Peripheral Joint Mobilization

PJM

Manual therapy techniques that are used to modulate pain and treat joint dysfunctions that limit ROM by specifically addressing the altered mechanics of the joint

-pain

-muscle guarding

-joint effusion

-contractures

-adhesions in the joint capsules or supporting ligaments

-malalignment or subluxation of the boney surface

Stretching

Use of lever significantly magnifies the force at the joint

Force causes excessive joint compression in the direction of the rolling bone

Roll without a slide=not normal joint mechanism

Joint mobilization

Force applied close to joint surface and controlled at an intensity compatible with the pathology

Direction of force replicates the sliding component of the joint mechanics and does NOT compress the cartilage

Amplitude of motion is small yet specific to the restricted or adherent portion or the capsule or ligaments>forces are selectively applied to desired tissue

Mobilization and Manipulation

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

Varying speeds and amplitudes could range from small-am force applied at high velocity to large-am force applied at slow velocity

There is continuum of intensities and speeds at which the technique could be applied

Accessory movements

Movements in the joint and surrounding tissues that are necessary for normal ROM but CANNOT be actively performed by the patient

Component Motions

Motions that accompany active motion but are not under voluntary control

Often used synonymously with the term “accessory movement”

Component Motion 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.

Joint play

Motions that occur between the joint surfaces and also the distensibility or “give” in the joint capsules, which allows the bones to move. Movements are necessary for normal joint function through the ROM and can be demonstrated passively, but the cannot be performed actively by the patient

(Distraction, sliding, compression, rolling and spinning) arthrokinematics

Manipulation under anesthesia

Medical procedure used to restore full ROM by breaking adhesions around a joint while the patient in anesthetized

May be rapid thrust or a passive stretch using physiological or accessory movements

Rolling

One bone rolling on other

Surfaces are incongruent

New points on one surface meet new points on opposing surface

Results in angular motion of the bone

Always same direction as the swinging bone motion

Causes compression of the surfaces on the side to which the bone is swinging and separation on the other side

Normal functioning joints, pure rolling does NOT occur ALONE but in combination with SLIDING and SPINNING

Slide/translation

One bone sliding across another

Surfaces must be congruent, either flat or curved, does not occur in human joints

Same point on one surface comes into contact with the new points on the opposing surface

Combined Roll-Slide

More congruent joint surface is, more sliding there is of one bony partner on the other

More incongruent the joint surface is, the more rolling there is of one bony partner on the other

Joint mobilization techniques use the sliding component of joint motion to restore joint play and reverse joint hypomobility

Spinning

Rotation of a segment about a stationary mechanical axis

Same point on the moving surface creates an arc of a circle as the bone spins

Rarely occurs alone, combination with rolling and sliding

Humerus articulating with scapula, femur articulating with the acetabulum or pelvis, radius articulating with distal humerus

Compression

Decrease in joint space

Occurs normally in joints and spinal column when weight bearing

Normal intermittent compressive loads help move synovial fluid and help maintain cartilage health

Abnormally high compression loads may lead to articulat cartilage changes and deterioration

Traction

Longitudinal pull

Distraction

Separation or pulling apart. Does not always occur when traction force is applied

Example: traction applied to the shaft of humerus in resting position results in a glide of the joint surface

When humerus is positioned at right angles to the glenoid fossa, distraction force results

Indications for PJM

Pain

Muscle guarding

Spasm

Reversible joint hypomobility

Positional faults/subluxations

Progressive limitations

Functional immobility

Limitations of PJM

Cannot change the disease process of disorders such as RA or the inflammatory process of injury

Skill of therapist affects the outcome

Contraindications of PJM

Hypermobility

Joint effusion

Inflammation

Conditions requiring special precautions for stretching

-malignancy, bone disease, unhealed fracture, excessive pain, hypermobility in associated joints

-total joint replacements

-newly formed/weakened CT such as immediately after surgery, injury, or disuse or with certain medications such as corticosteroids

Systemic CT disease

Elderly individuals with weakened CT and diminished circulation

PJM Graded Oscillation Techniques

1. Small amplitude rhythmic oscillations are performed at beginning range

2. Large amplitude rhythmic oscillations are performed within the range, not reaching the limit

3. Large amplitude rhythmic oscillations performed up to the limit of available motion and are stressed into tissue resistance

4. Small amplitude rhythmic oscillations performed at the limit of available motion and stressed into tissue resistance

PJM Grades-sustained translatory joint play techniques

1. Small amplitude distraction applied where no stress is placed on capsule. Equalizes cohesive forces, muscle tension, and atmospheric pressure acting on the joint. Used with all gliding motions and may be used for pain relief

2. Enough distraction or glade is applied to tighten tissues around the joint. Initial treatment to determine how sensitive joint is. Once joint reaction is known, treatment dosage is increased or decreased accordingly (take up slack)

3. Distractions or glides used to stretch the joint structures and increase joint play

Dosage/Intensity

Dosage 1&2 are low intensity… do not cause stretch force on the joint capsule or surrounding tissue

Graded oscillations: back and forth movement

Sustained grade: distraction force that is held or sustained

For pain: grade 1 or 2 oscillations or slow intermittent grade 1 or 2 sustained joint distraction

Loss of joint play with decreased joint ROM

Sustained techniques applied in a cyclic manner are recommended: longer the stretch force can be maintained the greater the creep and plastic deformation of the CT

Maintain available range

Either grade 2 oscillations or sustained grade 2 can be used