Joint Mobilizations: Introduction

Introduction to Self-Administered Joint Mobilizations

by Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, ACSM H/FS

Definition:

Joint mobilization - a gentle, often oscillatory, passive movement applied to a joint with the intent to increase passive range and/or achieve a therapeutic effect.

There is more to achieving optimal motion than interventions for the muscular system. The muscular system has a large influence on motion and is perhaps the easiest to target with self-administered and manual techniques, but joint dysfunction (arthrokinematic dyskinesis) can dramatically alter the quality of human movement as well. Joint mobilizations add a set of techniques that specifically address joint dysfunction; enhancing our ability to optimize motion.

Arthrokinematic Motion versus Osteokinematic Motion:

Definitions

Osteokinematics (Movement of bones) – Movement of bones around a joint, described by the terms flexion, extension, abduction, adduction, etc. You could think of this in terms of movement of the shafts of bones relative to one another.
Arthrokinematics (Movement of joint surfaces) – Small amplitude movements occurring between joint surfaces, described by the terms, roll, glide, spin, compression and distraction.
- Roll - A movement in which someone or something turns or is turned over on itself
- Spin (rotate) - Motion in a circle around an axis or center
- Glide (slide) - To move along a surface while one point or area maintains in constant contact with a surface
- Distraction (Traction) - Pulling to surfaces apart from one another. Creating a gap between joint surfaces.
- Compression - Approximating joint surfaces, increasing pressure between joint surfaces, squeezing joint surfaces.

Optimal motion is achieved when both arthrokinematic and osteokinematic motion occur in the appropriate direction, proportions and magnitude. Joint mobilizations, are generally techniques that are designed to return optimal arthrokinematic motion to a joint that has adopted a compensatory or dysfunctional pattern.

Arthrokinematics Lecture (Snippet from "Intro to Human Movement Science")

The forces that maintain optimal arthrokinematics during osteokinematic motion (congruence between joint surfaces during functional activities) are likely the combination of forces created by both passive and active structures.

The passive structures involved include the joint capsule and ligaments, as well as, the tonicity of muscles not actively involved in the joint motion. For example, during shoulder abduction, excessive superior glide is opposed by the inferior glenohumeral ligament, portions of the joint capsule and the inherent tone and resistance to stretch of the latissimus dorsi and teres major (1).
The active structures involved in maintaining joint congruence are generally the antagonists, and proximal stabilizing muscles. For example, during shoulder flexion active resistance to anterior translation is produced by the posterior deltoid and rotator cuff .

Although mobilizations are generally designed with the intent to target adaptively shortened passive structures (ligaments, capsule, intra-articular structures), mobilizations may also have an affect on active structures through the mechanical deformation of tissue and the stimulation of receptors affecting muscle activity (tone). See "Hypothesis of How Mobilizations Work" below.

Illustration of How Muscles Affect Joint Motion by the National Academy of Sports Medicine :

Assessment:

Self-administered joint mobilizations are intended to increase mobility, implying that there use should be limited to joints exhibiting stiffness or arthrokinematic dyskinesis resulting in a loss of osteokinematic range of motion (hypomobility).

Direct Assessment:

Passive Accessory/Arthrokinematic Motion Assessment (Cyriax/Maitland Joint Assessment)
- For licensed practitioners, it is advised that passive accessory assessment is done prior to recommending any joint mobilization technique. Further, licensed professionals will likely gain more from manual mobilizations, and should consider the techniques proposed in the following lessons as support for their manual interventions (e.g. part of an exercise intervention or home exercise program).

Indirect Assessment:

Overhead Squat Assessment :
- The overhead squat assessment can be used to implicate joints that may be exhibiting stiffness/arthrokinematic dyskinesis based on predictive models of postural dysfunction and the accompanying joint dysfunction.
Goniometry :
- Although goniometry assesses osteokinematic motion, a loss in range of motion may be influenced by, or the result of arthrokinematic dyskinesis. Like the overhead squat assessment , goniometry may be used to identify hypomobile joints that may benefit from techniques to optimize arthrokinematics.

Best Practice:

Use when assessment highlights an apparent mobility restriction that is not alleviated by muscular system interventions (foam rolling, release techniques, stretching, etc.. .).
Only mobilize hypo-mobile joints
If mobilization causes pain stop immediately
If mobilization is ineffective, give it a couple of tries, if still not effective abandon the technique

Self-Administered Joint Mobilization General Guidelines (Acute Variables):

Assess
Carefully position the band on the appropriate bone close to the restricted joint
Ensure force is applied in the desired direction
Apply enough tension to ensure arthrokinematic motion is achieved and tension is maintained throughout the entire range of the oscillation
Oscillate with:
1. Small amplitude (1 - 3 inches)
2. 15 – 30 seconds (20 - 50 repetitions)
3. Rate of roughly 1 – 2 oscillations per second
4. 1 - 2 sets
Re-assess

What Should You Feel?:

In two words: "not much." Joint mobilizations will not produce the feelings of tension, stretch or pressure with the same intensity that release and lengthening techniques will; other than the pressure exerted by the band itself. It is not uncommon for the patient/client to feel nothing in the joint being mobilized. When a mild sensation is felt, it is most often described as a "light stretch", an "opening" or "movement within the joint". It is important that changes in the motion being assessed (e.g. the overhead squat assessment) are used to demonstrate to the client/patient the need for the technique, and that intense feelings of tension or stretch are not used as a bench mark. As with any mobility technique, too much, too often, for too long can create hyper-mobility and further dysfunction.

Predictable Patterns of Arthrokinmatic Dyskinesis

The effect of Postural Dysfunction/Movement Impairment on Joint Motion

Definition:

Ideal Posture is ideal arthro- and osteo-kinematics maintained by optimal myofascial activity and length, as a result of accurate sensation, integration and activation by the nervous system – both statically and dynamically.
Postural Dysfunction is the absence of ideal posture as a result of maladaptation by one or multiple tissues within the human movement system.

Several studies have linked dysfunction, compensation and altered muscle activity with an increased risk of injury, pain, and/or decreased performance (15-24). These patterns of dysfunction are common and often predictable and have lead to the development of predictive models of dysfunction by Janda, Sahrmann, Clark and the models of postural dysfunction proposed by the Brookbush Institute (3-5). These compensatory patterns, despite being less than optimal, may be the result of inherent qualities in our human movement system – whether it be nuanced mechanical imperfections in the skeletal system, the varying rates of adaptation seen in different tissues, response to the continuous force of gravity, reflexive muscular activity in response to receptor adaptation, re-emergent developmental patterns, re-emergent primitive patterns, in either of the latter, implying that these motor patterns are pre-programmed in our central nervous system (CNS). These compensatory movement strategies may provide an alternative set of motor units when optimal motor patterns suffer fatigue, provide alternative ways to dissipate force when a segment of the human movement system is damaged, or they may simply be a means of shifting stress between tissues.

The affect postural dysfunction has on arthrokinematics may also be predictable, resulting in "common compensatory patterns" for each joint. The studies by Lawrence et al. (6 - 7) are examples of new research that may help to refine predictive models of joint dysfunction. As noted above, arthrokinematics are the result of forces from both passive and active structures, implying that the muscle imbalance inherent to these predictive models of postural dysfunction will also have an affect on joint motion. Combined with the finding from a limited set of research studies, and "commonly effective mobilizations" referred to by texts and respected clinicians, it may be possible to hypothesize regarding common compensatory patterns of arthrokinematic dyskinesis (2, 8-13).

Arthrokinematic Dyskinesis - Altered motion between joint surfaces as a result of, or cause of dysfunction.

Developing Self-administered Mobilization Techniques:

Common compensatory patterns were used to develop the techniques in the following lessons and videos. By addressing the most common compensatory patterns these techniques have the highest likelihood of returning ideal arthrokinematics, ideal posture and ideal motion. That does not imply, that these techniques will be successful in all cases, or that other compensatory patterns do not exist. Further, practice and clinical experience have lead to modifications that may appear less than ideal based on our predictive models of compensation. Most often these modification have been made to optimize body position, decrease muscle activity, or accommodate for band placement and direction of pull. In essence, these modifications were made when theory met practical application. Each mobilization technique discussed will include a video (and still image), the joint, band placement, recommended band color, direction of joint mobilization, hypothesized pattern of arthrokinematic dyskinesis, the associated postural dysfunction(s), "target tissue(s)", and assessment and signs that may indicate the need for these techniques.

Hypotheses on How Mobilizations Work:

Research on the mechanism by which mobilizations affect joint motion and alter sensation is ongoing. Several hypotheses have been considered; however, no one hypothesis can explain the various mechanical, physiological and sensory affects that joint mobilizations have. Below is a brief summary of current theories.

Mechanical force exerted through stiffness/obstruction
Change in intra-articular pressure (1)
Increase in synovial fluid production
Decrease in tonicity of over-active muscles proximal to the joint
Increased elasticity of connective tissue (joint capsule, etc.)
Receptor desensitization
Afferentation and central nervous system mediated adaptation
Integrated pathways (Summary by Steven Roffers, DC, PT)
- For C0-C3: Force --> spindle receptors --> fastigial nucleus of the cerebellum -->which aids in the control of muscle tone.
- For C4 and below: Force --> spindle receptors --> IML --> PMRF --> Cerebellum -->which then aides in the control of muscle tone.
  - Upper cervical mobilizations may get much more profound and faster results due to spindle receptors of C0-C3 firing directly into the fastigial nucleus.

It is likely that many of these hypothesis play a role in the positive changes noted post joint mobilization, and that further research will add additional hypothesis to this list.

History:

Joint mobilizations have quite literally been developing for 1000's of years, with early depictions of mobilizations dating back to Thailand (2000 BC) and Hippocrates (500 BC); however, a more organized approach to mobilization did not begin until the trade of Bone Setting developed in England in 1656. 200 years later osteopaths (Still 1876) and chiropractors (Palmer 1895) would create schools to formalize education and advance the practice of mobilizations further. Over the last 100 years, the advancement of joint mobilizations and their inclusion in the medical model can be largely attributed to individuals such as Cyriax, Maitland, Kaltenborn, Dutton, McKenzie, Mulligan and Paris. In the last 20 years the focus has shifted away from individuals and "schools of thought", and strongly toward evidence-based practice and a larger focus on outcome measures. You can expect more Research Reviews on joint mobilizations and manipulations from the Brookbush Institute in the future, with the intent to aid in the continued growth, education, sophisticated exercise selection, and best practices within our professions.

Lessons on Self-administered Joint Mobilizations:

Bibliography:

Donald A. Neumann, Kinesiology of the Musculoskeletal System: Foundations of Rehabilitation – 2nd Edition © 2012 Mosby, Inc.
Phillip Page, Clare Frank , Robert Lardner , Assessment and Treatment of Muscle Imbalance: The Janda Approach © 2010 Benchmark Physical Therapy, Inc., Clare C. Frank, and Robert Lardner
Lawrence, R.L., Braman, J.P., Staker, J.L., Laprade, R.F., Ludewig, P.M. (2014) Comparison of 3-dimensional shoulder complex kinematics in individuals with and without shoulder pain, Part 2: Glenohumeral joint. Journal of Orthopaedic & Sports Physical Therapy 44(9). 646-B3
[Lawrence, R. L., Braman, J. P., Laprade, R. F., & Ludewig, P. M. (2014). Comparison of 3-dimensional shoulder complex kinematics in individuals with and without shoulder pain, part 1: sternoclavicular, acromioclavicular, and scapulothoracic joints. journal of orthopaedic & sports physical therapy, 44(9), 636-A8.](http://Lawrence,%20R. L., Braman, J. P., Laprade, R. F., & Ludewig, P. M. (2014). Comparison of 3-dimensional shoulder complex kinematics in individuals with and without shoulder pain, part 1: sternoclavicular, acromioclavicular, and scapulothoracic joints. journal of orthopaedic & sports physical therapy, 44(9), 636-A8.)
Maitland Australian Physiotherapy Seminars. MT - O Evidence Based Orthopedic Diagnostic Evaluation: Including Evidence Based Screening, Diagnosis & Treatment © 2009 - 2012 Maitland Australian Physiotherapy Seminars
Maitland Australian Physiotherapy Seminars. MT - 1 Evidence Based Orthopedic Diagnostic Evaluation: Including Evidence Based Screening, Diagnosis & Treatment © 1985 - 2009 Maitland Australian Physiotherapy Seminars
Maitland Australian Physiotherapy Seminars. MT - 3: Intermediate Spinal © 1985-2009 Maitland Australian Physiotherapy Seminars
Padua, D. A., Bell, D. R., & Clark, M. A. (2012). Neuromuscular characteristics of individuals displaying excessive medial knee displacement. Journal of athletic training, 47(5), 525.
Mauntel, T., Begalle, R., Cram, T., Frank, B., Hirth, C., Blackburn, T., & Padua, D. (2013). The effects of lower extremity muscle activation and passive range of motion on single leg squat performance. Journal Of Strength And Conditioning Research / National Strength & Conditioning Association, 27(7), 1813-1823.
Ramskov, D., Barton, C., Nielsen, R. O., & Rasmussen, S. (2015). High Eccentric Hip Abduction Strength Reduces the Risk of Developing Patellofemoral Pain Among Novice Runners Initiating a Self-Structured Running Program: A 1-Year Observational Study. journal of orthopaedic & sports physical therapy, 45(3), 153-161.
José Miota Ibarra, Hong-You Ge, Chao Wang, Vicente Martínez Vizcaíno, Thomas Graven-Nielsen, Lars Arendt-Nielsen. Latent Myofascial Trigger Points are Associated With an Increased Antagonistic Muscle Activity During Agonist Muscle Contraction. The Journal of Pain, Volume 12, Issue 12, December 2011, Pages 1282–1288
Hodges, P., Richardson, C. (1996). Inefficient Muscular Stabilization of the Lumbar Spine Associated With Low Back Pain: A Motor Control Evaluation of Transverse Abdominis. Spine,21(22), 2640-2650.
Franettovich, S. M., Honeywill, C. O. N. O. R., Wyndow, N., Crossley, K. M., & Creaby, M. W. (2014). Neuromotor control of gluteal muscles in runners with achilles tendinopathy. Medicine and science in sports and exercise, 46(3), 594-599.
Ayhan, C., Camci, E., & Baltaci, G. (2015). Distal radius fractures result in alterations in scapular kinematics: A three-dimensional motion analysis. Clinical Biomechanics, March 2015Volume 30, Issue 3, Pages 296–301
Kado, D.M., Huang, M., Karlamangla, A.S., Barrett-Connor, E., Greendale, G.A. (2004). Hyperkyphotic posture predicts mortality in older community-dwelling men and women: A prospective study. JAGS S2: 1662-1667
Cholewicki, J., Silfies, S., Shah, R., Greene, H., Reeves, N. Alvi, K., Goldberg, B. (2005). Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 30(23), 2614-2620.
Tateuchi, H., Taniguchi, M., Mori, N., Ichihashi, N. Balance of hip and trunk muscle activity is associated with increased anterior pelvic tilt during prone hip extension (2013) Journal of Electromyography and Kinesiology 22 (3). 391-397
Hewett, T. E., Myer, G. D., Ford, K. R., Heidt, R. S., Colosimo, A. J., McLean, S. G., & Succop, P. (2005). Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes A prospective study. The American journal of sports medicine, 33(4), 492-501.

Questions, comments, and criticisms are welcomed and encouraged –