Joint Mobilization

BACKGROUND AND PURPOSE Passive joint mobilization is commonly used by physical therapists as an intervention for acute ankle inversion sprains. A randomized controlled trial with blinded assessors was conducted to investigate the effect of a specific joint mobilization, the anteroposterior glide on the talus, on increasing pain-free dorsiflexion and 3 gait variables: stride speed (gait speed), step length, and single support time. SUBJECTS Forty-one subjects with acute ankle inversion sprains (<72 hours) and no other injury to the lower limb entered the trial. METHODS Subjects were randomly assigned to 1 of 2 treatment groups. The control group received a protocol of rest, ice, compression, and elevation (RICE). The experimental group received the anteroposterior mobilization, using a force that avoided incurring any increase in pain, in addition to the RICE protocol. Subjects in both groups were treated every second day for a maximum of 2 weeks or until the discharge criteria were met, and all subjects were given a home program of continued RICE application. Outcomes were measured before and after each treatment. RESULTS The results showed that the experimental group required fewer treatment sessions than the control group to achieve full pain-free dorsiflexion. The experimental group had greater improvement in range of movement before and after each of the first 3 treatment sessions. The experimental group also had greater increases in stride speed during the first and third treatment sessions. DISCUSSION AND CONCLUSION Addition of a talocrural mobilization to the RICE protocol in the management of ankle inversion injuries necessitated fewer treatments to achieve pain-free dorsiflexion and to improve stride speed more than RICE alone. Improvement in step length symmetry and single support time was similar in both groups.

Primary shoulder impingement syndrome is a common shoulder problem which, if treated ineffectively, can lead to more serious pathology and expensive treatment. This study examined whether subjects receiving joint mobilization and comprehensive treatment (hot packs, active range of motion, physiologic stretching, muscle strengthening, soft tissue mobilization, and patient education) would have improved pain, mobility, and function compared with similar patients receiving comprehensive treatment alone. Subjects were eight men and six women (mean age = 52.9 years) with primary shoulder impingement syndrome (superolateral shoulder pain, decreased active humeral elevation, limited overhead function). Following random assignment to experimental (N = 7) and control groups (N = 7), three blinded evaluators tested 24-hour pain (visual analog scale), pain with subacromial compression test (visual analog scale), active range of motion (goniometry), and function (reaching forward, behind the head, and across the body in an overhead position) before and after nine treatments. One-tailed analyses of covariance (baseline values as covariates) showed that the experimental group had less 24-hour pain and pain with subacromial compression test but no differences in range of motion and function (Mann-Whitney U) compared with controls. The experimental group improved on all variables, while the control group improved only on mobility and function (one-tailed, paired t tests; Wilcoxon matched pairs). Age, side of dominance, duration of symptoms, treatment attendance, exercise quality, and adherence had no effect on the outcomes. Results may be affected by inadequate sample size, minimal capsular tightness, insensitive functional scale, nonspecific motion measurements, position at which mobilization treatment was given, or a strong effect of comprehensive treatment. Mobilization decreased 24-hour pain and pain with subacromial compression test in patients with primary shoulder impingement syndrome, but larger replication studies are needed to assess more clearly mobilization's influence on motion and function.

The purpose of this study was to examine the effects of a single joint mobilization treatment on dorsiflexion range of motion (DF ROM), posterior talar glide, and dynamic and static postural control in individuals with self‐reported chronic ankle instability (CAI). In this randomized cross‐over study, subjects received a Maitland Grade III anterior‐to‐posterior joint mobilization treatment and a control treatment of rest for 5 min. Weight‐bearing DF ROM, instrumented posterior talar displacement and posterior stiffness, the anterior, posteromedial, and posterolateral reach directions of the Star Excursion Balance Test (SEBT), and time‐to‐boundary (TTB) single‐limb stance static postural control were assessed on both treatment days in 9 males and 11 females with CAI. The results indicated that the joint mobilization treatment was associated with significantly greater DF ROM (p = 0.01) and TTB in the anterior–posterior direction with eyes‐open (p < 0.05). Although not significant, trends were identified in posterior talar displacement (p = 0.08) and the mean of TTB in the medial‐lateral (ML) direction (p = 0.07). No significant differences were observed in the standard deviation of TTB in the ML direction, the SEBT, or posterior stiffness (p > 0.05). This indicates that a single joint mobilization treatment has mechanical and functional benefits for addressing impairments in sensorimotor function and arthrokinematic restrictions commonly experienced by individuals with CAI. © 2010 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 29:326–332, 2011

The purpose of this investigation was to determine the effects of passive mobilization and active exercises in patients with painfully restricted shoulders. Twenty patients with painful glenohumeral restrictions were randomly placed in one of two groups. The experimental group received mobilization and active exercises two to three times per week for 4 weeks. The controls received only active exercises. Pain questionnaires were answered and isolated glenohumeral mobility measurements were taken initially and at weekly intervals during the 4 weeks of treatment. With the exception of internal rotation in the control groop, all motions increased significantly from baseline in both groups. Passive abduction improved significantly more in the mobilization group than in the control group. Pain scores decreased more in the mobilization group; however, the difference between the groups was not significant. The results suggest that joint mobilization and exercises are clinically effective in the treatment of painfully stiff shoulders. J Orthop Sports Phys Ther 1985;6(4):238-246.

We examined the effect of a 2‐week anterior‐to‐posterior ankle joint mobilization intervention on weight‐bearing dorsiflexion range of motion (ROM), dynamic balance, and self‐reported function in subjects with chronic ankle instability (CAI). In this prospective cohort study, subjects received six Maitland Grade III anterior‐to‐posterior joint mobilization treatments over 2 weeks. Weight‐bearing dorsiflexion ROM, the anterior, posteromedial, and posterolateral reach directions of the Star Excursion Balance Test (SEBT), and self‐reported function on the Foot and Ankle Ability Measure (FAAM) were assessed 1 week before the intervention (baseline), prior to the first treatment (pre‐intervention), 24–48 h following the final treatment (post‐intervention), and 1 week later (1‐week follow‐up) in 12 adults (6 males and 6 females) with CAI. The results indicate that dorsiflexion ROM, reach distance in all directions of the SEBT, and the FAAM improved (p < 0.05 for all) in all measures following the intervention compared to those prior to the intervention. No differences were observed in any assessments between the baseline and pre‐intervention measures or between the post‐intervention and 1‐week follow‐up measures (p > 0.05). These results indicate that the joint mobilization intervention that targeted posterior talar glide was able to improve measures of function in adults with CAI for at least 1 week. © 2012 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 30:1798–1804, 2012

STUDY DESIGN Randomized clinical trial. OBJECTIVE To compare the effectiveness of anterior versus posterior glide mobilization techniques for improving shoulder external rotation range of motion (ROM) in patients with adhesive capsulitis. BACKGROUND Physical therapists use joint mobilization techniques to treat motion impairments in patients with adhesive capsulitis. However, opinions of the value of anterior versus posterior mobilization procedures to improve external rotation ROM differ. METHODS AND MEASURES Twenty consecutive subjects with a primary diagnosis of shoulder adhesive capsulitis and exhibiting a specific external rotation ROM deficit were randomly assigned to 1 of 2 treatment groups. All subjects received 6 therapy sessions consisting of application of therapeutic ultrasound, joint mobilization, and upper-body ergometer exercise. Treatment differed between groups in the direction of the mobilization technique performed. Shoulder external rotation ROM measured initially and after each treatment session was compared within and between groups and analyzed using a 2-way ANOVA, followed by paired and independent t tests. RESULTS There was no significant difference in shoulder external rotation ROM between groups prior to initiating the treatment program. A significant difference between groups (P = .001) was present by the third treatment. The individuals in the anterior mobilization group had a mean improvement in external rotation ROM of 3.0 degrees (SD, 10.8 degrees; P = .40), whereas the individuals in the posterior mobilization group had a mean improvement of 31.3 degrees (SD, 7.4 degrees; P < .001). CONCLUSIONS A posteriorly directed joint mobilization technique was more effective than an anteriorly directed mobilization technique for improving external rotation ROM in subjects with adhesive capsulitis. Both groups had a significant decrease in pain.

Background: Posterior shoulder tightness, as demonstrated by limited internal rotation range of motion, is a suggested factor in many shoulder pathologies. Methods to increase posterior shoulder mobility may be beneficial. Hypothesis: Shoulder internal rotation range of motion will not change with either of 2 interventions: cross-body stretch alone and cross-body stretch plus posterior capsule joint mobilization. Study Design: Randomized controlled single-blinded clinical trial. Methods: The study comprised 39 college-age asymptomatic participants (7 men, 32 women) who were randomly assigned to 1 of 2 groups: stretching only (n, 20) and stretching plus posterior joint mobilizations (n, 19). All had a between-shoulder difference of internal rotation of 10° or more. Shoulder internal and external rotation was measured before and after a 4-week intervention period and 4 weeks postintervention. Participants in the stretching-only group performed the cross-body stretch on the limited side. Those in the other group (cross-body stretch plus joint mobilization) were treated with posterior joint mobilization techniques on the limited side. Results: Overall means for internal rotation of the treated shoulders significantly increased over baseline at the end of the intervention period and at 4 weeks postintervention. External rotation in all shoulders remained unchanged. By the end of intervention, total motion increased significantly from baseline but decreased significantly from the end of intervention to 4 weeks postintervention. Although not statistically significant, the second group (cross-body stretch plus joint mobilization) had greater increases in internal rotation. At 4 weeks postintervention, the second group had maintained its internal rotation gains to a greater degree than those of the stretching-only group. Conclusion: Internal rotation increased in both groups. Inclusion of joint mobilization in a rehabilitation program created trends toward increased shoulder internal rotation mobility. Clinical Relevance: Both methods—cross-body stretch and cross-body stretch plus joint mobilization—may be beneficial for those with limited internal rotation range of motion.

Joint mobilization is a treatment approach commonly used by physical therapists for the management of a variety of painful conditions. However, the clinical effectiveness when compared to placebo and the neurophysiological mechanism of action are not known. The purpose of this study was to establish that application of a manual therapy technique will produce antihyperalgesia in an animal model of joint inflammation and that the antihyperalgesia produced by joint mobilization depends on the time of treatment application. Capsaicin (0.2%, 50 μ l) was injected into the lateral aspect of the left ankle joint and mechanical withdrawal threshold assessed before and after capsaicin injection in Sprague‐Dawley rats. Joint mobilization of the ipsilateral knee joint was performed 2 h after capsaicin injection for a total of 3 min, 9 min or 15 min under halothane anaesthesia. Control groups included animals that received halothane for the same time as the group that received joint mobilization and those whose limbs were held for the same duration as the mobilization (no halothane). Capsaicin resulted in a decreased mechanical withdrawal threshold by 2 h after injection that was maintained through 4 h. Both 9 and 15 min of mobilization, but not 3 min of mobilization, increased the withdrawal threshold to mechanical stimuli to baseline values when compared with control groups. The antihyperalgesic effect of joint mobilization lasted 30 min. Thus, joint mobilization (9 or 15 min duration) produces a significant reversal of secondary mechanical hyperalgesia induced by intra‐articular injection of capsaicin.

This study was designed to investigate whether concurrent quantitative feedback of performance could improve the learning of a joint mobilization technique. A group of 110 physical therapy students had been randomly divided into two groups for teaching purposes. All students had previously learned mobilization of peripheral joints and were currently learning spinal mobilization. From one of the groups, 22 students volunteered to comprise a control group, which was taught a spinal mobilization technique in the traditional way. Additional concurrent quantitative feedback of the level of force applied to the patient was given to 31 volunteers from the other group. These students formed the experimental group. A force plate was used for force measurement, and the feedback was given via an oscilloscope. The average force applied by the students' instructors was taken as an "ideal" force. The oscilloscope showed both the applied force and the "ideal" force. Consistency was measured by the variance of the group's performance. Accuracy was assessed by calculating the difference between the applied force and the "ideal" force. Results indicated that this feedback was associated with a significant improvement in accuracy and consistency in the application of the mobilizing force. This improvement was still present at a follow-up test conducted one week later. This result supports a greater use of such feedback in the teaching and practice of joint mobilization techniques, although the need for further research is emphasized.

STUDY DESIGN An experimental laboratory study with a repeated-measures crossover design. BACKGROUND Treatment effects of joint mobilization may occur in part by decreasing excitability of central nociceptive pathways. Impaired conditioned pain modulation (CPM) has been found experimentally in persons with knee and hip osteoarthritis, indicating impaired inhibition of central nociceptive pathways. We hypothesized increased effectiveness of CPM following application of joint mobilization, determined via measures of deep tissue hyperalgesia. OBJECTIVE To examine the effect of joint mobilization on impaired CPM. METHODS An examination of 40 individuals with moderate/severe knee osteoarthritis identified 29 (73%) with impaired CPM. The subjects were randomized to receive 6 minutes of knee joint mobilization (intervention) or manual cutaneous input only, 1 week apart. Deep tissue hyperalgesia was examined via pressure pain thresholds bilaterally at the knee medial joint line and the hand at baseline, postintervention, and post-CPM testing. Further, vibration perception threshold was measured at the medial knee epicondyle at baseline and post-CPM testing. RESULTS Joint mobilization, but not cutaneous input intervention, resulted in a global increase in pressure pain threshold, indicated by diminished hyperalgesic responses to pressure stimulus. Further, CPM was significantly enhanced following joint mobilization. Diminished baseline vibration perception threshold acuity was enhanced following joint mobilization at the knee that received intervention, but not at the contralateral knee. Resting pain was also significantly lower following the joint intervention. CONCLUSION Conditioned pain modulation was enhanced following joint mobilization, demonstrated by a global decrease in deep tissue pressure sensitivity. Joint mobilization may act via enhancement of descending pain mechanisms in patients with painful knee osteoarthritis.