Joint Mobilization



Joint Mobilization



Deborah Gross Saunders, J. Randy Walker and David Levine


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Manual therapy techniques are skilled hand movements intended to improve tissue extensibility, increase range of motion (ROM), induce relaxation, mobilize or manipulate soft tissue and joints, modulate pain, and reduce soft tissue swelling, inflammation, or restriction.1 The primary techniques included in manual therapy are mobilization and manipulation of joints and associated soft tissues. Mobilizations are passive movements that are either oscillatory or sustained stretch performed in such a manner that the patient can prevent the motion if so desired. These motions are performed anywhere within the available ROM. The intent of this chapter is to provide an overview of the principles of manual therapy, followed by selected treatment techniques for the hip, stifle, elbow, shoulder, carpus, and the thoracic and lumbar spine. The techniques of GD Maitland,2,3 an Australian physical therapist who developed a clinically based approach in the 1960s and 1970s, are emphasized in this chapter. Maitland described four grades of mobilization (I-IV) (Figure 26-1) and manipulation. Manipulation, a grade V mobilization, is a high velocity, low amplitude passive movement that cannot be prevented by the patient and is typically performed near the end of the available ROM.



There have been numerous randomized controlled trials (RCTs) in humans that have demonstrated the efficacy of manual therapy for treating patients with a variety of disorders in the spine and peripheral joints. Many of these studies have compared “traditional treatments,” such as exercise, pharmaceutical interventions, rest, and placebo, with manual therapy. Other RCTs have compared these traditional forms of therapy to groups receiving both the traditional therapies plus manual therapy. The majority of these studies have found that manual therapy is as effective if not superior to traditional therapies.4-15 Common outcome measures assessed have been pain, functional scales, disability levels, ROM, number of treatments needed, length of time in treatment, and cost effectiveness of treatment. Despite the growing body of evidence for manual therapy, it is viewed as a complementary therapy in human medicine by many, even though its effectiveness seems well substantiated and the risks are low. The most likely reason for its slow acceptance is that the skill level required to properly apply these techniques is higher than with traditional therapies such as exercise or modalities. Rationales for the reasons manual therapies may work have been investigated and include reducing muscle inhibition,16 decreasing pain,17,18 improving intervertebral disk hydration,19 correcting joint displacement, adjusting joint subluxations, restoring bony alignment, reducing nuclear protrusion,20,21 and placebo effect.8 More recent theories include evidence supporting the need for adequate stresses and normal movement as being critical to maintain the integrity of collagenous tissues, muscles, and bones.22 Evidence of the effectiveness of manual therapy must be established in small animals. Although many anatomic similarities exist between humans and small animals, we cannot assume the techniques will yield the same results.




Contraindications and Precautions for Manual Therapy


The list of contraindications presented by Dutton23 includes spinal instability, bacterial infection, malignancy, systemic localized infections, sutures over the area, recent fracture, cellulitis, febrile state, hematoma, acute circulatory condition, an open wound at the treatment site, osteomyelitis, advanced diabetes, hypersensitivity of the skin, inappropriate end feel (spasm, empty, bony), constant severe pain, extensive radiation of pain, pain unrelieved by rest, any undiagnosed lesion, and severe irritability (pain that is easily provoked, and that does not go away within a few hours). Additional contraindications specific to dogs include contractures such as fibrotic myopathy and quadriceps contracture, or in other circumstances in which manual therapy is unlikely to effect any change and may be painful. An overly aggressive or fearful dog that may bite the therapist or unrelaxed dogs are also contraindications. Total elbow and hip replacements should be considered a contraindication for grades III-V accessory mobilizations until the appropriateness of joint mobilization techniques are further evaluated for these procedures.


Precautions (proceed with caution) identified by Dutton23 include joint effusion or inflammation, rheumatoid arthritis, presence of neurologic signs, osteoporosis, hypermobility, pregnancy (if the technique is to be applied to the spine), and steroid or anticoagulant therapy.



Basic Principles of Manual Therapy


There are a number of approaches to manual therapy, including those developed by physicians24-26 and by physical therapists.2,3,2729 Regardless of the approach, there are several principles that should be considered as the patient is examined and treated. Maitland stresses the importance of communicating with the patient to fully “understand what the patient is enduring.”2 Of course, in the case of animals, the examiner must communicate with two constituents—the dog and the owner. Body postures, pain patterns, and respiratory patterns should be closely monitored in the patient.




Concave and Convex Relationship of Joints


All synovial joints have a convex-concave relationship. When the examiner is passively moving a joint, caution should be made to move the joint in a manner similar to how it moves when the joint is being actively moved by the dog. Osteokinematics is defined by how the bone is being moved through space (i.e., flexion, abduction). Arthrokinematics is defined by how the joint surfaces are moving as the bone is being moved (i.e., rolling, sliding, and spinning). When the joint surface is convex with respect to the other concave side of the joint, the articular surface moves in the opposite direction of the shaft of the bone. When the shoulder joint is being flexed (as in the swing phase of gait) by moving the humerus on the scapula, the convex surface of the proximal humerus is sliding and spinning on the concave glenoid of the scapula. When the joint surface is concave, the articular surface moves in the same direction of the shaft of the bone. When the distal radius is being moved on the stationary carpal bones (as in the stance portion of gait), the concave surface of the radius is rolling and sliding on the convex proximal row of carpal bones. Manual therapists strive to move joint surfaces physiologically to avoid injuries such as joint subluxations and sprains.



Relationship of Pain and Range of Motion


Maitland states, “During examination and assessment, pain should never be considered without relation to range nor range without relation to pain.”2 Depending on the nature of the injury or disease, joints are affected by the presence of pain and stiffness. If pain is the primary problem, it may limit motion, as in hip dysplasia. When the pain diminishes, the ROM may improve. If the primary problem is joint dysfunction or stiffness, pain will be most evident at or near the end of available ROM. As the available ROM increases, pain will be less of a factor. In those cases in which both pain and loss of motion occur simultaneously, the examiner must decide which is the primary problem. These relationships are the basis of deciding which grade of passive movement and other therapies should be used to treat the problem.


If pain occurs before the examiner feels resistance, the primary problem is pain; if the pain occurs when resistance is felt, or after, the primary problem is limitation of motion with joint involvement. In addition, if active and passive motions are limited or painful in the same direction, the lesion is in the noncontractile tissues. For example, if the cranial joint capsule of the stifle is tight, flexion of the stifle is limited with active and passive flexion of the joint. Conversely, if active and passive motions are limited or painful in opposite directions, the lesion is in the contractile tissues—muscle and associated tendon. For example, if the biceps tendon is affected, active flexion of the elbow and passive extension of the elbow are painful with a possible reduction in ROM. These presentations affect which grade and type of mobilization should be used to treat the problem.


The dog exhibits a capsular pattern if the entire capsule of the joint is inflamed or involved. Cyriax24 described a capsular pattern as a joint-specific pattern of loss of motion with arthritis. These have not been described for dogs, but limitations in movement accompany certain disorders. An example is that hip extension and hip abduction are typically the most limited motions in a dog with hip dysplasia.


End feel is the sensation imparted to the examiner when the end of passive ROM is encountered. The passive motion must be performed with a relatively quick movement and the end of range is bumped briskly. Cyriax24 described the quality of normal and abnormal end feels, which are defined in Table 26-1.




Assessment


The therapist participates in three activities while managing a patient problem: examination, treatment, and assessment. Although each is important to the provision of a complete and quality program, assessment is the keystone. Assessment involves “open-mindedness, mental agility and mental discipline, linked with a logical and methodical process of assessing cause and effect.”2 The therapist is thinking and assessing to make certain that the right task is being performed and that the task is being performed correctly. The therapist must continually assess the decision-making process during examination and treatment procedures. Assessment is implemented at three points of the patient interaction. The first assessment is implemented during the initial examination of the patient, making certain that clinical signs are examined and evaluated to reach the best diagnosis and formulate an appropriate plan of care. The second assessment occurs during the treatment session. The therapist assesses the appropriateness of the treatment techniques while the patient response is evaluated. The third assessment is an analytic process to consider the entire treatment program to determine whether the patient is progressing as a result of the treatment and to determine the prognosis for resolution of the current problem.



The Clinical Environment


The clinical setting should be safe for both the patient and the therapist so that the desired outcome of the examination and treatment session will more likely be achieved. First, a quiet area that is free of distractions for the dog facilitates relaxation and cooperation. The area should also be safe for the dog and therapist. It may be necessary to muzzle the dog initially, especially with a fearful or apprehensive dog. Second, the therapist should make certain he or she is using proper body mechanics to prevent undue stress on the spine and joints of both the dog and the therapist. Third, the therapist should approach the dog from a position where the dog can see the therapist, and he or she should touch the dog with firm, but not aggressive hands. Touch the dog at a place that is not painful and gradually move toward the involved area. Finally, the affected part should be cradled or held with a firm but gentle supporting grip to encourage relaxation and trust by the dog. If at any time the dog or therapist is not relaxed, the activity should be discontinued and further assessment and correction of the situation should be pursued.




Treatment with Mobilization


The effectiveness of the manual therapy treatment program is affected by the environment and the skills of the therapist. Efforts must be made to facilitate relaxation of the dog to avoid excessive pain and stress to the animal. The therapist’s grip should be firm enough to support the limb, but not excessive. Good body mechanics and positioning by the therapist will help to make the movements controlled and in the desired pattern.



Grades


Joint mobilization should be planned with a specific grade of mobilization in mind. Grades are assigned to the mobilizations depending on the range through which the mobilization is applied and the point in the range where it is applied. Figure 26-1 shows a modification of Maitland’s graded mobilizations.2


R represents resistance. R1 is the point in passive ROM at which the therapist senses resistance from a stretch on the noncontractile structures of a joint. R2 is the resistance felt at the end of available passive ROM.







How to Choose the Appropriate Mobilization Grade

When ROM is decreased due to pain:



When ROM is decreased due to stiffness:



If both pain and stiffness are present, the therapist must decide what the primary problem is. Does the pain limit ROM or does the stiffness cause the pain? The sequence of pain and resistance can contribute to the treatment plan. For example:



There are two types of mobilizations:



There are additional guidelines to help the therapist decide which type of mobilization to perform.





Open versus Closed Kinetic Chain


Dutton defines open kinetic chain activities as when the “involved end segment of an extremity [is] moving freely through space, resulting in isolated movement of a joint.”23 Examples of an open kinetic chain activity in a dog include when a paw is swinging forward in the gait cycle or when the dog is moving a forelimb while in lateral recumbency. On the other hand, closed kinetic chain activity occurs when the distal segment of an extremity is in contact with a surface and the limb is weight bearing.28 Examples of a closed kinetic chain activity include the stance phase of gait. It is of value to note whether a limb is being exercised in the open versus closed kinetic chain. Closed kinetic chain activities facilitate proprioception, muscles working in groups, and coordination of joint function. On the other hand, it is easier to achieve isolated joint motion in the open kinetic chain.


Dogs perform a large array of movements to maintain function. The restoration of normal movement plays a significant role in the treatment of the dog. Joint mobilization offers one method of obtaining the motion required for the restoration of function through manual therapy skills.


Prior to beginning mobilization on the dog, it is essential that the therapist be completely familiar with the bony landmarks associated with the joint. The joint should be evaluated to be certain that pathologic joint luxation or subluxation is not present. Hair may need to be pulled out of the way or clipped to expose the joint. Active and passive ROM should be functionally assessed and measured by goniometry prior to beginning the treatment. The assessment of passive and active ROM is an important aspect of the treatment process. The comparison of ROM before and after treatment demonstrates the effectiveness of the treatment.


The initial treatment of a dog’s joint depends largely on the nature of the problem, in particular, pain or stiffness. If the primary problem is pain, a relaxation technique, such as light massage, may be used to calm the dog and to gain trust. If the animal is not in pain, but has stiffness, the joint or joints to be mobilized should be prepared for treatment with a warming modality or light exercise. Moist heat, massage, or therapeutic ultrasound may be used prior to treatment. Active exercise, including aquatic therapy, may also be used. The joint mobilization treatment should then be followed with passive and active ROM accentuating the motion addressed. Therapeutic exercises prescribed should also address the motion. Ice may then be applied after the session to help prevent soreness from the mobilization and other activities.


Forelimb injuries are common in dogs. Elbow dysplasia and resultant osteoarthritis of the elbow occurs quite frequently in dogs. In agility and jumping events, problems in the shoulder, elbow, and carpus are common secondary to the stresses placed on the forelimbs. Functional ROM at the carpus and elbow is essential to perform activities. For example, full elbow ROM is required for normal function. ROM demands in working and athletic dogs are greater than in pet dogs. For example, full shoulder extension is required for dogs participating in agility activities such as jumping.


The hindlimb is responsible for generating propulsion of the dog. Decreased ROM may result in a loss of power and function, especially loss of joint extension. Decreased joint motion in the hindlimb is common with hip dysplasia, cruciate disease, muscle injuries, and osteoarthritis.



The Shoulder Joint


The shoulder, or glenohumeral joint, is a ball-and-socket joint and follows the convex on concave rule of motion (Box 26-1). Impairment of shoulder ROM may be seen after a fracture of the humerus, bicipital tenosynovitis, osteochondritis dissecans, infraspinatus contracture, scapular fracture, surgical repair of shoulder instability, and other conditions. Compensations in the shoulder complex may also be seen as a result of hindlimb or spinal problems such as intervertebral disk disease, canine hip dysplasia, cruciate disease, or neurologic problems. It is believed that dogs increase the amount of weight placed on their forelimbs to compensate for a problem affecting the spine or hindlimb. Over time, problems may develop in the forelimbs secondary to the increased forces placed on the joint.



Jul 8, 2016 | Posted by in SUGERY, ORTHOPEDICS & ANESTHESIA | Comments Off on Joint Mobilization
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