that it helps in break down of

Muscle shortening and reduce the fibroblastic

proliferations inside the joints.

• Forceful passive movements has shown to

rupture of intra-articular adhesion that forms

during immobilization.

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Pain & Muscle guarding

• Wyke’s explained that Receptors nerve

endings present in various periarticular

structures.

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• Type I (postural) & Type II (dynamic)

mechanoreceptors are located in joint capsule.

• They have low threshold and excited by repetitive

movements including oscillations.

• Type III mechanoreceptors are found in joint

capsules and extracapsular ligaments.

• They are excited in stretching & thrust

maneuvers.

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• Type IV, (Pain receptors), are found in capsule,

ligaments, Fat pads and Blood vessel walls.

• These receptors are fired by noxious stimuli as

in trauma and have a relatively high threshold.

• Type IV are Slow conducting fibers,

• Type I & II are Fast conducting fibers.

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EFFECT OF MANUAL

THERAPY PAIN REDUCTION

• During Oscillatory glides, faster impulses

overwhelm the slower impulses.

• It helps in closing of gate at spinal level.

• Release of Endorphins from CNS.

Melzack R, Torgerson WS: On the language of pain, Anesthesiology, 1971

Wyke B: Articular neurology—a review, physiotherapy, 1958

EFFECTS OF MANUAL

THERAPY

Pain Reduction

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Small amplitude distraction,

Oscillatory

movement

Stimulate mechanorece

ptors

Inhibit

Transmission of Nociceptive

stimuli

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Brings nutrition to Avascular

Articular cartilage

Small Amplitude

Distractions

& Glides

Stimulates Synovial

Fluid motion

Gentle Joint play helps in

maintain Nutrient

exchange

Prevent Painful

Degeneration

Muscle Relaxation

• Type III receptors in joint & golgi tendon organ

fire by stretching or thrusting of a joint result in

temporary inhibition or relaxation of muscle.

• This itself cause an increase Range of motion

and helps prepare the joint for further

stretching & mobilization.

Paris SV: extremity dysfunction and mobilization . Institute Press, Atlanta 1980

Wyke B: Articular neurology—a review, physiotherapy, 1958

IMPORTANT RULES FOR

MOBILIZATION

Described by Stanley. V. Paris.

1. Identify the location and direction of the

limitation. for e.g Ankle stiffness, posterior glide

of talus is restricted.

2. Prepare the soft tissue, (i.e) first reduce the

swelling, pain, muscle guarding or tightness.

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3) Protect neighboring hypermobilities. If patient

is having shoulder dislocation, following a

anterior laxity, mobilization focused on

improving abduction and rotation.

4) Communicate with the surgeon, find out which

tissue have been cut or scarified, and what

motions should be avoided initially.

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WHAT IS THE NAME OF A

CROSS BREED BETWEEN THIS

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