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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:
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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
Wise CH & Gulick DT. Mobilization Notes. FA Davis, 2009; used with permission6
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Concave-Convex RuleDirection of joint glide is in the same direction as osteokinematicmotion
Wise CH & Gulick DT. Mobilization Notes. FA Davis, 2009; used with permission7
Indications for Joint Mobilizations
Improve accessory or physiologic movement
Restore normal articular relationships
Symptom relief & pain control
Enhance motor function
Reduce muscle guarding
Wise CH & Gulick DT. Mobilization Notes. FA Davis, 2009; used with permission8
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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
Wise CH & Gulick DT. Mobilization Notes. FA Davis, 2009; used with permission9
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
Wise CH & Gulick DT. Mobilization Notes. FA Davis, 2009; used with permission10
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Mov’t Impairment AlgorithmExamination
Reactivity
How
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
Wise CH & Gulick DT. Mobilization Notes. FA Davis, 2009; used with permission12
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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
Wise CH & Gulick DT. Mobilization Notes. FA Davis, 2009; used with permission13
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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Gulick DT. iOrtho+ Mobile App, 2019
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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
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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
Gulick DT. Therapeutic Articulations, LLC 2019Video 221
Gulick DT. Therapeutic Articulations, LLC 2019
Mode A Mode B
Video 322
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Value of Mobil-Aider & Feedback
Gulick DT. Therapeutic Articulations, LLC 2019Video 423
Value of Mobil-Aider & Feedback
Gulick DT. Therapeutic Articulations, LLC 2019Video 524
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Mobilization Questions
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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
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Glenohumeral glides - inferiorImproves elevation
Gulick DT. Therapeutic Articulations, LLC 201928
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Glenohumeral glides - inferior
Video 6 Gulick DT. Therapeutic Articulations, LLC 201929
Glenohumeral glides - inferior
H-E attachment
Gulick DT. Therapeutic Articulations, LLC 201930
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Glenohumeral glides - inferior
Video 7 Gulick DT. Therapeutic Articulations, LLC 201931
Glenohumeral glides - inferior
Gulick DT. Therapeutic Articulations, LLC 201932
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Concave-Convex Rule for IR / ER
Wise CH & Gulick DT. Mobilization Notes. FA Davis, 2009; used with permission33
Glenohumeral glides - posteriorImproves rotation
Gulick DT. Therapeutic Articulations, LLC 201934
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Glenohumeral glides - posterior
Video 8 Gulick DT. Therapeutic Articulations, LLC 201935
Glenohumeral glides - posterior
H-D attachment
Gulick DT. Therapeutic Articulations, LLC 201936
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Glenohumeral glides - posterior
Video 9 Gulick DT. Therapeutic Articulations, LLC 201937
Glenohumeral glides - posterior
Video 10 Gulick DT. Therapeutic Articulations, LLC 201938
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Glenohumeral glides - anteriorImproves rotation
Gulick DT. Therapeutic Articulations, LLC 201939
Glenohumeral glides - anterior
Video 11 Gulick DT. Therapeutic Articulations, LLC 201940
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Glenohumeral glides - anterior
H-D attachment
Gulick DT. Therapeutic Articulations, LLC 201941
Glenohumeral glides - anterior
Video 12 Gulick DT. Therapeutic Articulations, LLC 201942
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Sternoclavicular glides - posterior
Improves Horiz abd
Gulick DT. Therapeutic Articulations, LLC 201943
Sternoclavicular glides - posterior
Video 13 Gulick DT. Therapeutic Articulations, LLC 201944
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Shoulder Mobilization Questions
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Elbow Mobilizations
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Elbow Mobilizations• Humero-ulnar medial glide = elbow flexion
• Humero-ulnar lateral glide = elbow extension
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Humero-ulnar glides: medialImproves Flexion
Gulick DT. Therapeutic Articulations, LLC 201948
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Humero-ulnar glides: medial
H-E Attachment
Gulick DT. Therapeutic Articulations, LLC 201949
Humero-ulnar glides: medial
Video 14 Gulick DT. Therapeutic Articulations, LLC 201950
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Humero-ulnar glides: lateralImproves Extension
Gulick DT. Therapeutic Articulations, LLC 201951
Humero-ulnar glides: lateral
H-E Attachment
Gulick DT. Therapeutic Articulations, LLC 201952
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Humero-ulnar glides: lateral
Video 15 Gulick DT. Therapeutic Articulations, LLC 201953
Humero-radial glide: anterior
Improves Flex/Pronation
Gulick DT. Therapeutic Articulations, LLC 201954
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Humero-radial glide: posterior
Improves Ext/Supination
Gulick DT. Therapeutic Articulations, LLC 201955
Elbow Mobilization Questions
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Wrist & HandMobilizations
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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)
Gulick DT. Therapeutic Articulations, LLC 201959
Radiocarpal glide: dorsal (flexion)
H-F Attachment
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Radiocarpal glide: dorsal (flexion)
Video 16 Gulick DT. Therapeutic Articulations, LLC 201961
Radiocarpal glide: volar (extension)
H-F Attachment
Gulick DT. Therapeutic Articulations, LLC 201962
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Radiocarpal glide: volar (extension)
Video 17 Gulick DT. Therapeutic Articulations, LLC 201963
Radiocarpal glide: medial (RD)
Gulick DT. Therapeutic Articulations, LLC 201964
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Radiocarpal glide: medial (RD)
Video 18 Gulick DT. Therapeutic Articulations, LLC 201965
Radiocarpal glide: lateral (UD)
Video 19 Gulick DT. Therapeutic Articulations, LLC 201966
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Midcarpal & Intercarpal glide
Gulick DT. Therapeutic Articulations, LLC 201967
CMC glide
1st posterior = abd1st anterior = add2-5 volar/anterior = flex
2-5 dorsal/posterior = ext
1st medial = flex1st lat = ext
Gulick DT. Therapeutic Articulations, LLC 201968
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MCP glide: dorsal (extension) & volar (flexion)
Gulick DT. Therapeutic Articulations, LLC 201969
IP glide: dorsal (extension) & volar (flexion)
Gulick DT. Therapeutic Articulations, LLC 201970
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Wrist/Hand Mobilization Questions
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Knee Mobilizations
Gulick DT. iOrtho+ Mobile App, 201972
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Knee Mobilizations• Anterior glides = extension– Supine– Prone
Biomechanically usually better to push
than pull
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Knee glides: anterior (supine)
FacilitatesExtension
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Knee glides: anterior (supine)
H-BAttachment
Gulick DT. Therapeutic Articulations, LLC 201975
Knee glides: anterior (supine)
Video 20 Gulick DT. Therapeutic Articulations, LLC 201976
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Knee glides: anterior (prone)
FacilitatesExtension
Gulick DT. Therapeutic Articulations, LLC 201977
Knee glides: anterior (prone)
Video 21 Gulick DT. Therapeutic Articulations, LLC 201978
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Knee glides: anterior (prone)H-C
Attachment
Gulick DT. Therapeutic Articulations, LLC 201979
Knee glides: anterior (prone)
Video 22Gulick DT. Therapeutic Articulations, LLC 2019
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Knee Mobilization Questions
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Ankle & Foot Mobilizations
Gulick DT. iOrtho+ Mobile App, 201982
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Ankle & Foot Mobilizations• Talocrural posterior glide = dorsiflexion
• Talocrural anterior glide = plantarflexion
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Talocrural glides: posterior
Moving talus posterior on tib/fib
Distal hand helps facilitate dorsiflexion
X
Indication:To improve talocrural dorsiflexion
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Talocrural glides: posterior
H-EAttachment
Gulick DT. Therapeutic Articulations, LLC 201985
Talocrural glides: posterior
Video 23 Gulick DT. Therapeutic Articulations, LLC 201986
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Talocrural glides: anterior
Indication:To improve talocrural plantarflexion
Gulick DT. Therapeutic Articulations, LLC 201987
Talocrural glides: anterior
H-CAttachment
Gulick DT. Therapeutic Articulations, LLC 201988
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Talocrural glides: anterior
Video 24 Gulick DT. Therapeutic Articulations, LLC 201989
Subtalar glide - medial
Indication:To improve subtalar eversion
Gulick DT. Therapeutic Articulations, LLC 201990
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Subtalar glide - medial
Video 25 Gulick DT. Therapeutic Articulations, LLC 201991
Subtalar glide - lateral
Indication:To improve subtalar inversion
Gulick DT. Therapeutic Articulations, LLC 201992
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Subtalar glide - lateral
Video 26 Gulick DT. Therapeutic Articulations, LLC 201993
TMT glides
Gulick DT. Therapeutic Articulations, LLC 201994
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MTP glides
Indication:To improve MTP flexion (plantar) & extension (dorsal) motions
Gulick DT. Therapeutic Articulations, LLC 201995
IP glides
Indication:To improve IP flexion (plantar) & extension (dorsal) motions
Gulick DT. Therapeutic Articulations, LLC 201996
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Ankle Mobilization Questions
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Dosing Variables
Location
Speed or Rhythm
Amplitude
Frequency &
Duration (set,reps,daily)
Wise CH & Gulick DT. Mobilization Notes. FA Davis, 2009; used with permission 98
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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
Wise CH & Gulick DT. Mobilization Notes. FA Davis, 2009; used with permission 99
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
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Post-Course Questions• Dawn T Gulick, PhD, PT, AT, CSCS• [email protected]• www.iortho.xyz
• For PhysicalTherapy.com• Discount Code: PT20• 20% iOrtho+ Mobile App
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