MOBILIZATION

INDICATIONS,
CONTRAINDICATIO
NS AND EFFECTS
 INDICATIONS

1. Pain, Muscle guarding & spasm and Spasm

2. Reversible joint hypomobility

3. Positional faults/ Subluxations

4. Progressive limitation

5. Functional immobility
 1. PAIN, MUSCLE GUARDING, AND SPASM
• Painful joints, reflex muscle guarding, and muscle spasm can be treated
with gentle joint-play techniques to stimulate neurophysiological and
mechanical effects.
• NEUROPHYSIOLOGICAL EFFECTS:
Small amplitude oscillatory movement & distraction
movements

Stimulates the mechanoreceptors

Inhibit transmission of nociceptive stimuli at spinal

cord & brain stem level

Decreases pain
• MECHANICAL EFFECTS:

Small amplitude distraction or gliding

movement

Synovial fluid motion

Bring nutrients to the avascular portions of

articular cartilage

Decreases pain of ischemia

Gentle joint play

Maintain nutrient exchange

Prevent painful effects of stasis when joint is

painful or swollen & can’t move through a
ROM (but not in acute or massive swelling
 2. REVERSIBLE JOINT HYPOMOBILITY

• Progressively vigorous joint-play stretching techniques to elongate hypomobile

capsular and ligamentous connective tissue.

• Sustained or oscillatory stretch forces are used to distend the shortened tissue
mechanically.
 3. POSITIONAL FAULTS/ SUBLUXATIONS

• A faulty position of one bony partner with respect to its opposing surface may result in
limited motion or pain.
• Occur with a traumatic injury, after periods of immobility, or with muscle imbalances.
• The faulty positioning may be perpetuated with maladapted neuromuscular control across
the joint, so whenever attempting active ROM, there is faulty tracking of the joint surfaces
resulting in pain or limited motion.
• MWM techniques attempt to realign the bony partners while the person actively moves the
joint through its ROM.
• Thrust techniques are used to reposition an obvious subluxation, such as a pulled elbow or
capitate-lunate subluxation.
 4. PROGRESSIVE LIMITATION

• Diseases that progressively limit movement can be treated with joint-play

techniques to maintain available motion or retard progressive mechanical
restrictions.

• The dosage of distraction or glide is dictated by the patient’s response to

treatment and the state of the disease.
 5. FUNCTIONAL IMMOBILITY

• When a patient cannot functionally move a joint for a period of time, the joint
can be treated with non-stretch gliding or distraction techniques to maintain
available joint play and prevent the degenerating and restricting effects of
immobility
Non-thrust oscillation techniques
Grade Indications

Grade I & II To treat joints limited by pain or muscle

guarding.

Grade III & IV Stretching maneuvers

Vary the speed of oscillations for different effects, such as low amplitude and high
speed, to inhibit pain or slow speed to relax muscle guarding.
 Non-thrust sustained joint play
techniques
Grade Indications
Grade I With all gliding motions and may be
used for relief of pain.
Grade II Initial treatment to determine the
sensitivity of the joint.
Intermittently may be used to inhibit
pain.
To maintain joint play when ROM is not
allowed.
Grade To stretch the joint structures and thus
increase joint play.

 Apply Grade I intermittent distraction for 7 to 10 seconds with a few seconds of rest in between for several
cycles. Note the response and either repeat or discontinue. T/t dosage is increased or decreased according
to joint reaction.
 For restricted joints, apply a minimum of a 6-second stretch (Grade III) force followed by partial release (to
grade I or II), then repeat with slow, intermittent stretches at 3- to 4-second intervals.
 CONTRAINDICATIONS
SR. NO. ABSOLUTE RELATIVE/PRECAUTIONS

1. Hypermobility/ Joint laxity Hypermobility in associated joints

2. Joint effusion Bone disease detectable on radiographs
3. Inflammation Skin rash or wound in T/t area
4. Cancer in T/t area Suspected cancer in T/t area
5. Spinal cord injury Excessive pain
6. Fracture in T/t area Unhealed Fractures
7. Stroke or Heart problems Total joint replacement
8. Nerve injury Systemic CT diseases - RA
9. Circulation problems (Blood clotting disorder) Elderly individuals with weakened CT and diminished
circulation
10. Surgery in T/t area Newly formed or weakened CT {immediately after injury,
surgery, disuse, pt. on certain medications as
corticosteroids
1. Hypermobility –
• Joints of pt. with potential necrosis of the ligaments or capsule should not be mobilized with stretching
techniques.
• Pt. with painful hypermobile joints may benefit from gentle joint-play techniques if kept within the limits of
motion. Stretching is not done.
2. Joint effusion –
• Capsule of joint is stretched to accommodate the extra fluid which limits joint motion and muscle response
to pain is not from shortened fibers.
• Gentle oscillating motions that do not stress or stretch the capsule may help block the transmission of a pain
stimulus so it is not perceived and also may help improve fluid flow while maintaining available joint play.
3. Inflammation –
• Stretching increases pain and muscle guarding and results in greater tissue damage.
• Gentle oscillating or distraction motions may temporarily inhibit the pain response.
 PRECAUTIONS
1.Unhealed fracture. (The site of the fracture and the stabilization provided
will dictate whether or not manipulative techniques can be safely applied.)
2.Excessive pain. (Determine the cause of pain and modify treatment
accordingly.)
3.Hypermobility in associated joints. (Associated joints must be properly
stabilized so the mobilization force is not transmitted to them.)
4.Total joint replacements. (The mechanism of the replacement is self-
limiting, and, therefore, the mobilization techniques may be inappropriate.)
5.Newly formed or weakened connective tissue such as immediately
after injury, surgery, or disuse or when the patient is taking
certain medications such as corticosteroids. (Gentle progressive
techniques within the tolerance of the tissue help align the developing
fibrils, but forceful techniques are destructive.)
6.Systemic connective tissue diseases such as rheumatoid arthritis,
in which the disease weakens the connective tissue. (Gentle
techniques may benefit restricted tissue, but forceful techniques may
Precautions and Contraindications to Spinal Mobilization and
Manipulation Interventions:
1. Spinal cord involvement in the area being treated.
2. Spondylolisthesis in the area being treated.
3. Severe scoliosis in the area being treated.
4. Suspected aneurysm in the area being treated.
5. Positive neurologic signs if the spine or pelvis is being treated with grade V
techniques.
Precautions and Contraindications Specifically to Cervical Spine
Mobilization and Manipulation Interventions:
1. Any indication of vertebrobasilar insufficiency in the upper cervical spine,
such as reports of dizziness with extension or rotation movements, because
cervical spine joint manipulation has been shown to produce
cerebrovascular accidents.
2. Any indication of ligamentous instability in the upper cervical spine because
cervical spine joint manipulation has been shown to cause injury to the
spinal cord.
3. Rheumatoid arthritis in the cervical spine because joint
mobilization/manipulation might produce subluxation or dislocation of
cervical spine joints.
4. Traumatized upper cervical ligaments, if there is any evidence that the
trauma might have caused the upper cervical joints to become unstable.
5. Genetic disorders affecting joint laxity in the spine, such as Down syndrome.
Precautions and Contraindications Specifically to Lumbar Spine and
Pelvic Joint Mobilization and Manipulation Interventions:
1. Cauda equina syndrome because mobilization/manipulation might
exacerbate the condition.
2. Pregnancy because there is speculation (but no evidence) that mobilization/
manipulation techniques might induce labor
 EFFECTS
• NEUROPHYSIOLOGICAL EFFECTS –
1. Stimulates mechanoreceptors to reduce pain
2. Affect muscle spasm & muscle guarding – nociceptive stimulation
3. Increase in awareness of position & motion because of afferent nerve impulses
• NUTRITIONAL EFFECTS –
1. Distraction or small gliding movements – cause synovial fluid movement
2. Movement can improve nutrient exchange due to joint swelling & immobilization
• MECHANICAL EFFECTS –
1. Improve mobility of hypomobile joints (adhesions & thickened CT from immobilization –
loosens)
2. Maintains extensibility & tensile strength of articular tissues
3. Cracking noise may sometimes occur
 Physiological Effects Mechanical Effects:
1. Increased Joint Lubrication: Joint mobilization 1. Enhanced Joint Stability: Stimulating
stimulates synovial fluid production, enhancing proprioceptors improves neuromuscular
joint lubrication and reducing friction between control and coordination, enhancing joint
joint surfaces. stability.
2. Pain Modulation: Activation of 2. Reduction of Joint Stiffness: Breakup of
mechanoreceptors inhibits pain signal adhesions and scar tissue restores normal
transmission, leading to reduced pain tissue mobility, reducing joint stiffness and
perception and improved tolerance to promoting smoother movement.
movement. 3. Stretching of Surrounding Tissues: Gentle
3. Improved Joint Nutrition: Enhanced blood stretching of muscles, ligaments, and
flow facilitates the delivery of nutrients and capsules around the joint improves
oxygen to the joint, supporting tissue repair flexibility and reduces tissue tension.
and regeneration. 4. Normalization of Joint Mechanics: By
4. Increased Joint Mobility: Stretching of tight guiding joints through their natural range of
soft tissues around the joint gradually motion, joint mobilization helps restore
increases joint mobility, restoring full range of optimal joint mechanics and movement
motion. patterns.
 Nutritional Effects
1. Delivery of Nutrients: Increased blood flow carries essential nutrients, such as
oxygen, glucose, amino acids, and vitamins, to the joint tissues. These nutrients are
vital for cellular metabolism, energy production, and tissue repair processes.
2. Removal of Metabolic Waste: Along with delivering nutrients, improved circulation
aids in the removal of metabolic waste products, including carbon dioxide and
lactic acid, from the joint tissues. Efficient waste removal helps prevent tissue
accumulation of toxins, reducing inflammation and promoting tissue health.
3. Stimulation of Tissue Healing: Nutrient-rich blood provides the necessary building
blocks for tissue repair and regeneration. Joint mobilization can accelerate the
healing process by supplying the injured tissues with the resources they need to
rebuild and restore normal function.
4. Maintenance of Tissue Homeostasis: Optimal nutrition is essential for maintaining
the homeostasis of joint tissues. Joint mobilization supports this by ensuring a
consistent supply of nutrients, promoting tissue health, and reducing the risk of
degenerative changes associated with poor nutrition.
 1. DECREASES PAIN
Numerous of neurological mechanisms have been proposed to explain the effect of
pain reduction secondary to joint mobilization/manipulation technique. One of theory
proposed that pain reduction occurs via activation of pain inhibitory mechanisms or pain
control centers in the central or in the peripheral nervous system, or via chemical changes in
peripheral nociceptors.

Although, validity of these theories and to date no single theory has emerged as
being more widely accepted than others. So, pain reduction from joint mobilization/
manipulation is a multifaceted phenomenon.
2. PROMOTES MUSCLE RELAXATION

Mobilization/manipulation stimulates joint receptors

Pain reduction by means of neurological mechanisms

Reflexively causes relaxation of periarticular muscles

 3. INCREASES JOINT EXTENSIBILITY AND JOINT ROM
• Accessory motion can be decreased even when joint range of motion is normal, and that this impairment can
lead to limitations in function. Articular and periarticular restrictions have been shown to result from
immobilization of joints.
IMMOBILIZATION
decrease in water content
reduction in the distance between the fibers
constituting the joint capsule
increase in fiber cross-link formation,
produces adhesions.
new collagen tissue is produced

additional cross-linking occurs

adhesions between synovial folds

fibrofatty connective tissue proliferates within
the joint and adheres to cartilaginous
structures
strength of collagen tissue decreases
decrease in the load-to-failure
rate.
mechanical effect of increasing the amount of
arthrokinematics motion and consequently
osteokinematic motion at a joint

by promoting movement between

capsular fibers

increase in interstitial water content

and interfiber distance

synovial tissue stretches in a selective

manner, causing a gradual rearrangement of
collagen tissue with a reduction of cross-link
formation and the development of parallel
fiber configuration in newly forming collagen
tissue

More aggressive manipulation techniques are

thought to break adhesion in the joint capsule
and synovial folds and increase the length of
capsular fibers
 4. IMPROVE JOINT NUTRITION

• Articular surfaces are avascular and receive their nutrition from synovial fluid. For diffusion
of nutrients to occur, the synovial fluid must circulate within the capsule to allow nutrients
to contact the articular surface.

• In normal joints, joint movement through functional activities provides a mechanism for the
circulation of synovial fluid.

• Joints that are restricted often cannot obtain adequate nutrition because insufficient range
of motion reduces movement of synovial fluid within the synovium.

• Joint mobilization/manipulation is believed to improve nutrition to synovial tissue by

promoting the circulation of synovial fluid within the capsule.
 5. CORRECTS POSITIONAL FAULTS
• Joint surfaces can alter their position in relation to one another. If this alteration in position is
severe, it is called a dislocation; however, if minimal, it is considered a positional fault.

• Even minimal displacement is believed to place abnormal stress on periarticular structures and
can be a source of pain and neuromuscular dysfunction.

• Mobilization/manipulation of one of the joint surfaces in the direction consistent with

realigning it into its correct position is thought by some clinicians to normalize the static
positioning of one joint surface in relation to the other, thereby reducing pain.

• While some believe that the positional fault can be eliminated if the joint is
mobilized/manipulated in the direction of greatest restriction.

• Positional faults are believed to be more common in the spine than in the extremities.
 6. ELIMINATE MENISCOID IMPINGEMENT

• Intracapsular meniscoid structures are present in some joints, most notably tibiofemoral and
spinal facet articulations.

• Facet menisci are believed to be capable of becoming entrapped, or impinged, between the
two facet joint surfaces, causing the joint surfaces to lock.

• This impingement is thought to occur most often with movement into spinal flexion and
rotation and is accompanied by pain.

• Spinal manipulation techniques that allow the facet joint surfaces to gap are thought to
release the entrapped meniscoid tissue and restore normal joint motion.
 7. REDUCES SPINAL JOINT DISC HERNIATION

During spinal manipulation, some clinicians believe that sufficient negative

pressure is created between the vertebral bodies to draw the herniated disc
material back into the intervertebral space.
 8. INCREASES MUSCLE STRENGTH

• Swelling secondary to joint impairments has been shown to be a cause of inhibition of muscles that act
on that joint. Some clinicians believe that this inhibition is decreased when normal joint mechanics are
restored using joint mobilization/manipulation techniques.

• Joint mobilization/manipulation performed through tissue resistance seems to have the effect of
increasing muscle strength in the short term, regardless of whether or not the joints receiving the
intervention are impaired.

• Also an inhibitive effect on specific muscles. And the muscles that showed inhibition are recognized as
those that often guard the impaired joints that were treated. It is therefore possible that these muscles
were in spasm.

• The evidence suggests that joint mobilization improves muscle performance, regardless of the presence
or nature of the muscle impairment.
 9. SYSTEMIC PHYSIOLOGICAL EFFECTS
• Mobilization/manipulation can cause measurable changes in the physiology of
numerous remote tissues.
• Some studies shows that, after joint mobilization/manipulation heart rate and
blood pressure increased, and all measures of cutaneous (skin conductance,
skin temp., cutaneous blood flow) sympathetic nervous system function were
activated after the mobilization with movement technique, but were
unchanged after the placebo and control conditions.
• These studies indicate that some mobilization/manipulation techniques
produce a generalized sympathoexcitatory response. Nevertheless, the
relevance of an increase in sympathetic nervous system activity in the
treatment of joint impairments is unclear, other than its potential indirect
effect on pain reduction.
 10. PLACEBO AND PSYCHOLOGICAL EFFECTS
• With joint mobilization/manipulation intervention one common concern of
researchers is the potential threat to validity caused by a placebo effect. This is
especially the case in research involving the effect of manual techniques on pain
because these techniques have been shown in numerous studies to be powerful
placebos.
• Although clinicians are eager for patients to improve regardless of the reason
for the improvement, it is important to recognize that when treating patients
with pain, it is estimated that 30% of the effect is attributable to providing
attention and hands-on care to patients.
• Patients are better served if we choose techniques that have an effect on
outcomes beyond the effect of placebo.
• The effects of placebo are likely to have less of an influence on other outcomes,
such as range of motion.