Joint Mobilization

Replies to This Discussion

Permalink Reply by Michelle Doyle, D.C., CNMT on December 16, 2009 at 2:21am

I find joint mobilization an excellent way to finish a session after the muscles are warmed and there still are joint restrictions. I agree, it is a powerful treatment tool that a MT can employ. It is my opinion that some bodyworkers may have apprehension using this treatment technique because it may resemble a chiropractic adjustment or osteopathic manipulation and they might have concerns it is outside their scope of practice (there might even be an audible at the end of the stretch when the joint releases). Moreover, the level of specificity of the stretch (compared to broad, generalized stretching) coupled with the small range of motion involved might be a source of intimidation.

However, joint mobilization is not considered a chiropractic adjustment, it is simply a specific form of stretch within the normal range of motion of the joint. Where the chiropractic adjustment uses a quick thrust at the limit of the stretch, the MT uses a firm, slow, even pressure applied for a second or two. It is worth the time and practice required of the practicioner to master the techniques of joint mobilization.

My question is...is the only difference between a joint mobilization and a chiropractic adjustment the use of a quick thrust? Do the mobilization and the adjustment both occur in the range of motion called joint play, at the limit of the passive range of motion?

Permalink Reply by Joseph E. Muscolino on December 16, 2009 at 8:35am

Hi Michelle,
Good question. I have always described a chiropractic/osteopathic adjustment as bringing a person's joint to the end range of passive motion, and then introducing a fast thrust that further stretches the joint tissues into the realm of joint play. With a joint mobilization, I feel that you also first bring the person's joint to end of passive range of motion and then introduce a slower "smaller" stretch that is NOT fast (hence the descriptions of one being "high velocity" and the other "low velocity"). Given that the joint mobilization also begins at the end of passive range of motion, doesn't any extra stretch gained have to be within the range of motion called joint play? That is how I have always described and written about it. It just seems that the speed of the chiropractic/osteopathic thrust allows for a greater excursion into joint play.

I like your point about the specificity of the joint mobilization stretch. In the articles, and certainly when I teach, I describe joint mobilization as being a form of pin and stretch because we are pinning one vertebra as we move the adjacent one. This focuses the stretch to the specific soft tissues between those two vertebra, whereas when a general broad stretch is done, if that one joint level is restricted, then adjacent levels could compensate by becoming hypermobile instead. This stops the stretch from actually stretching the desired joint level that we wanted to treat. Joint mobilization can be superior in that it targets the "target" level.

Permalink Reply by Robert Downes on December 17, 2009 at 4:24pm

Hi Joe, I will check out your article. You can check out http://3doptimalperformance.blogspot.com/2009/12/introduction-to-fu.... Functional Manual Reaction (FMR) is a type of manual therapy that uses joint mobilizations (Rolls and Glides) in a stabilized functional environment.

Permalink Reply by Joseph E. Muscolino on December 17, 2009 at 11:03pm

Hi Bob,

I read the info at the link. Unless I missed the meat, I really did not get much from it other than how wonderful the technique is... and the fact that a solid foundation in anatomy and physiology. etc., is needed (I liked that part!).

I tend to not be a big fan of all these "techniques" that have wonderful sounding names and are promoted to therapists. It is not that they do not have something wonderful, I am sure that every one of then does, it is just that they are so often hyped. Okay, I have to stop for a second and apologize to FMR and every other technique that is near and dear to everyone's heart. Sorry folks!
What I am trying to say is that I vastly prefer to get to the bottom of the mechanisms of these techniques and talk about the mechanical and neural treatment techniques upon which these trademarked techniques are based.
Then the therapist can critically think through what they think of the technique and decide if this or that technique is one that they want to invest time and money and energy to learn.

Somewhat apropos of this conversation, I am reminded of one of my favorite sayings...
"Follow the man who seeks the truth. Beware of the man who has found it."

So... what is the underlying principle of FMR??? Let's talk about that... :)

Robert Downes said:

Hi Joe, I will check out your article. You can check out http://3doptimalperformance.blogspot.com/2009/12/introduction-to-fu.... Functional Manual Reaction (FMR) is a type of manual therapy that uses joint mobilizations (Rolls and Glides) in a stabilized functional environment.

Permalink Reply by Robert Downes on December 18, 2009 at 9:24pm

Hi Joe, I just finished reading your Lumbar Spine Mobiliztion Article. Very Cool! Please help me understand some of your steps. What do you mean by, "it is usually best accomplished by positioning the client so that her body weight stabilizes the upper lumbar spine..." What do you mean by, "it is extremely important that the client's upper back is not torqued or twisted, and her shoulders remain vertically stacked as possible." What does vertically stacked mean? You also state, "when done properly, there will be no twist in the client's upper or lower back." Do you have any modifications to use if the person has "tight hips" and cannot adduct the hip without twisting the lower back in the Transverse plane? When you state, "hold it for only one second or less." Why do you use this time frame? When you write, "repeat it for two to four times." Why do you choose this rep scheme?

Thanks Joe, I will come back to the FMR when everyone has discussed your Lumbar, Thoracic and Cervical Mobilization Articles.

Permalink Reply by Robert Downes on December 20, 2009 at 1:20pm

I want to add another question to my previous above questions. In the Lumbar Mobilization are you doing a Type I (Left Lateral Flexion with Right Rotation) spinal mobilization?

Permalink Reply by Joseph E. Muscolino on December 20, 2009 at 10:07pm

I will reply to Bob's questions here to keep the thread of the conversation easier to follow.

What I mean by using the client's body weight to stabilize the lumbar spine is... we want to move the sacroiliac and lower lumbar region, so the upper lumbar spine needs to be stabilized. It can be stabilized by having the client's trunk weight stabilize it; we assist this by using our hand on their body wall to better stabilize it. Does this make sense?

We do not want to introduce any spinal rotation that can be avoided. For this reason, keeping her shoulders "vertically stacked" means that the shoulder that is contacting the table is directly under the shoulder that is away from the table. Perhaps to see this visually, if a ruler were placed vertically along her back, ideally the ruler should be perfectly vertical.

I am not clear on your "tight hip" question. Adduction of the thigh at the hip joint is a frontal plane motion; "twisting"/"rotation" of the spine is a transverse plane motion. I don't see the corrolation. Do you mean to write "adduction"? Oh wait, I see! You mean horizontal adduction (also known as horizontal flexion). A restriction with horizontal adduction would not be much of a problem. It would mean that the motion (stretching force) would be transferred to the sacroiliac joint that much more readily.

Joint mobilization is not comfortable to hold for very long. The patient/client would start to "resist" and tighten up.

Regarding the recommend number of reps being 2-4, I don't have a scientific study to prove this number. Once is not enough and more than four times may start to irritate the area. If I feel that I want more than four'ish reps, then I would probably leave the area and then come back again later in the session. Of course it also all depends on how much joint mobilization force we are applying with each rep.

The force for the joint mobilization can vary. I did not go into that in the article because the format of the column article does not really allow that kind of depth. Also, this article is meant to be more of an introduction to doing this type of mobilization. The best "precise" direction for the joint mobilization force would be where the restriction is felt, similar to any stretch, right? It is primarily into flexion and rotation; lateral flexion is difficult to introduce because the table is in the way (if the client is side-lying, then the table is in the frontal plane blocking any appreciable frontal plane motion).

Your questions are excellent. I do think that if you try this technique and practice it a bunch of times, some of these questions would answer themselves.

BTW, I am not familiar with the terminology of "Type 1" stretch. Where is that from?

Permalink Reply by Robert Downes on December 21, 2009 at 6:31pm

Hi Joe. I see Transverse plane motion because you adducted the hip AND flexed the hip. In Applied Functional Science (AFS) we deal with this all the time. We use the term "Triangulation" to specify angle, verticality and horizontal distance. In Figure 7. you can see the Transverse contour of the person's back. I see you chest pressure doing Frontal Plane Right side pelvic depression and therefore Left Lateral Flexion of the trunk. Because your hand is on one side of the sacrum I see your treatment hand doing Left pelvic rotation which is Right lumbar spine Rotation (Right rotation of Sacrum-L5).

To reiterate I see Spinal Left Lateral Flexion with Spinal Right Rotation.

In AFS we call the coupled motions of the F plane with the T plane Type I if the coupled motions are opposite each other and Type II if the couple motions are in the same direction. Hence, I called your Sacrum-L5 mobe Type I.

In your Lumbar spine mobilization are you doing an anterior glide (S plane) with the treatment hand?

Is your top hand at the clients shoulder blocking any unwanted motion and are you using the clients top right leg to preposition the sacrum?

The bottom line is I like your techniques they are very valuable and I will use them.

Again Terminology!!!

Thanks Joe

Permalink Reply by Joseph E. Muscolino on December 21, 2009 at 7:25pm

Yes. Terminology! There are too many terminologies out there. I always try to say as basic and foundational whenever possible.


So...regarding terminology, I am precise (some would say picky) so that we are clearly speaking of the same thing...

The thigh is not "adducting", it is "horizontally adducting", which is not exactly the same. I make this point so we are all picturing the same thing... having said that, horizontal adduction DOES occur in the transverse plane, hence your observation and excellent connection to T plane motion. Yes.

Depression (lateral tilt) of the right pelvis is not exactly the same as LLF of the trunk, but it is the reverse action of it. Yes.

When my hand is on the right side of the pelvis, it is more to move (rotate) the pelvic bone (ilium) than to move the entire pelvis as a whole. This motion is meant to be introduced into the sacroiliac joint and hopefully will NOT introduce rotation into the spine. Having said that, there is no way of perfectly isolating the motion to the SI and there will be some rotation introduced into the lumbar spine (and it would be the equivalent of right rotation, although it is really left rotation of the lower vertebrae relative to the upper ones; again reverse action).

Thanks for the explanation of your usage of "Type 1"f from AFS. Would you like to give a thumbnail sketch for readers of this group on what AFS is...?

I am not looking to introduce any type of "pure" anterior glide. Some anterior glide force would occur though given the posterior to anterior vector of the force...

My "top" (cephalad) hand is meant to block motion, i.e., stabilize, yes. It should specifically help to stop/decrease spinal rotation if done correctly (see previous comment about that).

The client's lower extremity that is away from the table is used as a lever to introduce force into the SI joint and beyond that to the lumbar spine. It "presets" the tension and then the treatment hand adds the final joint mobilization force. :)

VERY astute observations! You really made me think!!!



Robert Downes said:

Hi Joe. I see Transverse plane motion because you adducted the hip AND flexed the hip. In Applied Functional Science (AFS) we deal with this all the time. We use the term "Triangulation" to specify angle, verticality and horizontal distance. In Figure 7. you can see the Transverse contour of the person's back. I see you chest pressure doing Frontal Plane Right side pelvic depression and therefore Left Lateral Flexion of the trunk. Because your hand is on one side of the sacrum I see your treatment hand doing Left pelvic rotation which is Right lumbar spine Rotation (Right rotation of Sacrum-L5).

To reiterate I see Spinal Left Lateral Flexion with Spinal Right Rotation.

In AFS we call the coupled motions of the F plane with the T plane Type I if the coupled motions are opposite each other and Type II if the couple motions are in the same direction. Hence, I called your Sacrum-L5 mobe Type I.

In your Lumbar spine mobilization are you doing an anterior glide (S plane) with the treatment hand?

Is your top hand at the clients shoulder blocking any unwanted motion and are you using the clients top right leg to preposition the sacrum?

The bottom line is I like your techniques they are very valuable and I will use them.

Again Terminology!!!

Thanks Joe

Permalink Reply by Robert Downes on December 21, 2009 at 7:40pm

Thanks Joe. It really helped me when you said you were trying to move the ilium and not the entire pelvis - I did not consider that!

I would be glad to give a sketch of AFS but I want everyone to have a chance to ask you about your Mobilizations. I myself would like to go over your Thoracic Mobilization and then your Cervical Mobilization.

Thanks again,
Bob D

Permalink Reply by Joseph E. Muscolino on December 21, 2009 at 8:21pm

Interesting Rick. Given that joint mobilisation (a nod spelling-wise to you across the pond) is essentially a form of stretching, I would think that it works better after some type of a warm up. I am not sure that I would recommend it after "very" deep work though because very deep work often causes the client to guard a bit and that would impede mobilisation. Thanks for sharing!

Permalink Reply by Robert Downes on December 22, 2009 at 9:37am

Hi Joe, I have something on opening/closing the lumbar facet in each plane and a question on the Thoracic Spine Mobilization Article.

Let's look at the Right Lumbar Facet. The Right Lumbar Facet will be closed by Extension in the Sagittal Plane, Side Bending to the Right in the Frontal Plane and Rotation (from the top down) to the Left. Therefore if we want to facilitate opening in all three planes we would Trunk Flex, Side Bend Left and Rotate (from the top down) to the right.

Here's a question for the group: What happens to the right lumbar facet in each plane when the right foot heel strikes the gound in walking?

My question about the Thoracic Mobilization Article is when you write, "The pressure is applied forward and laterally, but also into the client" are you doing a rotational force?

Thanks,
Bob D

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