Flexibility Flexibility

Definition

The ROM available in a jt. The ROM available in a jt. or or group of jts.group of jts.

The ability of a m. to relax The ability of a m. to relax && yield to a stretching force. yield to a stretching force.

The freedom The freedom or or ability to move part ability to move part or or parts of body in a wide R parts of body in a wide R of purposeful movs at the required speed.of purposeful movs at the required speed.

The ability to move a jt. Through a normal ROM with undue The ability to move a jt. Through a normal ROM with undue stress to musculo-tendinous unit.stress to musculo-tendinous unit.

FlexibilityFlexibility Extensibility of periarticular tissues to allow Extensibility of periarticular tissues to allow

normal motion of a joint. normal motion of a joint. or or a limb.a limb.

* * HypermobilityHypermobility The ROM in excess of the accepted The ROM in excess of the accepted

normal in most of joints. normal in most of joints. (may be normal)

* * LaxityLaxity Excessive jt. instability Excessive jt. instability && abnormal motion abnormal motion

of a given joint. of a given joint. (pathological)

Types of Flexibility

Ballistic FlexibilityBallistic Flexibility::

Normal ROM associated with bouncing Normal ROM associated with bouncing && rhythmic movements.rhythmic movements.

Dynamic Functional FlexibilityDynamic Functional Flexibility: :

Activities that need certain angle to certain joints. Activities that need certain angle to certain joints. && particular patterns particular patterns (usual activities).(usual activities).

Factors Affecting Flexibility

1. Wrong habits: ↓ flexibility sitting for a long period (in school, watching TV, computer work, sedentary games)

2. Good habits: → ↑ flexibility.

3. Genetic factors: females > males.4. Hormonal factors: females > males.5. Body build proportion & ↑ height → ↑ flexibility .6. Body wt. ↑ → ↓ flexibility7. Age: flexibility changes during a certain age

↑ 2 - 6 y ↓ 6 - 12 y ↑ 18 - 22 y ↓ 35 - up

8. Skills & sport activities → ↑ flexibility.

Contractile & Non-contractile Tissue

Contractile 1.1. MMss

Non-contractileNon-contractile1.1. SSkinkin2.2. CCTT3.3. LLigamentsigaments4.4. TTendonsendons5.5. CCapsulesapsules6.6. SSynovial Membrane ynovial Membrane

**N.B.

Soft tissues that can restrict joint motionSoft tissues that can restrict joint motion areare::1.1. SkinSkin2.2. CT, tendons, ligamentsCT, tendons, ligaments3.3. MsMs Each one has unique qualities affecting its extensibility Each one has unique qualities affecting its extensibility (ability to elongate).(ability to elongate).

Factors affecting soft tissues lengtheningFactors affecting soft tissues lengthening::1.1. Velocity of stretch forceVelocity of stretch force2.2. Intensity of stretch forceIntensity of stretch force3.3. Duration of stretch forceDuration of stretch force4.4. Mechanical properties of contractile Mechanical properties of contractile && non-contractile tissues non-contractile tissues5.5. Neuro-physiological properties of contractile tissuesNeuro-physiological properties of contractile tissues

When soft tissue is stretched, either elastic or plastic changes occur

Elasticity Elasticity Ability of soft tissue to return to its resting length Ability of soft tissue to return to its resting length

after passive stretching. after passive stretching.

Plasticity Plasticity Tendency of soft tissue to assume new Tendency of soft tissue to assume new & & greater greater

length after the stretch force has been removed.length after the stretch force has been removed.

Both contractile & non-contractile tissues have elastic & plastic Both contractile & non-contractile tissues have elastic & plastic properties.properties.

Degrees of Deformity

11stst degree degree (grade I): can can be corrected actively be corrected actively ((shortnessshortness).).

22ndnd degree degree (grade II): cancan be corrected passively be corrected passively ((shortnessshortness).).

33rdrd degree degree (grade III): can’tcan’t be corrected be corrected neitherneither actively actively nor passively passively (contractures).

Indications of Stretching

1.1. Limited ROM due to adhesions Limited ROM due to adhesions & & scar tissues formation scar tissues formation leading to leading to shortening of Muscles, CT shortening of Muscles, CT && Skin. Skin.

2.2. Prevention of structural (Prevention of structural (neglected soft tissue neglected soft tissue →→ shortening shortening →→

structural limitations structural limitations →→skeletal deformities deformities (prophylactic intervention)

3.3. When contractures interfere with every day functional activities When contractures interfere with every day functional activities or or nursing care.nursing care.

3.3. When there’s muscle weakness When there’s muscle weakness & & opposing tissue tightness. opposing tissue tightness. * * Tight muscle must be elongated before weak m. can be effectively strengthenedTight muscle must be elongated before weak m. can be effectively strengthened. .

Goals of Stretching

1.1. To regain To regain oror re-establish normal joint. ROM re-establish normal joint. ROM & & mobility of soft mobility of soft tissue surrounding a jt..tissue surrounding a jt..

2. 2. To prevent irreversible contractures. To prevent irreversible contractures.

3.3. To To ↑ ↑ general flexibility of a part of the body prior to vigorous general flexibility of a part of the body prior to vigorous strengthening excerises.strengthening excerises.

4.4. To prevent or minimize risk of musculo-tendinous injuries To prevent or minimize risk of musculo-tendinous injuries

related to specific physical activities related to specific physical activities & & sports.sports.

Precautions to Stretching

1.1. Don’t passively stretch (force) a joint beyond its normal ROM Don’t passively stretch (force) a joint beyond its normal ROM (Remember that normal ROM varies among normal individuals).(Remember that normal ROM varies among normal individuals).

2.2. Newly united # should be protected by stabilization between # site Newly united # should be protected by stabilization between # site & & the joint where motion takes place.the joint where motion takes place.

3.3. Extra caution in pts. with known Extra caution in pts. with known oror suspected osteoporosis due to: suspected osteoporosis due to:a.a. Disease Disease b.b. Prolonged bed rest Prolonged bed restc.c. Aging Aging d.d. Prolonged use of steroids Prolonged use of steroids (cortisone)(cortisone)

4.4. Avoid vigorous stretching of muscles Avoid vigorous stretching of muscles & & CT that have been CT that have been immobilized over a long period of time. CT immobilized over a long period of time. CT (tendons & ligaments) lose their tensile strength after prolonged immobilization.lose their tensile strength after prolonged immobilization.

Precautions to Stretching

a. High intensity, short duration procedures →→ traumas traumas → → soft tissue weaknesssoft tissue weakness

b.b. Stretching should be low intensity for long Stretching should be low intensity for long duration stretch.duration stretch.

c.c. Strengthening excerises should be added to Strengthening excerises should be added to stretching program at some point, stretching program at some point, so so patient will be able to develop appropriate patient will be able to develop appropriate balance between flexibility balance between flexibility && strength. strength.

Contraindications to Stretching

1.1. Acute infections.Acute infections.

2.2. Signs of inflammation.Signs of inflammation.

3.3. Pain at the site to be stretched.Pain at the site to be stretched.

4.4. Osteomyelites Osteomyelites ((acute stageacute stage).).

5.5. Bone tumors.Bone tumors.

6.6. Advanced osteoporosis.Advanced osteoporosis.

7.7. Severe spasticity. Severe spasticity.

8.8. Pain that isn’t yet evaluated by the Pain that isn’t yet evaluated by the PT PT or or physician.physician.

9.9. Joint laxity Joint laxity ((hypermobilityhypermobility).).

10.10. Joint subluxation. Joint subluxation.

11.11. Joint dislocation. Joint dislocation.

12.12. Joint fusion. Joint fusion.

13.13. Joint deformity. Joint deformity. 14.14. Tissue adhesions Tissue adhesions ((contracturescontractures).).

15.15. Acute TraumasAcute Traumas

Principles of Stretching

1. Consider the best stretching type to ↑ ROM.

2. Explain goals of stretching to the pt.

3. Position the pt. in a comfortable relaxed pos. → allow the best plane of motion to conduct stretching.

4. Free the area from restrictive clothing, bandage, splints.

5. Apply superficial heating to the soft tissues to be stretched.

6. It will ↓ possibility of injury.

7. Stretch direction is done opposite to tightness.

7. The pt. must be completely relaxed throughout stretching ,employ relaxation techniques before stretching.

8.8. Stretching movs. or exs. are performed at least Stretching movs. or exs. are performed at least 3 3 times/week times/week to maintain flexibility. Progress to to maintain flexibility. Progress to daily daily stretching routines.stretching routines.

9.9. 1-3 repetitions of each stretch must be done. The No. of 1-3 repetitions of each stretch must be done. The No. of repetitions can be repetitions can be ↑↑ if the goal is toif the goal is to ↑↑ ROM.ROM.

10.10. Degree of stretch can be Degree of stretch can be ↑ ↑ oror ↓↓ depending on depending on timetime of stretch of stretch & & external external force appliedforce applied. .

11.11. Tension produced Tension produced shouldn’t cause painshouldn’t cause pain, the pt should only , the pt should only feel a feel a slight tensionslight tension, which , which ↓ ↓ with stretching. with stretching. (due to adaptation)(due to adaptation)

12.12. Stretch Stretch ↑↑ graduallygradually, , building to building to a maxa max. as the tissues release.. as the tissues release.

13.13. Stretch should be Stretch should be removed removed graduallygradually to prevent to prevent rebouncing rebouncing

oror tighteningtightening of the msof the ms..

Stretching depends on:

1.1. Type of stretching force.Type of stretching force.

2.2. Intensity.Intensity.

3.3. DurationDuration

4.4. VelocityVelocity..

Types: A. Passive Stretching

PT applies an external force & controls stretch 1direction, 2speed, 3intensity & 4duration to the tight m..

Don’t Don’t confuse between:confuse between:1.1. Passive stretchingPassive stretching → → elongation of soft tissues elongation of soft tissues beyond

full R of restriction.2.2. Passive ROM exs.Passive ROM exs.

→ → applied applied within the unrestricted (available)(available) ROM.

Pt. must be completely relaxed during passive stretching.Pt. must be completely relaxed during passive stretching.

Time of stretch force is usually Time of stretch force is usually 1515 : : 30 sec30 sec & & repeated several repeated several times during ex. session.times during ex. session.

1 .Manual Passive Stretching

Usually considered a short-duration stretch.Usually considered a short-duration stretch. No specific No. of secs. are determined to be the most effective No specific No. of secs. are determined to be the most effective

duration. duration. In a study to stretch hip abd. of healthy subjectsIn a study to stretch hip abd. of healthy subjects 1515, , 4545 sec & sec &

2 min at the same speed → 2 min at the same speed → no differenceno difference.. Intensity Intensity && duration of stretch depend on: duration of stretch depend on:

1.1. Pt’s tolerancePt’s tolerance

2.2. PT strengthPT strength & & endurance endurance Low intensity, long duration manual stretch is more Low intensity, long duration manual stretch is more

comfortable comfortable && tolerated by pt. tolerated by pt.

MaintainedMaintained versus versus Ballistic Ballistic StretchStretch

MANUAL PASSIVE STRETCH

HIGH INTENSITY STRETCH

MAINTAINED,GENTLE

PROLONGED 15-30 SEC OR MORE

VERYSLOW

QUICK LENGTHENING

VERY SHORTDURATION

BOUNCING

Inhibit stretch reflex&

↓ Muscle tension

Facilitate muscle contraction &

↑ tension

2 .Prolonged Mechanical Stretch

Low intensity external force (5-15 lb) (2: 6 kg) applied to shortened Low intensity external force (5-15 lb) (2: 6 kg) applied to shortened

tissues over a prolonged period by mech. equipments.tissues over a prolonged period by mech. equipments.

Stretch force is applied through positioning with weighted traction, Stretch force is applied through positioning with weighted traction,

pulley system, dynamic splint pulley system, dynamic splint && serial casts. serial casts.

Prolonged stretch may be maintained for 20-30 min. Prolonged stretch may be maintained for 20-30 min. or or longer longer →→

effective stretch effective stretch && ↑ ↑ ROM ROM

((low intensity mechanical stretchlow intensity mechanical stretch).).

Comparing long-duration mech. stretch Comparing long-duration mech. stretch & & manual passive stretch manual passive stretch

( the latter is rather short ( the latter is rather short & there’s transient there’s transient & temporary

achievement of ROM).

Examples

1. Bohannon evaluated the effectiveness of an 8 min mechanical hamstring stretch compared to a 20 min or longer using overhead pulley system. The 8 min stretch resulted in a small ↑ in hamstring flexibility, which was lost in 24 hrs.

It was suggested that 20 min or longer stretch is more effective to ↑ ROM & has a more permanent basis.

2. Use of tilt table-wedge board standing for 30 min/daily → ↑ dorsiflexion in neurological pts.

3. Dynasplint (dynamic splint) → prolonged low intensity stretch of elbow, wrist, knee & ankle → ↑ ROM.

4. Low intensity prolonged stretch of 5-12 lb applied for 1 hr/daily has been found to be more effective than manual passive stretch over a 4-week period with pt’s with bilateral knee flexion contractures. It is more comfortable

Permanent lengtheningPermanent lengthening

((Plastic changes in contractilePlastic changes in contractile & & non-contractile tissuesnon-contractile tissues)) has been reported with has been reported with long duration stretch.long duration stretch.

The term “The term “Permanent lengtheningPermanent lengthening” means ” means that the length is maintained after the that the length is maintained after the stretching force is removed. stretching force is removed.

33 . .Cyclic Mechanical StretchingCyclic Mechanical Stretching

It is passive stretching using a mechanical devices as an It is passive stretching using a mechanical devices as an Autorange using a Autorange using a 20-sec 20-sec high intensity high intensity (up to the patient’s pain tolerance).

1.1. IntensityIntensity of stretch, of stretch, 2.2. LengthLength of each cycle, of each cycle,3.3. No. of stretch cycles/minNo. of stretch cycles/min Can be adjusted with the unit.Can be adjusted with the unit.

It is similar It is similar && may be used as a useful alternative to may be used as a useful alternative to manual passive stretching.manual passive stretching.

B. Active Inhibition

Is a tech. in which the patient reflexively relaxes muscles to be elongated prior to stretching maneuver. When the patyent is relaxed → minimal R to elongate the m.

It relaxes only the: - Contractile structures, - Not the CT.

The m. must be: Normally innervated and Under voluntary control.

It Can’t be used with pts having: 1. Weakness, 2. Spasticity 3. Paralysis (From a neuromuscular disease).

It Can be used in: Post-operative patient. (to avoid tightness).

Active Inhibition Techniques.

1.1. Contract-relaxContract-relax (hold-relax): Pt performs an isometric contraction of tight muscle before it isPt performs an isometric contraction of tight muscle before it is passively stretched (lengthened).passively stretched (lengthened). M. will relax as a result of ”autogenic inhibition” M. will relax as a result of ”autogenic inhibition”

(Golgi tendon organ may fire at (Golgi tendon organ may fire at ↓↓ tension). tension).

2.2. Contract-relax-contractContract-relax-contract (hold-relax-contract).a.a. 11stst a contraction of tight muscle. a contraction of tight muscle.b.b. 22ndnd relaxation of tight muscle. (autogenic inhibition).relaxation of tight muscle. (autogenic inhibition).c.c. 33rdrd concentric contraction of opposite muscle (reciprocalconcentric contraction of opposite muscle (reciprocal inhibition of tight m.).inhibition of tight m.).

In a study, the contract-relax-contract produced a greater ↑ in In a study, the contract-relax-contract produced a greater ↑ in ankle dorsiflexion > contract-relax tech. (in short calf m ).ankle dorsiflexion > contract-relax tech. (in short calf m ).

* Both techs produce ↑ ROM > manual stretching.* Both techs produce ↑ ROM > manual stretching.

3 .Agonist Contraction

AgonistAgonist == muscle opposite to the tight muscle. muscle opposite to the tight muscle.

AntagonistAntagonist == Tight muscle. Tight muscle.

Patient dynamically contracts Patient dynamically contracts (shortens)

the muscle opposite to the tight muscle against the muscle opposite to the tight muscle against

resistance resistance → → reciprocal inhibition of tight muscle.reciprocal inhibition of tight muscle.

C. C. Self-Stretching

Is a type of flexibility excerises. the patient carries Is a type of flexibility excerises. the patient carries out by himself.out by himself.

Pt. may passively stretch Pt. may passively stretch his his tightness tightness by:by:

1.1. HisHis//herher own body weight. own body weight. ((&& gravitygravity))

2.2. Active Active inhibition.inhibition.

3.3. Manual Manual passive stretch passive stretch ((using sound limbusing sound limb))

PPeripheral eripheral jjoint oint mmobilizationobilization

Definition:Definition:

PPeripheral eripheral jjoint oint mmobilization (obilization (PJMPJM) is the use of ) is the use of

skilled graded forces skilled graded forces toto mobilize joints: mobilize joints: to improve motion & normalize to improve motion & normalize joint function.joint function.

Mobilization Techniques are used Mobilization Techniques are used toto

1.1. ImproveImprove jt. nutrition. jt. nutrition.

2.2. ImproveImprove m. spasm m. spasm && tension tension

3.3. ReduceReduce pain. pain.

4.4. ReverseReverse jt. hypomobility. jt. hypomobility.

5.5. ImproveImprove or or restore motion. restore motion.

6.6. Treat Treat jt. dysfunction as stiffness.jt. dysfunction as stiffness.

The PT should recognizeThe PT should recognize

When the mobilizing techniques When the mobilizing techniques are are indicated (at any ROM), indicated (at any ROM), or or

If other stretching techniques are If other stretching techniques are more effective more effective (stretching, stretching ex’s or CTM)(stretching, stretching ex’s or CTM)

To regain the lost motionTo regain the lost motion

A. Joint MobilizationA. Joint Mobilization

Is a type of passive mov performed by the PT at a speed slow enough Is a type of passive mov performed by the PT at a speed slow enough that the pt. that the pt. can can stop the movstop the mov..

The tech. may be applied with:The tech. may be applied with: 1.1. Oscillatory motion Oscillatory motion or or

2.2. Sustained stretch Sustained stretch toto

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

The tech. The tech. may use:may use:

1.1. PhysiologicPhysiologic oror2.2. Accessory Accessory movsmovs..

Mobilization TechniquesMobilization Techniques

Physiologic Physiologic movementsmovements

1.1. Movs. that the pt Movs. that the pt

can can perform voluntarily as perform voluntarily as

flex, ext, abd, add flex, ext, abd, add & rot. rot.

2. 2. Described as Described as (Osteokinematic)(Osteokinematic). .

i.e. mov of bones in relation to each i.e. mov of bones in relation to each

othersothers

Accessory movementsAccessory movements

1.1. Movs within the jt Movs within the jt &

surrounding tissues that are surrounding tissues that are

necessary necessary for normal ROMfor normal ROM,, can’tcan’t be be

donedone by pt.by pt.

2. 2. Described as Described as a.a. Component motionsComponent motions b.b. joint playjoint play..

Accessory motionsAccessory motions

Accessory motionsAccessory motions Motions that Motions that

accompany active mov,accompany active mov, but but

Aren’t Aren’t under voluntary control under voluntary control

Component mov is the often used term with Component mov is the often used term with accessory mov.accessory mov.

AsAs: : upward rot. of scapula upward rot. of scapula & & clavicle clavicle occurring in sh. flex. occurring in sh. flex.

B. Joint PlayB. Joint Play Motions that occur in jts Motions that occur in jts

& & distensibilitydistensibility oror give ingive in of the jt of the jt capsule,capsule, which allow bones to move which allow bones to move..

Are necessary for normal functioning Are necessary for normal functioning through the ROM.through the ROM.

CanCan be demonstrated passively be demonstrated passively, , Can’t Can’t be performed actively by the pt.be performed actively by the pt. IncludeInclude::

distraction, sliding, compression, rolling, spinning of the jt surfaces.

Arthrokinematic Arthrokinematic is used to describe these is used to describe these motions of motions of bone surfacesbone surfaces within the jt. within the jt.

B. ManipulationB. Manipulation

Is a passive movIs a passive mov using using physiologicphysiologic oror

accessory accessory motionsmotions.. It It may be applied:may be applied: 1.1. With a With a thrustthrust , , (cyropractic) (cyropractic) or or 2.2. Under Under anesthesiaanesthesia

B. ManipulationB. Manipulation

THRUSTTHRUST A A sudden mov performed sudden mov performed

with a high velocity with a high velocity..

Without anaesthesia.Without anaesthesia. Short amplitude motionShort amplitude motion, , can’t can’t

be prevented by the pt.be prevented by the pt. Performed Performed

A At end of pathologic limitt end of pathologic limit (end of available ROM, (end of available ROM, when there’s restriction). when there’s restriction).

Using:Using: 1.1. Physiologic, Physiologic, or or 2.2. Accessory movs. Accessory movs.

EffectsEffects:: 1. Snaps adhesions.1. Snaps adhesions.2. Stimulates jt receptors.2. Stimulates jt receptors.

MANIPULATION UNDER ANAESTHESIAMANIPULATION UNDER ANAESTHESIA Medical procedure used to restore full ROM by Medical procedure used to restore full ROM by

breaking adhesions surrounding jt. breaking adhesions surrounding jt.

With anaesthesiaWith anaesthesia..

PerformedPerformed through:through: 1.1. Rapid thrust, Rapid thrust, or or 2.2. Passive stretch Passive stretch..

Using:Using: 1.1. Physiologic, Physiologic, or or 2.2. Accessory movs. Accessory movs.

Factors Affecting Jt. MotionFactors Affecting Jt. Motion

A. Jt. shape.A. Jt. shape.

B. Types of Motion.B. Types of Motion.

C. Other Accessory motions. C. Other Accessory motions.

Factors Affecting Joint motionFactors Affecting Joint motion

A. A. Joint ShapeJoint Shape The type of motion is influenced The type of motion is influenced

by jt. shape.by jt. shape.

OvoidOvoid: : one convex surface one convex surface & & one concave (as A).one concave (as A).

SellarSellar (Saddle):(Saddle): oneone surface surface isis concave in one concave in one direction direction && convex in the other, with the opposing convex in the other, with the opposing surface surface convexconvex && concave concave ( (as a horse back rider) (as B).as a horse back rider) (as B).

B.B. Types of Motion Types of Motion

When a When a bony lever bony lever (bone)(bone) moves about an axis of motionmoves about an axis of motion →→ mov of mov of bony bony surfacessurfaces on the opposing bone surface within the jt. on the opposing bone surface within the jt.

i.e. i.e.

1.1. Movement of bony leverMovement of bony lever - - Called swing Called swing as (flex, ext, add, abd as (flex, ext, add, abd & & rot.)rot.)

- Measured in degrees. - Measured in degrees. - - Called ROM.Called ROM.

2.2. Motion of the bony surfacesMotion of the bony surfaces - - Within jt is a combination of rolling, sliding Within jt is a combination of rolling, sliding && spinning. spinning.

- These accessory motions allow greater angulation of - These accessory motions allow greater angulation of bone as it swings. bone as it swings.

- This needs adequate capsule laxity - This needs adequate capsule laxity or or jt. play.jt. play.

a. Rolla. Roll

One bone rolls on another. The surfaces are incongruent.One bone rolls on another. The surfaces are incongruent.

New points on one surface meet new points on the opposing surface.New points on one surface meet new points on the opposing surface.

Results in angular motion.Results in angular motion.

Always rolling occur in the same direction of the mov., Always rolling occur in the same direction of the mov., whether the surface is convex whether the surface is convex or or concave.concave.

There’s compression of the surface on the side to which the bone is There’s compression of the surface on the side to which the bone is angulating angulating && separation on the other side. separation on the other side.

In normal functioning jts, pure rolling In normal functioning jts, pure rolling doesn’t doesn’t occur alone, but in combination occur alone, but in combination with sliding with sliding & & spinning.spinning.

b. Slideb. Slide

One bone slides across another.One bone slides across another.

For pure slide, the surface must be congruent either flat For pure slide, the surface must be congruent either flat oror curved. curved.

There’s no pure slide as jt surfaces There’s no pure slide as jt surfaces aren’t aren’t completely congruent.completely congruent.

Same point on one surface comes into contact with new points on the Same point on one surface comes into contact with new points on the opposing surface.opposing surface.

Direction of slides depends on whether the surface is convex Direction of slides depends on whether the surface is convex oror concave.concave.

If the moving surface is convex If the moving surface is convex →→ Sliding is in the opposite Sliding is in the opposite direction of angular mov. direction of angular mov.

If the moving surface is concave If the moving surface is concave →→ Sliding is in the same direction Sliding is in the same direction as the angular mov. as the angular mov.

This mechanical relationship is known as This mechanical relationship is known as convex-concave ruleconvex-concave rule. . It determinesIt determines the the direction of the mobilization forcedirection of the mobilization force,, when jt when jt mobilization gliding techniques are used.mobilization gliding techniques are used.

c. Combined roll-sliding in a jointc. Combined roll-sliding in a joint

The more congruent the jt surface → the more sliding of one bony partner on the other with movs.

(e.g. metatarsals & metacarpals)

The more incongruent the jt surface → the more rolling movs.

(e.g. hip & sh)

For Joint Mobilization For Joint Mobilization TechniquesTechniques SlidingSliding Is Is used used toto

↓↓

1.1. Restore jt. playRestore jt. play

2.2. Reverse jt. Reverse jt. HypomobilityHypomobility

RollingRolling Is Is not used, not used, asas

↓ ↓

1.1. Jt. CompressionJt. Compression

E.g.E.g. hip abd hip abd & addadd

sh abd sh abd & addadd

When PT passively moves the articulating surface in When PT passively moves the articulating surface in

the direction in which the slide normally occursthe direction in which the slide normally occurs → → Translatory glide (glide)

↓↓ used toused to

1.1. Control painControl pain or or 2.2. Stretch capsuleStretch capsule

IfIf applied applied gently gently IfIf with with stretch forcestretch force

d. Spind. Spin

Rotation of one bony segment about a stationary mechanical axis.Rotation of one bony segment about a stationary mechanical axis.

Spinning rarely occurs alone, but in combination with rolling Spinning rarely occurs alone, but in combination with rolling && sliding.sliding.

3 examples of spinning in the body jts:3 examples of spinning in the body jts:1.1. Sh.:Sh.: with flex/ext. with flex/ext.2.2. Hip:Hip: with flex/ext. with flex/ext.3.3. Radio-humeralRadio-humeral: with sup./pron.: with sup./pron.4.4. ****Knee ext either by closed or open chainKnee ext either by closed or open chain

C. C. Other Accessory Motions that Other Accessory Motions that affect the Jointaffect the Joint

e. Compression.

f. Traction (A&B).

e.e. CompressionCompression Is the Is the ↓↓ in jt space. in jt space.

Occurs in Occurs in LLLL && spinal jtsspinal jts with wt. bearing. with wt. bearing.

Some compression occurs as Some compression occurs as m. contm. cont →→ provide stability to jt.provide stability to jt.

As one As one bone rollsbone rolls on the otheron the other, some compression occurs on , some compression occurs on the side to which the bone is angulating. the side to which the bone is angulating.

Normal intermittent compression loadsNormal intermittent compression loads → → help in moving synovial fluid help in moving synovial fluid so so →→ maintain cartilage health. maintain cartilage health.

Abnormal high compression loadsAbnormal high compression loads →→ articular cartilage changes & deterioration. (friction (friction →→ erosion erosion & & OA) OA)

f.f. TractionTraction

Distraction or separation of jt surfaces.Distraction or separation of jt surfaces.

For distraction to occur, the surfaces must be pulled apart. The mov For distraction to occur, the surfaces must be pulled apart. The mov isn’t always the same.isn’t always the same.

Pulling on the long axis of one bonePulling on the long axis of one bone (as pulling the (as pulling the shaft of humerus shaft of humerus →→ glide jt surface) (long axis traction).glide jt surface) (long axis traction).

Distraction of gleno-humeral jt requires Distraction of gleno-humeral jt requires a pull at a 90° to the glenoid fossa → distraction & jt traction or jt separation.

Distraction is used to:Distraction is used to:1.1. Control Control oror relieve pain: relieve pain: IfIf applied gently. applied gently.2.2. StretchStretch the capsules: the capsules: If If applied with stretching force. applied with stretching force.

Effects of Joint MotionEffects of Joint Motion

1.1. Skim. biologic activity by moving synovial fluid Skim. biologic activity by moving synovial fluid →→ brings nutrients to the brings nutrients to the avascularavascular articular cartilage of jt surfaces articular cartilage of jt surfaces & & intra-articular fibrocartilage of the menisci.intra-articular fibrocartilage of the menisci.

2.2. Maintains extensibility Maintains extensibility & & strength of: strength of: articular articular & & periarticular tissues periarticular tissues (ligs, ms, tendons & capsules).(ligs, ms, tendons & capsules).

With immobilizationWith immobilization → → fibrofatty prolifiration fibrofatty prolifiration → → intra-articular adhesions intra-articular adhesions & & biochemical changes in biochemical changes in [tendons, ligs & jt capsule][tendons, ligs & jt capsule] → → m. contractures , jt stiffness m. contractures , jt stiffness && lig. weakening. lig. weakening.

3.3. Provide proprioceptive feedback (awareness of pos. Provide proprioceptive feedback (awareness of pos. & & mov. sense)mov. sense)a.a. Static pos. Static pos. & & sense of speed of mov.sense of speed of mov.b.b. Change of speed of mov.Change of speed of mov.c.c. Sense of direction of mov.Sense of direction of mov.d.d. Regulation of m. tone.Regulation of m. tone.

Indications of Joint MobilizationIndications of Joint Mobilization

1.1. Pain, m. guardingPain, m. guarding && spasm spasm All can be treated with gentle jt play tech to All can be treated with gentle jt play tech to stim. stim.

neurophysiologicalneurophysiological && mechanical effects.mechanical effects.

a.a. Neurophysiological effectNeurophysiological effect:: Small amplitude Small amplitude oscillatory mov oscillatory mov →→ stim mechanoreceptors stim mechanoreceptors →→ ↓↓ transmission of nociceptive transmission of nociceptive stimuli at spinal cord stimuli at spinal cord & & brain stem levels.brain stem levels.

b.b. Mechanical effectsMechanical 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)

Reversible Jt. HypomobilityReversible Jt. Hypomobility

Can be treated with:Can be treated with:

1.1. Progressive vigorous jt. play stretching techs. Progressive vigorous jt. play stretching techs. → → elongate hypomobile elongate hypomobile structures.structures.

2.2. Sustained or oscillatory stretch forcesSustained or oscillatory stretch forces →→ mechanically distend shortened mechanically distend shortened tissues.tissues.

Progressive LimitationsProgressive Limitations Diseases that progressively limit movement can be Diseases that progressively limit movement can be

treated by jt. play techs to: treated by jt. play techs to:

1.1. Maintain Maintain available motion. available motion. 2. Retard 2. Retard progressive mechanical restrictions.progressive mechanical restrictions.

4.4. Functional ImmobilityFunctional Immobility (obligatory bedriddeness)(obligatory bedriddeness)

In this case the aim is to: In this case the aim is to:

1. Maintain1. Maintain available jt. play.available jt. play. 2. Prevent2. Prevent degenerating. degenerating.3. 3. Delay or reduce Delay or reduce the effects of immobilitythe effects of immobility..

N.B. N.B. Mobilization techniquesMobilization techniques

Can’tCan’t change the disease process change the disease process ofof disordersdisorders as: as:

1.1. RheumatoidRheumatoid arthritis. arthritis. 2.2. InflammationInflammation..

It only It only cancan::1.1. MinimizesMinimizes pain. pain.2.2. MaintainMaintain available jt. Play. available jt. Play.3.3. Reduces Reduces effects of mech. limitations.effects of mech. limitations.

Contra-indicationsContra-indications

1.1. Hypermobility: AS PJM Hypermobility: AS PJM →→

• Potential necrosis of ligs.Potential necrosis of ligs. or or capsules.capsules.

(Hypermobile pts may benefit from jt. play tech.(Hypermobile pts may benefit from jt. play tech. if kept within the if kept within the

limits of motionlimits of motion).).

2.2. Joint EffusionJoint Effusion

NeverNever mobilize or stretch a swollen jt with: mobilize or stretch a swollen jt with: 1.1. mobilizationmobilization oror 2.2.

passive stretchingpassive stretching.. The capsule is already stretched by the extra fluid. The capsule is already stretched by the extra fluid. Extra fluid Extra fluid & & m. response to pain (spasm) m. response to pain (spasm) →→ limited motion. limited motion.

Gentle oscillating motions that don’t stretch capsuleGentle oscillating motions that don’t stretch capsule oror stress it stress it →:→:1.1. Improve fluid flow.Improve fluid flow.2.2. ↓ ↓ pain. pain. 3.3. Maintains available jt play.Maintains available jt play.

If pt response to jt play is If pt response to jt play is ↑↑ painpain or or jt. Irritability: jt. Irritability: The techs. were The techs. were either:either:

1.1. TooToo vigorous,vigorous, or or 2.2. Don’tDon’t suit the current state of pathology.suit the current state of pathology.

3.3. InflammationInflammation Stretching in presence ofStretching in presence of inflammation inflammation → →

1.1. ↑↑ Pain.Pain.

2.2. ↑↑ muscle guarding.muscle guarding.

3.3. GreaterGreater tissue damage.tissue damage.

4.4. SpreadingSpreading the inflam. process the inflam. process && infection.infection.

PrecautionsPrecautions

In most cases jt mobilization is safer than passive angular stretching.In most cases jt mobilization is safer than passive angular stretching. But But SometimesSometimes Jt mobilization can be used with extreme care in: Jt mobilization can be used with extreme care in:

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

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

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

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

Procedure for Applying Jt Procedure for Applying Jt Mobilization TechniquesMobilization Techniques

33 Possibilities for painPossibilities for pain

!!!! !!!! While moving or mobilizing & foundWhile moving or mobilizing & found!!!!!!!!1.1. BBefore efore tissue limitationtissue limitation (after acute (after acute

injury injury or or active stage of a disease)active stage of a disease), , useuse p pain inhibiting jt. ain inhibiting jt. tech to relieve paintech to relieve pain & & maintain jt. play.maintain jt. play.

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

3.3. After After tissue limitations tissue limitations (as (as stretching a tight capsule stretching a tight capsule oror a peri-articular tissue a peri-articular tissue of ch. stiff jts)of ch. stiff jts),, useuse ↓ ↓ force offorce of thethe stretching stretching techniquestechniques..

IIf the capsule is limiting the f the capsule is limiting the motion, motion, there’sthere’s::

B. Grades of mov. B. Grades of mov. (Dosage, (Dosage, Amplitude)Amplitude)

2 systems of techniques:2 systems of techniques:

1. G1. Graded oscillation.raded oscillation.

2. S2. Sustainedustained translatory jt. Play.translatory jt. Play.

11 . .Graded Oscillation Tech. Graded Oscillation Tech. DosageDosage

Grade Grade II SmallSmall amplitudeamplitude rhythmic oscillations rhythmic oscillations at the at the beginningbeginning of ROM. of ROM.

Grade Grade IIIILargeLarge amplitudeamplitude rhythmic oscillations rhythmic oscillations within within the ROM, the ROM, butbut notnot reaching the reaching the limitation.limitation.

Grade Grade IIIIII

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

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

Grade Grade VV

SmallSmall amplitudeamplitude, high velocity, , high velocity, thrust thrust tech.. tech.. 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

TechniquesTechniques

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

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

2- 2- Jt. play Jt. play (arthrokinematic)(arthrokinematic) techs. techs.

Sustained Translatory jt. Play Sustained Translatory jt. Play TechniqueTechnique Grade IGrade I (Loosen): (Loosen):

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

1.1. Equalizes cohesive force, Equalizes cohesive force, 2.2. 2. 2. M. tension M. tension 3.3. 3. 3. Atmospheric pressure actingAtmospheric pressure acting on the jt.on the jt.

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

DistractionDistraction or or glide applied to tightendglide applied to tightend tissues around jt. tissues around jt.

Grade III:Grade III:

Distraction Distraction or or glide with large enough amplitude to place glide with large enough amplitude to place

a stretch on jt. capsule a stretch on jt. capsule & & surrounding peri-articular structuressurrounding peri-articular structures..

Sustained translatory joint-play technique

UsesUses

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

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

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

Technique:Technique:

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

N.BN.B..

The The consistencyconsistency between the dosage of the two grading systems is 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 techUsing oscillating or sustained tech., ., depends on the pt’s response.depends on the pt’s response.

Pain managementPain management: : use oscillating tech.use oscillating tech.

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

To maintain available RTo maintain available R.:.:

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

C. Patient PositionC. Patient Position

1.1. C. Patient PositionC. Patient Position The pt. & treated The pt. & treated extremity should extremity should be carefully be carefully positioned & relaxed. positioned & relaxed.

2. The jt. is positioned so that the 2. The jt. is positioned so that the capsule has greatest laxity.capsule has greatest laxity.

D. StabilizationD. Stabilization

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

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

E. ForceE. Force

Treatment force Treatment 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 The larger the contact surface of PT handof PT hand

→ → the more comfortable procedurethe more comfortable procedure will be.will be. e.ge.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.

F. Direction of MovementF. Direction of Movement

Either parallel to, or perpendicular to ttt plane.Either parallel to, or perpendicular to ttt plane.

Jt. tractionJt. traction: Perpendicular to ttt : Perpendicular to ttt plane.plane.

The entire bone is moved The entire bone is moved → → jt surfaces are separated.jt surfaces are separated.

Gliding tech.Gliding tech.: : 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 glide.- If the surface of moving bone is convex -→ opposite direction glide.

- - If the surface of moving bone is concave → If the surface of moving bone is concave → glide in the same direction.glide in the same direction.

The entire bone is moved, so there’s gliding of one jt. surface on the other.The entire bone is moved, so there’s gliding of one jt. surface on the other. No swing of the bone that causes rolling & compression of the jt. surfacesNo swing of the bone that causes rolling & compression of the jt. surfaces