Mobilization is a technique generally given by physiotherapist for improving mobility in different segments of the body

1. Mobilization
Rushi Gajjar
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2. • Joint mobilization refers to manual therapy techniques that are
used to modulate pain and treat joint dysfunctions that limit
range of motion (ROM) by specifically addressing the altered
mechanics of the joint
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3. Causes for alter joint mechanics
• Pain and muscle guarding,
• Joint effusion,
• Contractures or adhesions in the joint capsules or supporting
ligaments,
• Malalignment or subluxation of the bony surfaces.
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4. Terms
• Mobilization/Manipulation
• Self-Mobilization (Auto-mobilization)
• Mobilization with Movement
• Physiological Movements
• Accessory Movements
• Thrust
• Manipulation Under Anaesthesia
• Muscle Energy
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5. 5
PHYSIOLOGICAL LIMIT

6. Mobilization/ Manipulation
• Mobilization and manipulation are passive, skilled manual therapy
techniques applied to joints and related soft tissues at varying
speeds and amplitudes using physiological or accessory motions for
therapeutic purposes.
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7. Self-Mobilization (Auto-mobilization)
• Self-mobilization refers to self-stretching techniques that
specifically use joint traction or glides that direct the stretch
force to the joint capsule
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8. Mobilization with Movement
• Brian Mulligan
• Mobilization with movement (MWM) is the concurrent application
of sustained accessory mobilization applied by a therapist and an
active physiological movement to end range applied by the patient
• Passive end-of-range overpressure, or stretching, is then delivered
without pain as a barrier.
• The techniques are always applied in a pain-free direction and are
described as correcting joint tracking from a positional fault
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10. Physiological Movements
• Physiological movements are
movements the patient can do
voluntarily
• The term osteo-kinematics is
used when these motions of
the bones are described.
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11. Accessory Movements
• Accessory movements are
movements in the joint and
surrounding tissues that are
necessary for normal ROM but
that cannot be actively
performed by the patient.
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12. • Component motions are those motions that accompany active
motion but are not under voluntary control.
• For example, motions such as upward rotation of the scapula and
rotation of the clavicle, which occur with shoulder flexion, and
rotation of the fibula, which occurs with ankle motions, are
component motions
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13. Joint play
• Joint play describes the motions that
occur between the joint surfaces and
also the distensibility or “give” in
the joint capsule, which allows the
bones to move
• The movements include distraction,
sliding, compression, rolling, and
spinning of the joint surfaces.
• The term arthro-kinematics is used
when these motions of the bone
surfaces within the joint are
described.
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14. Thrust
• Thrust is a high-velocity, short-amplitude motion such that the
patient cannot prevent the motion.
• The motion is performed at the end of the pathological limit of
the joint and is intended to alter positional relationships, snap
adhesions, or stimulate joint receptors
• Pathological limit means the end of the available ROM when there
is restriction
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16. Manipulation Under Anaesthesia
• Manipulation under anesthesia is a medical procedure used to
restore full ROM by breaking adhesions around a joint while the
patient is anesthetized
• The technique may be a rapid thrust or a passive stretch using
physiological or accessory movements.
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17. Muscle Energy
• Muscle energy techniques use active contraction of deep muscles
that attach near the joint and whose line of pull can cause the
desired accessory motion.
• A command for an isometric contraction of the muscle is given
that causes accessory movement of the joint
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OVOID
SURFACE
SELLAR
SURFACE

19. ARTHROKINEMATICS
• Joint Shapes
• ovoid or Sellar
• In ovoid joints one surface is convex, the other is concave
• In Sellar joints, one surface is concave in one direction and convex
in the other, with the opposing surface convex and concave,
respectively; similar to a horseback rider being in complementary
opposition to the shape of a saddle
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21. Types of Motion
• The movement of the bony lever is called swing
• The amount of movement can be measured in degrees with a
goniometer and is called ROM.
• Motion of the bone surfaces in the joint is a variable combination
of rolling and sliding, or spinning
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22. Roll
• Representation of one surface rolling on another. New points on
one surface meet new points on the opposing surface.
• Rolling results in angular motion of the bone (swing).
• Rolling is always in the same direction as the swinging bone
motion whether the surface is convex (Fig. 5.3A) or concave (Fig.
5.3B).
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24. Slide/Translation
• Representation of one surface sliding on another, whether (A) flat
or (B) curved. The same point on one surface comes into contact
with new points on the opposing surface.
• Sliding is in the opposite direction of the angular movement of the
bone if the moving joint surface is convex (Fig. 5.5A). Sliding is in
the same direction as the angular movement of the bone if the
moving surface is concave (convex-concave rule)
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25. Convex-concave rule 25

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27. Spin
• Representation of spinning. There is rotation of a segment about a
stationary mechanical axis.
• The same point on the moving surface creates an arc of a circle as
the bone spins.
• combination with rolling and sliding.
• Example shoulder with flexion/extension, the hip with
flexion/extension, and the radio-humeral joint with
pronation/supination
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29. Other Accessory Motions that Affect the Joint
• Compression
• Compression is the decrease in
the joint space between bony
partners.
• Normal intermittent compressive
loads help move synovial fluid
and thus help maintain cartilage
health.
• Abnormally high compression
loads may lead to articular
cartilage changes and
deterioration.
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30. • Traction/Distraction
• Traction is a longitudinal pull. Distraction is a separation, or pulling
apart.
• whenever there is pulling on the long axis of a bone, the term long-axis
traction is used. Whenever the surfaces are to be pulled apart, the term
distraction, joint traction, or joint separation is used.
• For joint mobilization techniques, distraction is used to control or
relieve pain when applied gently or to stretch the capsule when applied
with a stretch force. A slight distraction force is used when applying
gliding techniques.
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32. Effects of Joint Motion
• Maintain extensibility and tensile strength of the articular and
peri-articular tissues
• Provide awareness of position and motion
• With injury or joint degeneration, there is a potential decrease in
an important source of proprioceptive feedback that may affect
an individual’s balance response.
• Joint motion provides sensory input
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33. INDICATIONS FOR JOINT MOBILIZATION
• Pain, Muscle Guarding, and Spasm
• Reversible Joint Hypo-mobility
• Positional Faults/Subluxations
• Progressive Limitation
• Functional Immobility
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34. INDICATIONS FOR JOINT MOBILIZATION
• Pain, Muscle Guarding, and Spasm
• gentle joint-play techniques to stimulate neurophysiological and mechanical
effects.
• Neurophysiological Effects
• may inhibit the transmission of nociceptive stimuli at the spinal cord or brain
stem levels.2
• Mechanical Effects
• synovial fluid motion, which is the vehicle for bringing nutrients to the
avascular portions of the articular cartilage (and intra-articular fibrocartilage
• Gentle joint-play techniques help maintain nutrient exchange and thus prevent
the painful and degenerating effects of stasis when a joint is swollen or painful
and cannot move through the ROM. The small-amplitude joint
• The small-amplitude joint techniques used to treat pain, muscle guarding, or
muscle spasm should not place stretch on the reactive tissues
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35. • Reversible Joint Hypo-mobility
• Reversible joint hypo-mobility can be treated with progressively
vigorous joint-play stretching techniques to elongate hypo-mobile
capsular and ligamentous connective tissue.
• Sustained or oscillatory stretch forces are used to distend the
shortened tissue mechanically
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36. • Positional Faults/Subluxations
• Malposition of one bony partner with respect to its opposing
surface may result in limited motion or pain.
• MWM techniques attempt to realign the bony partners while the
person actively moves the joint through its ROM.21 Manipulations
are used to reposition an obvious subluxation, such as a pulled
elbow or capitate-lunate subluxation
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37. • Progressive Limitation
• Diseases that progressively limit movement can be treated with
joint-play techniques to maintain available motion or retard
progressive mechanical restrictions.
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38. • Functional Immobility
• When a patient cannot functionally move a joint for a period of
time, the joint can be treated with non-stretch gliding or
distraction techniques to maintain available joint play and prevent
the degenerating and restricting effects of immobility.
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39. LIMITATIONS OF JOINT MOBILIZATION
TECHNIQUES
• Mobilization techniques cannot change the disease process of
disorders such as rheumatoid arthritis or the inflammatory process
of injury.
• In these cases, treatment is directed toward minimizing pain,
maintaining available joint play, and reducing the effects of any
mechanical limitation
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40. CONTRAINDICATIONS
• Hypermobility
• Patients with painful hypermobile joints may benefit from gentle
joint-play techniques if kept within the limits of motion
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41. • Joint Effusion
• There may be joint swelling (effusion) due to trauma or disease. Rapid
swelling of a joint usually indicates bleeding in the joint and may occur
with trauma or diseases such as hemophilia
• necrotizing effect on the articular cartilage. Slow swelling (more than 4
hours) usually indicates serous effusion (a buildup of excess synovial
fluid) or edema in the joint due to mild trauma, irritation, or a disease
such as arthritis.
• If the patient’s response to gentle techniques results in increased pain or
joint irritability, the techniques were applied too vigorously or should
not have been done with the current state of pathology
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42. • Inflammation
• Whenever inflammation is present, stretching increases pain and
muscle guarding and results in greater tissue damage. Gentle
oscillating or distraction motions may temporarily inhibit the pain
response
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43. PRECAUTIONS
• Malignancy
• Bone disease detectable on radiographs
• Unhealed fracture
• Excessive pain
• Hypermobility in associated joints
• Total joint replacements
• Newly formed or weakened connective tissue such as immediately after
injury, surgery, or disuse or when the patient is taking certain
medications such as corticosteroids
• Systemic connective tissue diseases such as rheumatoid arthritis, in
which the disease weakens the connective tissue
• Elderly individuals with weakened connective tissue and diminished
circulation
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44. PROCEDURES FOR APPLYING PASSIVE JOINT
MOBILIZATION TECHNIQUES 44

45. Quality of pain
• If pain is experienced before tissue limitation: muscle guarding
after an acute injury or during the active stage of a disease
• If pain is experienced concurrently with tissue limitation:
damaged tissue begins to heal
• If pain is experienced after tissue limitation: tight capsular or
peri-articular tissue, the stiff joint
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46. Capsular restriction
• Passive ROM is limited
• Firm capsular end feel
• Decrease joint play movement
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47. Subluxation or dislocation
• Subluxation: Partial displacement of the articulating joint surfaces
• Dislocation: Total displacement of the articulating joint surfaces
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48. Grades or dosages of movement 48

49. Grades and their usages 49
Grade I and II are primarily used for
treating joints limited by pain.
Grades III and IV are primarily used as
stretching maneuvers (Increase ROM).

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Anterior
Posterior

51. Kaltenborn’s Sustained Translatory Joint-Play
Techniques 51

52. Grades and usages 52
Grade I distraction is used with all gliding motions and
may be used for relief of pain.
Grade II distraction is used for the initial treatment to
determine how sensitive the joint is. Once the joint
reaction is known, the treatment dosage is increased or
decreased accordingly
Gentle grade II distraction applied intermittently may be
used to inhibit pain.
Grade II glides may be used to maintain joint play when
ROM is not allowed.
Grade III distractions or glides are used to stretch the
joint structures and thus increase joint play

53. 53
Glenoid cavity
Humerus
Capsule/ Ligaments
Separating force

54. Positioning and Stabilization
• Patient in relax position
• the first treatment are initially performed in the resting position
for that joint so the greatest capsule laxity is possible then end or
available ROM
• Firmly and comfortably stabilize one joint partner, usually the
proximal bone.
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55. Treatment Force and Direction of Movement
• Either gentle or strong
• The plane is in the concave partner, so its
position is determined by the position of the
concave bone
• Distraction techniques are applied
perpendicular to the treatment plane
• Gliding techniques are applied parallel to
the treatment plane
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57. Speed, Rhythm, and Duration of Movements
• Grades II and III are smooth, regular oscillations at 2 or 3 per
second for 1 to 2 minutes
• low amplitude and high speed to inhibit pain or slow speed to
relax muscle guarding
• For painful joints, apply intermittent distraction for 7 to 10
seconds with a few seconds of rest in between for several cycles.
• For restricted joints, apply a minimum of a 6-second stretch force
followed by partial release (to grade I or II), then repeat with
slow, intermittent stretches at 3- to 4- second intervals.
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58. MOBILIZATION WITH MOVEMENT: PRINCIPLES
OF APPLICATION
• Brian Mulligan’s concept
• self-stretching exercises, to therapist-applied passive physiological
movement, to passive accessory mobilization techniques
• pain-free accessory mobilization with active and/or passive
physiological movement. Passive end-range overpressure or
stretching is then applied without pain as a barrier
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59. Principles of MWM in Clinical Practice
• Comparable signs: A comparable sign is a positive test sign that
can be repeated after a therapeutic maneuver to determine the
effectiveness of the maneuver
• A comparable sign may include loss of joint play movement, loss of
ROM, or pain associated with movement during specific functional
activities such as lateral elbow pain with resisted wrist extension,
painful restriction of ankle dorsiflexion, or pain with overhead
reaching.
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60. • A passive joint mobilization
• Various combinations of parallel or perpendicular accessory glides
to find the pain-free direction and grade of accessory movement
• There should be increased ROM, and the motion should be free of
the original pain.
• The previously restricted and/or painful motion or activity is
repeated 6 to 10 times by the patient while the therapist
continues to maintain the appropriate accessory mobilization
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61. PERIPHERAL JOINT MOBILIZATION TECHNIQUES 61