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6/21/2019

Joint Mobilizations

Gulick DT. iOrtho+ Mobile App, 20191

Copyright/Permissions

• All materials in this presentation are the intellectual property of Therapeutic Articulations, LLC. The use of this material for any other reason then this course is expressly prohibited.

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Learner Outcomes

• Identify at least one clinician application for each of the 4 grades of joint mobilizations.

• Identify at least three absolute and relative contraindications related to joint mobilizations.

• Identify at least two advantages of being able to quantify mobilization techniques.

• Describe at least one mobilization for each of the joints presented in the presentation ( shoulder, elbow, wrist, knee, ankle).

• Dose joint mobilizations and evaluate the effects of joint mobilizations using the algorithm provided in the presentation.

After this course, participants will be able to:

Disclaimer• The author wishes to disclaim the financial

interest in the following:– iOrtho Mobile App, Therapeutic Articulations, LLC– OrthoNotes, F.A. Davis Publishing– Mobilization Notes, F.A. Davis Publishing– Mobil-Aider device, Therapeutic Articulations, LLC

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The skilled, passive movement to a joint directed toward restoring

accessory (arthrokinematic) motionParis, 1974

Wise CH & Gulick DT. Mobilization Notes. FA Davis, 2009; used with permission5

Convex-Concave Rule

Direction of joint glide is opposite of the direction of osteokinematicmotion

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Concave-Convex RuleDirection of joint glide is in the same direction as osteokinematicmotion

Indications for Joint Mobilizations

Improve accessory or physiologic movement

Restore normal articular relationships

Symptom relief & pain control

Enhance motor function

Reduce muscle guarding

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Contraindications - Absolute• Medically unstable• Joint hypermobility• Ligamentous laxity• Malignancy• Cauda equine lesions• Bowels & bladder

dysfunction

• Vertebral basilar insufficiency

• Bone disease• Status post joint fusion• Deteriorating CNS

pathology• Acute inflammation• Joint effusion

Contraindications - Precautions• Joint replacements• Pregnancy-Postpartum• Recent trauma• Early connective tissue

healing• Long-term use of

corticosteroids• Osteopenia/porosis

• Systemic connective tissue disorder

• Unfused joint plates• Open wounds• Communication or

cognitive disorders• Psychogenic patients

exhibiting symptom magnification

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Mov’t Impairment AlgorithmExamination

Reactivity

symptomatic?

Region of origin

Where are

symptoms?

Reproducible sign

What causes

symptoms?

Instability

Syndrome

Hypomobility

Syndrome

STABILIZATIONMOBILIZATION

Wise CH & Gulick DT. Mobilization Notes. FA Davis, 2009; used with permission 11

Effect of Joint MobilizationNEUROPHYSIOLOGIC EFFECTS (Grades I, II):

Firing of articular mechanoreceptors & proprioceptors

Firing of cutaneous & muscular receptors

Altered nocioception

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Effect of Joint MobilizationMECHANICAL EFFECTS (Grades III, IV):

Stretching of joint restrictions

Breaking of adhesions

Alter positional relationships

Diminish/eliminate barriers to normal motion

Distraction

1. Perpendicular to treatment plane

2. Separation of joint surfaces

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GLIDE (Maitland):Parallel to treatment plane

• Grade I: Small amplitude at beginning of range

• Grade II: Large amplitude within range, not reaching limit

• Grade III: Large amplitude up to limit of range

• Grade IV: Small amplitude at limit of end range

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Clinical Problem

Clinical application of these mobilization

techniques has been reported to be quite

variable

Lack of consistency can have a significant effect

on patient recovery

Mobil-AiderTM

Gulick DT. Therapeutic Articulations, LLC 2019Video 118

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Mobil-AiderTM

Gulick DT. Therapeutic Articulations, LLC 201919

Assess the EndfeelMode A

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Render a Treatment Mode B

Mode A Mode B

Video 322

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Value of Mobil-Aider & Feedback

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Mobilization Questions

Shoulder Mobilizations

Gulick DT. Ortho Notes. FA Davis, 2018; used with permission26

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Shoulder Mobilizations• Inferior glide = improves shoulder elevation,

i.e. flexion, abduction, scaption

• Anterior & Posterior glides = improves shoulder rotation & contributes to centering the humeral head in the glenoid socket

Glenohumeral glides - inferiorImproves elevation

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Glenohumeral glides - inferior

Video 6 Gulick DT. Therapeutic Articulations, LLC 201929

H-E attachment

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Concave-Convex Rule for IR / ER

Glenohumeral glides - posteriorImproves rotation

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Glenohumeral glides - posterior

H-D attachment

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Glenohumeral glides - anteriorImproves rotation

Glenohumeral glides - anterior

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H-D attachment

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Sternoclavicular glides - posterior

Improves Horiz abd

Sternoclavicular glides - posterior

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Shoulder Mobilization Questions

Elbow Mobilizations

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Elbow Mobilizations• Humero-ulnar medial glide = elbow flexion

• Humero-ulnar lateral glide = elbow extension

Humero-ulnar glides: medialImproves Flexion

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Humero-ulnar glides: medial

H-E Attachment

Humero-ulnar glides: medial

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Humero-ulnar glides: lateralImproves Extension

Humero-ulnar glides: lateral

H-E Attachment

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Humero-ulnar glides: lateral

Humero-radial glide: anterior

Improves Flex/Pronation

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Humero-radial glide: posterior

Improves Ext/Supination

Elbow Mobilization Questions

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Wrist & HandMobilizations

Wrist & Hand Mobilizations• Radiocarpal dorsal glide = flexion

• Radiocarpal volar glide = extension

• Radiocarpal medial glide = radial deviation

• Radiocarpal lateral glide = ulnar deviation

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Radiocarpal glide:dorsal (flexion) & volar (extension)

Radiocarpal glide: dorsal (flexion)

H-F Attachment

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Radiocarpal glide: dorsal (flexion)

Radiocarpal glide: volar (extension)

H-F Attachment

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Radiocarpal glide: volar (extension)

Radiocarpal glide: medial (RD)

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Radiocarpal glide: medial (RD)

Radiocarpal glide: lateral (UD)

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Midcarpal & Intercarpal glide

CMC glide

1st posterior = abd1st anterior = add2-5 volar/anterior = flex

2-5 dorsal/posterior = ext

1st medial = flex1st lat = ext

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MCP glide: dorsal (extension) & volar (flexion)

IP glide: dorsal (extension) & volar (flexion)

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Wrist/Hand Mobilization Questions

Knee Mobilizations

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Knee Mobilizations• Anterior glides = extension– Supine– Prone

Biomechanically usually better to push

than pull

Knee glides: anterior (supine)

FacilitatesExtension

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H-BAttachment

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Knee glides: anterior (prone)

FacilitatesExtension

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Knee glides: anterior (prone)H-C

Attachment

Video 22Gulick DT. Therapeutic Articulations, LLC 2019

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Knee Mobilization Questions

Ankle & Foot Mobilizations

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Ankle & Foot Mobilizations• Talocrural posterior glide = dorsiflexion

• Talocrural anterior glide = plantarflexion

Talocrural glides: posterior

Moving talus posterior on tib/fib

Distal hand helps facilitate dorsiflexion

Indication:To improve talocrural dorsiflexion

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H-EAttachment

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Talocrural glides: anterior

Indication:To improve talocrural plantarflexion

H-CAttachment

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Subtalar glide - medial

Indication:To improve subtalar eversion

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Subtalar glide - medial

Subtalar glide - lateral

Indication:To improve subtalar inversion

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Subtalar glide - lateral

TMT glides

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MTP glides

Indication:To improve MTP flexion (plantar) & extension (dorsal) motions

IP glides

Indication:To improve IP flexion (plantar) & extension (dorsal) motions

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Ankle Mobilization Questions

Dosing Variables

Location

Speed or Rhythm

Amplitude

Frequency &

Duration (set,reps,daily)

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Trial Intervention (1-5 reps)

Worse Better No Change

↑ 1 VariableMuch BetterSlightly Better↓ 1 Variable

Re-examineRepeat 1-5 x

Hold & Monitor

References• Chang J, Chang Chien C, Chang G, Chung K, Has A. Adaptability of learning on joint mobilization skill with

augmented feedback by using a joint translation simulator. Physiotherapy. 2007;93(s1):S75 • deSouza MS, Venturini C, Teixeira LM, Chagas MH, deResende MA. Force-displacement relationship during

anteroposterior mobilization of the ankle joint. J Manipulative Physiol Ther. 2008;31:285-292 • Gorgos KS, Wasylyk NT, Van Lunen BL, Hoch MC. Inter-clinician and intra-clinician reliability of force

application during joint mobilization: a systematic review. Manual therapy. 2014;19(2):90-6. • Gulick DT. Reliability and Validity of an Innovative Device for ACL Testing: The Mobil-AiderTM. Journal of

Sport Rehab. Accepted March 2019, publication pending• Hattori K, Ogawa M, Tanaka K, Matsuya A, Uematsu K, Tanaka Y. Can joint sound assess soft and hard

endpoints on the Lachman test? Biomedical Materials and Engineering. 2016:27:111-118 • Maitland GD. Peripheral manipulation. 3rd ed. London; Boston: Butterworth-Heinemann; 1991. • Neumann, D. Kinesiology of the Musculoskeletal System, 3rd ed, 2017• Paris, SV, Loubert, PV: Foundations of Clinical Orthopaedics, Course Notes. St. Augustine, FL, Institute

Press, 1990.• Prentice WE. Joint Mobilization and Traction Techniques in Rehabilitation. In: Hoogenboom BJ, Voight ML,

Prentice WE. eds. Musculoskeletal Interventions: Techniques for Therapeutic Exercise, Third Edition New York, NY: McGraw-Hill; 2013.

• Silvernail JL, Gill NW, Teyhen DS, Allison SC. Biomechanical measures of knee joint mobilization. The Journal of manual & manipulative therapy. 2011;19(3):162-71.

• Snodgrass SJ, Rivett DA, Robertson VJ. Manual forces applied during cervical mobilization. J Manipulative Physiol Ther. 2007;30:17-25

• Tragord BS, Gill NW, Silvernail JL, Teyhen DS, Allison SC. Joint mobilization forces and therapist reliability in subjects with knee osteoarthritis. The Journal of manual & manipulative therapy. 2013;21(4):196-206.

• Tuttle N, Jacuinde G. Design and construction of a novel low-cost device to provide feedback on manually applied forces. JOSPT. 2011;41(3):174-179

• Wise CH, Gulick DT. Mobilization Notes: A Rehabilitation Specialist's Pocket Guide. Philadelphia, PA: Davis Publishing; 2009.

• Witt DW, Talbott NR. In-vivo measurements of force and humeral movement during inferior glenohumeralmobilizations. Manual Therapy. 2016;21:198-203

6/21/2019

Post-Course Questions• Dawn T Gulick, PhD, PT, AT, CSCS• info@iortho.xyz• www.iortho.xyz

• For PhysicalTherapy.com• Discount Code: PT20• 20% iOrtho+ Mobile App

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