Joint Mobilization and Manipulation
Joint Mobilization and Manipulation
Joint mobilization is a treatment technique used to manage musculoskeletal dysfunction. Most manipulative and mobilization techniques are performed by physical therapists, and fall under the category of manual therapy.
In most cases, at the end of a long bone there is a joint or articulation. The long bone is attached or joined to another bone by a joint. For example, the femur is attached to the tibia at the knee joint. The knee joint is made up of the surface of the tibia, femur, ligaments, and capsule. Thus, the knee joint is stable and yet mobile. When an individual is sitting in a chair and freely kicks his leg out (knee extension), the tibia moves, while the femur is stationary. However, at the surface of the articulating bones (tibia and femur), there is other movement. This movement is known as slide or glide; some have termed it "joint play." When an individual kicks his leg out, the lower leg or tibia is not only moving forward, but also gliding across the end of the femur. Mobilization is the treatment technique that involves the clinician applying a force to mimic the gliding that occurs between bones. It is a passive movement, the goal of which is to produce a slide or glide. Mobilizations are usually completed at slow speed, sometimes with oscillations, and even with a "hold" or stretch. Manipulations are more aggressive, high velocity techniques, or thrusts. They occur very fast, and at the end of available joint play.
Mobilizations are used to restore joint play that has been lost due to injury or disease. In order for an individual to kick his leg out, there must be sufficient joint play, or freedom for the tibia to move on the femur. Thus, mobilizations are used when range of motion or mobility is lacking. Furthermore, gentle oscillations within the available joint play range is a technique used to decrease pain. Manipulations are quick movements that occur beyond the available joint play range. The purpose of manipulations, or joint thrusts, is to increase the available range if it is not full. Secondly, manipulations are done to break adhesions that disrupt joint movement.
Mobilizations and manipulations should not be done in the following circumstances:
- to the spine if there is severe osteoarthritis or osteoporosis
- if there is any tumor or malignancy in the area
- to the cervical region if there is dysfunction with the flow of blood within the vertebral artery
- if there is bleeding in a joint
- if there is a loose body in the joint
- to total joint replacements
- to joints near a growth plate
- if the joint is degenerative
- until a full diagnosis is reached
Peripheral joint mobilization means mobilizing the joints of the periphery or limbs. There is a grading system for completing mobilizations. The grading system is based on how much joint play is available. Thus, the clinician must know what the total range is by examination through passive movement. Furthermore, there are stretching mobilizations used for pain management and stretching. The first common mobilization techniques are sustained joint play movements that have three grades. These mobilizations aid in decreasing pain and increasing mobility.
The clinician applies passive movement in a very small range, approximately 15-25% of the available joint play range.
Bone is passively moved in a moderate range to 50% or half of the available joint play range.
Passive force by the clinician causes one bone to move on the other to the end of the available joint play range.
Within these three grades the stretch or "hold" is approximately five to seven seconds.
The other common mobilization technique is termed oscillatory mobilization. These mobilizations have five grades associated with them. Grades one to two are used to help decrease pain within a joint. Grades three to five are used to increase mobility of joint play. Interestingly, a grade five mobilization is really a manipulation. The following are grades for oscillatory mobilizations:
Slow oscillations within the first 20-25% of the available joint play range.
Slow oscillations within 45-55% of the available joint play range, or from the beginning to the middle of available joint play range.
Slow oscillations from the middle of the available joint play range to the end of available joint play range.
Slow oscillations at the end of the available joint play range.
Bone is passively moved to the end-range, and a fast thrust is performed. This is manipulation.
The clinician should be aware of the following prior to performing manipulations:
- The clinician must use good body mechanics and be comfortable with the patient and the technique.
- The clinician must understand the patient's pain and not proceed if the patient has pain.
- The patient must be comfortable with the clinician, and the procedure must be explained fully to the patient.
- The patient must be relaxed.
Individuals with a chronic joint problem may have Grade 1 and Grade 2 techniques used at the beginning of treatment to decrease pain. Then, after treatment, the patient progresses to more aggressive rehabilitation such as therapeutic exercise. At the end of a rehabilitation session, Grades 3 and 4 can be used in conjunction with stretching to increase mobility. In an acute joint pathology, only Grades 1 and 2 should be used. Grades 1 and 2 mobilizations can be used at the beginning of therapy to reduce pain in an effort to increase performance during therapeutic exercise. Grades 1 and 2 mobilizations can be used again at the end of the treatment before cryotherapy to help alleviate pain.
Some complications associated with mobilizations, but more so with manipulations are:
- joint capsule tearing
- ligamentous tearing
- muscle or tendon injury
- nerve damage
If done appropriately, mobilizations can help reduce pain and restore joint play, which is critical for normal mobility. Manipulations are beneficial for releasing adhesions and are usually done under anesthesia by a medical physician. Chiropractic manipulations are not discussed here.
Health care team roles
It is important that nurses and other members of the allied health care team be aware of patients who undergo mobilization and monitor pain and any possible inflammation after treatment. Moreover, pain and inflammation may need to be more closely monitored in individuals having manipulation to restore joint mobility. An example of a patient requiring closer monitoring is an individual having manipulation after total knee replacement secondary to increased adhesions and limited range of motion. Today, most manual therapy is done by physical therapists. However, the education for physical therapists to conduct forceful or thrust manipulations continues to grow and is becoming more a part of physical therapy education and post education.
Cryotherapy— Usually an ice or cold treatment after physical therapy treatment.
Femur— The long bone of the thigh which articulates with the hip bone and the tibia.
Knee extension— The act of straightening the knee or kicking the leg out, as in kicking a ball.
Ligaments— Fibrous structures that provide an attachment on bone to bone, and provide stability to joint structures.
Musculoskeletal— Pertains to the muscular and skeletal systems, and the relationship between the two.
Passive movement— Movement that occurs under the power of an outside source such as a clinician. There is no voluntary muscular contraction by the individual who is being passively moved.
Tibia— The larger, longer bone of the lower leg which articulates or joins with the ankle and knee.
Hertling D., and R.M. Kessler. Management of Common Musculoskeletal Disorders. Baltimore: Lippincott, Williams & Wilkins, 1996.
Lehmkuhl L.D., and L.K. Smith. Brunnstroms Clinical Kinesiology. Philadelphia: F.A. Davis Co., 1996.
Magee D. J. Orthopedic Physical Assessment. Philadelphia: W.B. Saunders Co., 1997.
American Physical Therapy Association. 1111 N. Fairfax Street, Alexandria, Va 22314. (703) 684-2782. 〈http://www.apta.org,〉.