Physio.co.uk : An introduction to mobilisation and manual therapy

@Physiocouk #manchesterphysio facebook.com/physiocouk

Welcome
An introduction to mobilisation and manual therapy for
sports and massage therapists
With Katie Emmett & Richard Gregory

3@Physiocouk #manchesterphysio facebook.com/physiocouk
Let’s connect
Website: www.physio.co.uk
Twitter: @physiocouk
Facebook: www.facebook.com/physiocouk
Katie’s LinkedIn: www.linkedin.com/katieemmett
Rich’s LinkedIn: www.linkedin.com/richardgregory

4
Aims of today
Learn the theory of joint mobilisations
Learn how to assess a joint before mobilising
Practice different joint mobilisations and manual therapy
treatments
Learn the evidence and research behind joint mobilisations

5
Itinerary
10.00 - 10.30: Induction/arrival
10.30 – 11.30: Theory: Mobilisations and Manual therapy
11.30 – 12.00: Assessment Practical
12.00 – 12.30: Lunch
12.30 - 13.30 : Practical: Mobilisations and Manual therapy
13.30 - 14.00: Evidence and recent research
14.00 – 15.00: Case studies and Practical

Theory:
Joint Mobilisations and
Manual Therapy

7
Definition of a joint
mobilisation
A skilled passive movement of the articular surfaces
performed by a physical therapist to decrease pain
or increase joint mobility.
Edward P. Mulligan, 2001

Anatomy of a synovial joint
• The synovial joint is the most common type of joint found in the
body
• Most evolved and therefore most mobile type of joints
• Articular surfaces are covered with hyaline cartilage

Anatomy of a synovial joint
• Between the articular surfaces there is a joint cavity filled with
synovial fluid
• The joint is surrounded by an articular capsule which is fibrous
in nature and is lined by synovial membrane
• The synovial membrane lines the entire joint except the
articular surfaces covered by hyaline cartilage

Types of synovial joints
• Pivot
• Ball and Socket
• Hinge
• Condyloid
• Saddle
• Gliding

Joint kinematics
Understanding joint movement…
• Physiological – “movement you see”
• Accessory – “movement you feel”

12
Physiological
• Known as Osteokinematic joint
movements
• The natural movements that
occur in our joints
• Rotational around an axis
• Can be analysed from
movement quality and
symptom response

Physiological
Movement occurs in different planes…

Rotation around an axis
• Imaginary line that is the pivotal/ rotational point at a joint
• Movement in the planes occurs around this point and it is
perpendicular to the planes
• Three axes of rotation:
 Anterior-posterior axis
 Mediolateral axis
 Longitudinal axis

17
Accessory
• Known as Arthrokinematic joint movements
• Articular movements between two joint surfaces:
• Roll
• Glide
• Spin
• Occur with all active/passive physiological joint movement
• Necessary for full, pain-free range of movement
• Movements that we FEEL

18
Arthrokinematic Roll
• New points of one surface come into contact with
the other surface
• This can only occur when the two joint surfaces are
incongruent
• Analogy: wheel

19
Arthrokinematic Glide
• One joint surfaces slides or translates over the other
• Occurs when two surfaces are congruent and flat, or
congruent and curved
• Analogy: An ice-skater’s blade (one point) sliding
across the ice surface (many points)

20
Arthrokinematic Spin
• Rotation around a longitudinal axis
• One joint surface rotates around another
• Analogy: a top spinning on the table (if it
were to remain upright and in one place)

21
Joint Morphology
Joint surfaces can be described as
either:
1. Convex: Male, Arched, Rounded
2. Concave: Female, Shallow, Hollowed
Knowing that a joint surface is concave
or convex is important because shape
determines motion

22
Convex on Concave
• Concave surface is fixed and
the convex surface moves
over it.
• Physiological and accessory
joint movements occur in the
opposite direction
• Glide and Roll are in opposite
directions

23
Concave on Convex
• Convex segment is static
with the concave surface
moving over it
• Physiological and accessory
joint motions are in the
same direction
• Roll and glide are in the
same direction

24
Assessment

25
Assessing physiological joint
movements
The therapist passively takes joints through their
available range.
Used to assess:
1. Available range of movement at a joint
2. Presence/absence of a capsular pattern
3. End-feel
4. Pain

26
Capsular Patterns – Cyriax (1982)
• A series of limitations of joint movement when the
joint capsule is a limiting structure.
• Usually represents pathology/restriction from within
the joint or capsule itself.
• Unique pattern to each synovial joint
• Assessed by evaluating the available ROM and ‘end-
feel’ in joints passively

Joint Capsular Pattern (in order of most
limited)
Cervical Spine Side flexion & rotations equally limited,
extension
Thoracic Spine Side flexion & rotation equally limited,
extension
Lumbar Spine Extension, Side flexion & rotation equally
limited.
Shoulder (Glenohumeral) Lateral rotation, abduction, medial
rotation
Elbow (Humeroulnar) Flexion, extension
Wrist Flexion & extension equally limited
Hip Medial rotation, flexion, abduction
Knee Flexion, extension
Ankle (Talocrural) Plantar flexion, dorsi flexion

28
End-feels
‘The specific sensation imparted through the examiner’s
hands at the extreme of passive movement’
(Cyriax, 1982)
Can be categorised as either:
• Normal end-feel
• Abnormal end-feel

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Normal End-feels
1. Hard
Bone-to-bone approximation
E.g. extension of the elbow
2. Soft
Characteristic of a stop to the movement due to
approximation of tissue
E.g. Knee flexion
3. Elastic
Felt when tissues are placed on a passive stretch causing an
elastic resistance
E.g. Lateral rotation of the hip or shoulder

30
Abnormal End-feels
1. Hard
Different from that of ‘normal’ hard end-feel
Often felt in early OA
Involuntary muscle spasm causes provides a break to movement
Also due to capsular contracture
2. Springy
Associated with mechanical joint displacement, usually a loose body
Feels like the joint springs or bounces back just before end range
3. Empty
Examiner does not have the opportunity to appreciate true end-feel
Due to pain or apprehension

31
Practical

32
Assessment Workshop 1
In pairs assess PROM in the following joints:
• Shoulder
• Hip
• Knee
• Lumbar Spine (AROM)
• Ankle
• Cervical Spine
Feedback capsular patterns for each joint

33
Assessment Workshop 2
Assessing the normal end-feel of joints.
• Knee flexion and extension
• Elbow extension
• Shoulder medial rotation
• Cervical side flexion
• Hip lateral rotation

Cause of limited motion Identification Intervention
Intra-articular
adhesions/capsular
stiffness
• Capsular end-feel
• Palpation
• ROM unaffected by
proximal or distal joint
positioning
• Joint mobilisations
Shortened muscle
groups/soft tissue
restrictions
• Palpation
• ROM affected by
proximal or distal joint
positioning
• Stretch
• Heat
• Soft tissue
mobilisation/Myofascial
release
Muscle weakness • ROM affected by
gravity/resistance
• Strengthen
Pain • Empty end-feel
• Reduced willingness to
perform active
movements
Nerve-root irritation • Neural tension tests • Neural mobilisations

35
Lunch

Aims of joint mobilisations
 Restoring normal range of movement
 Pain gate theory
 Descending inhibition
 Increased local blood flow
 Synovial sweep

Restoring normal range of
movement
• Reduces pain (PGT)
• Enables normal biomechanics
• Functional movement
• Indication of proper muscle tone and balance around a joint
• Abnormal joint function are secondary to abnormal postures,
injury and stress

Pain gate theory (PGT)
• Proposed in 1965 by Melzack and Wall
• Commonly used explanation of pain transmission
• Mobilisations increase excitation of a-Delta fibres
• 3 types of sensory nerves involved in the transmission
- a-beta fibres
Responsible for “sharp” pain, large diameter and
myelinated, fast transmission fibre

39
- a-Delta fibres
Small diameter and myelinated, responsive to vibration
and light touch – fast reactive
- C – fibres
Small diameter and un-myelinated, throbbing or burning,
slow
• Size = bigger a nerve, the quicker its conduction
• Speed = increased with myelin sheath
• a – Delta purely sensory nerve

• All nerves synapse onto projection cells and travel up the CNS
to the brain
• Spinal cord has inhibitory interneurons acts as “gate keeper”
• When there is no sensation from the nerves the inhibitory
interneurons stop signals – no need for brain response (“gate
closed”)
• When smaller fibres are stimulated the inhibitory interneurons
do not act – “gate open”
• Pain is sensed

Descending inhibition
• Mobilisations have shown to stimulate areas if the brain,
instrumental in experience of pain
• These areas include:
- Anterior cingulate cortex (ACC)
- Amygdyla
- Periaqueductal Gray (PAG)
- Rostral Ventromedial Medualla (RVM)
• The doral area of PAG and RVM, have been shown to selective
produce analgesia to cause sympatho-excitation and the
release of endorphins

Increased local blood flow
 Increased nutrition supply
 Remove inflammatory exudate
 Produces movement so that blood/fluid can move in and out of
articular cartilage within joints
 Maintenance of healthy articular cartilage and proper joint
function.
 Stimulates repair of cellular damage
 Enhances the healing process

Synovial sweep
• Lubrication of a joint through a 'synovial sweep' mechanism

Synovial sweep
• An oscillation/movement increases lubrication of
cartilage
• Provides nutrients to maintain healthy joints
• Elasticity increases range of movement
• Synovial fluid is found in the cavities of synovial
joints
• Egg white–like consistency, with the principal role of
reducing friction between the articulating surfaces
during movement.
• Lack of lubricated synovial fluid causes poor joint
dysfunction and secondary injuries

Precautions to joint
mobilisations
• Excessive pain or swelling
• Arthroplasty
• Pregnancy
• Hypermobility
• Spondylolisthesis
• Rheumatoid arthritis
• Vertebrobasilar insufficiency

ABSOLUTE
CONTRAINDICATIONS
• Malignancy in area of treatment
• Infectious Arthritis
• Metabolic Bone Disease
• Neoplastic Disease
• Fusion or Ankylosis
• Osteomyelitis
• Osteoporosis
• Fracture or Ligament Rupture

Treatment Principles
Need to consider the following:
1. The Desired Effect - what effect of the mobilisation is the
therapist wanting? Relieve pain or stretch tissues?
2. The Starting Position - of patient and therapist to make the
treatment effective and comfortable.
3. The Direction - AP/PA; Cephalad/Caudad

4. The Method of Application - The
position, grade, amplitude, rhythm and
duration of the technique.
5. The Expected Response - Should the
patient be pain-free, have an increased
range or have reduced soreness?
(Hengeveld and Banks, 2005)
Treatment Principles
1 oscillation per second = 30 oscillations if high SIN factor /
60 if low SIN factor (Donatelli, 2001)

Grading mobilisations

Small amplitude movement at the beginning of the
available ROM
Clinical Reasoning: Donatelli (2001)
• 7-10/10 VAS pain rating
• Pain before resistance upon palpation
• Acute phase of injury
• Inflammatory phase of healing
• Aim to reduce pain and neutralise joint pressures
Grade 1

Grade 2
Large amplitude movement at within the available ROM
• Pain and resistance occur simultaneously upon
palpation
• Proliferation stage of recovery
• Aim to reduce pain and neutralise joint pressures

Grade 3
Large amplitude movement that reaches the end ROM
• Resistance before pain
• Scar maturation/remodelling phase of healing
• Aim to treat stiffness/hypomobility

Grade 4
Small amplitude movement at the very end range of motion
• Increase ROM through promotion of capsular mobility
and plastic deformation

55
Practical

Lumbar Spine

Neck

Thoracic spine

Hip/SIJ

Ankle

61
Evidence

Upper Extremity
Comparison of Supervised Exercise With and Without Manual Physical
Therapy for Patients With Shoulder Impingement Syndrome (Bang et al,
2000):
Manual therapy combined with supervised clinical exercise resulted in
superior outcomes to exercise alone in patients with shoulder
impingement syndrome
The effect of joint mobilization as a component of comprehensive
treatment for primary shoulder impingement syndrome (Conroy et al,
1998):
Mobilisation decreased 24-hour pain and pain associated with
subacromial compression test in patients with shoulder impingement
syndrome

Lower Extremity
A randomised controlled trial of a passive accessory joint mobilization on
acute ankle inversion sprains (Green et al, 2001)
Addition of talocrural mobilizations to the RICE protocol in the
management of inversion ankle injuries necessitated fewer treatments to
achieve pain-free dorsiflexion and to improve stride speed more than RICE
alone.
Effect of physical therapy on limited joint mobility in the diabetic foot. A
pilot study (Dijs et al, 2001)
Joint mobilization and physical therapy resulted in a significant, although
temporary, improvement in the mobility of the ankle and foot in diabetic
patients with limited joint mobility and neuropathy

Spinal Mobilisations
Manipulation or mobilisation for neck pain: A Cochrane Systematic Review (Gross
et al, 2010)
27 trials reviewed by two authors
Moderate quality evidence suggested manipulation and mobilisation produced
similar effects on pain, function and patient satisfaction
Low quality evidence supported thoracic manipulation as an additional therapy
for pain reduction and increased function in acute pain
Mobilisation for neck pain, low quality evidence for subacute and chronic neck
pain indicated that:
1. A combination of Maitland mobilisation techniques was similar to
acupuncture for immediate pain relief and increased function
2. There was no difference between mobilisation and acupuncture as
additional treatments for immediate pain relief and improved function
3. Neural dynamic mobilisations may produce clinically important
reduction of pain immediately post-treatment.

References
• Cyriax, J. (1982). Textbook of Orthopaedic Medicine, 8th edn. Bailliere Tindell,
London.
• Hengeveld, E. & Banks, K. (2005). Maitland's Peripheral Manipulation. 4th ed.
Elsevier: London.
• Donatelli 2001
• Bang, M. D., & Deyle, G. D. (2000). Comparison of supervised exercise with and
without manual physical therapy for patients with shoulder impingement
syndrome. Journal of Orthopaedic & Sports Physical Therapy, 30(3), 126-137.
• Conroy, D. E., & Hayes, K. W. (1998). The effect of joint mobilization as a
component of comprehensive treatment for primary shoulder impingement
syndrome. Journal of Orthopaedic & Sports Physical Therapy, 28(1), 3-14.
• Green, T., Refshauge, K., Crosbie, J., & Adams, R. (2001). A randomized controlled
trial of a passive accessory joint mobilization on acute ankle inversion
sprains. Physical therapy, 81(4), 984-994.

66
Case Studies

Lumbar spine:
Case study 1
33 year old women who works as a social worker. Reports a
lifting and twisting injury 2 days ago. Immediate pain into lumbar
spine and referred unilateral leg sensations.
Aggravating factors are bending forwards and prolonged sitting.
Finds walking and bending backwards easing. She rates her pain
score 8/10 on the VAS scale.
• Diagnosis?
• What mobilisations would you perform to relieve symptoms?
• How many oscillations would you perform?

55 year old taxi driver involved in a RTC 2 weeks ago. Reports
instant pain and reduced range of movement and now struggles
to check blind spot during driving. His current VAS score is 7/10.
Objective findings of limitation in bilateral side flexion and
rotation.
• Diagnosis?
Neck:
Case study 2

SIJ:
Case study 3
23 year old female, sports therapist working full time.
Reports localised pain around lumbar spine/pelvis area. Left side
only. Gradual onset over the last 6 months and now reports
intermittent “clunks”. Vas scale: 4/10. Aggravating factors are
prolonged sitting and standing/ getting in and out of the car and
eases with heat.
• Diagnosis?

70
Thanks for coming!
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