Transcript Impaired Joint Mobility

Chapter 7
Impaired Joint Mobility and
Range of Motion
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Mobility Impairment
Arthrokinematic
 Movements of the joint
surfaces
 Descrptive terms – roll,
spin, glide
 Necessary component of
osteokinematic motion
Osteokinematics
 Movements of the bones
 Described in terms of
planes (e.g., elevation in
the sagittal plane)
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Continuum
Hypomobility – Contracture/adaptive shortening.
Contracture – Condition of fixed high resistance
to passive stretch of tissue resulting from fibrosis
or shortening of the soft tissues around a joint or
of the muscles.
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Continuum
Result of remodeling of dense tissue after
surgery, immobilization, etc.
Adaptive Shortening – May result from holding a
limb in a posture.
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Instability
Excessive range of osteokinematic or
arthrokinematic movement for which there is no
protective muscular control.
Hypermobility
Excessive joint mobility, laxity, or length of a tissue.
Hypermobility may lead to or have instability as well.
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Relative Flexibility
Comparative mobility
at adjacent joints
If Hypomobile
Adjacent
segment/joint are
hypermobile
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Morphology and Physiology of
Normal Mobility
 Normal mobility –
Osteokinematic motion,
arthrokinematic motion, and
neuromuscular coordination to
achieve purposeful movement.
 Joint ROM – Quantity of
motion available at a joint or
series of joints.
 Muscle ROM – Functional
excursion from its fully
lengthened position to its fully
shortened position.
Requires adequate tissue
length to allow full ROM
of articular surfaces

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





Interposed tissues
Joint capsule
Ligaments
Tendons
Muscles
Bursae
Fascia
Skin
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Causes and Effects of Decreased
Mobility
Adaptive
 Trauma to soft tissue
 Surgery (e.g., joint
replacement)
 Joint disease (e.g.,
osteoarthritis)
 Prolonged immobilization
 Neuromuscular disease
shortening
of soft
tissues
Disuse
Weakness
Pain
Decreased
loading
Mobility limitation
Compensation
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Effects On Muscle
Immobilization
The longer the
immobilization, the
greater the atrophy
Muscle fiber atrophy
(Type I > Type II)
Decrease in electrical
activity
Remobilization
Factors affecting rate
and end point –
position and time of
immobilization
Decrease in stiffness
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Effects On Tendon
Immobilization
Reduced collagen
fiber bundles, water
content,
glycosaminoglycans
(GAG), stiffness,
tissue weight, elastic
stiffness
Remobilization
Acceleration of
collagen synthesis
Early remobilization –
improvement of
tensile strength and
energy absorption
Less adhesions postsurgically
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Effects On Ligament
Immobilization
 Decreased collagen
mass, strength, and
stiffness, ligament’s
mechanical properties
Remobilization
 May restore mechanical
and structural properties
of insertion sites
 Structural properties
inferior to mechanical
stress
 Tissue response is
dependant on
immobilization period
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Effects On Articular Cartilage
Immobilization
 Degeneration of articular
surface
 Increased water content
 Altered proteoglycan
organization
 Decrease in GAG
content, cartilage
thickness, hyaluronic acid
content, proteoglycan
synthesis
Remobilization
 Depends on length of
immobilization, injury,
status prior to
immobilization, available
joint motion & load
distribution
 Remobilization may
prevent associated
degeneration, degradation
of articular cartilage and
progression to
osteoarthritis
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Effects On Bone
Immobilization
Resorption in early
phases
Bone mineral loss
Effects are more
profound than in other
tissues
Remobilization
Response exceeds
that of all other
tissues
Depends on bone
quality
Restoration of
mechanical forces
reverses bone loss
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Mobility Examination and Evaluation
Goniometric measurements (actively or
passively – reliability is greater for active
ROM)
Ensure proper positioning of patient
Selective tissue tension testing
Joint play maneuvers (arthrokinematics)
Muscle ROM (flexibility tests)
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Therapeutic Intervention for
Decreased Mobility
 Stretching
 Joint mobilizations
 Adjunctive agents may
enhance the
effectiveness of exercise
interventions
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Elements of the Movement System
Elements of the movement system must be
prioritized and amenable to the determined
physical therapy intervention.
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Activities to Increase Mobility
Passive ROM (PROM) – Mobility activities performed
without any muscular activation.
 Performed w/in available ROM
 Pulleys, CPMs, dynamic splinting
 Use of family members, various household objects
 PROM – commonly used when active ROM may disrupt
the healing process
Goal – Prevention of negative effects of immobilization,
joint contractures, soft tissue tightness, decreased pain
& enhancement of vascular dynamics and synovial
diffusion.
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Activities to Increase Mobility
Active Assisted ROM (AAROM)
Mobility activities in which some muscle
activation takes place.
Indicated when some activation is desired or
approved.
Used to initiate gentle muscle activity after
musculotendinous surgical procedures.
Indicated for pts unable to complete ROM
actively b/c of weakness from trauma, neuro
injury, neuromuscular disease, or pain.
Goal – same as PROM
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Activities to Increase Mobility
Active ROM (AROM)
Mobility activities performed by active muscle
contraction.
Goal – same as PROM + benefits muscle
contraction
Requires more muscle coordination (can be
gravity loaded or minimized).
Should follow any passive technique to reinforce
proper movement patterns.
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Considerations When Performing ROM
Ensure patient comfort and safety.
Ensure clinician safety by using good body
mechanics.
Support any areas at risk of injury resulting from
hypermobility, fracture, etc.
Perform ROM slowly and rhythmically.
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Considerations When Performing
ROM (cont.)
Move through full range as possible.
Avoid excessively tight grip by grasping over
large surface area.
Use cardinal plane motions, combined motions,
or functional movement patterns.
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Stretching
Used to increase the extensibility of the
muscle tendon unit and the periarticular
connective tissue.
 Contraindicated in acute inflammation and tissue
infection cases.
 Caution is used in patients with recent fractures,
osteoporosis, the elderly, prolonged immobilization, very
weak musculature.
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Stretching (cont.)
Held a minimum of 30 seconds – younger
patients, 60 seconds older patients
Position should be comfortable, in proper
alignment, and stable to allow proximal
stabilization.
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Categories of Stretching – 3
1. Static (muscles held at a certain length)
2. Ballistic (quick movements impose a rapid
change in length)
3. Proprioceptive neuromuscular facilitation
(PNF)
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Exercise Dosage
Dictated by:
Stage of healing
Response to loading
Dosage is matched to the patient’s
individual needs.
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Sequence
Depends on the purpose of the ROM activity.
Least amount of muscle activation  increasing
amount of voluntary activation
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Frequency, Intensity, Duration
Frequency
Inversely related to intensity & duration
Relative to physiologic, kinesiologic (performed
2–5 times per day)
Learning factors (e.g., postural re-education –
performed numerous times daily)
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Precautions and Contraindications
PROM, AAROM, AROM
Contraindicated when motion could disrupt
healing process.
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Joint Mobilization
“Continuum of skilled passive movements to the
joints and/or related soft tissues that are applied
at varying speeds and amplitudes, including
small-amplitude/high velocity therapeutic
movement.”
Classification systems focus on increasing
joint mobility by increasing joint play or
motion between the joint surfaces.
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Mobilization Grades
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Applications to Specific Joints
Shoulder
Elbow
Wrist and hand
Hip
Knee
Foot and ankle
Spine
Numerous
modifications
Positioning varies
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Causes and Effects of Hypermobility
Cause
Traumatic injury
Genetic
predisposition
Effect
May lead to instability
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Therapeutic Exercise Intervention for
Hypermobility
Spondylolysis at L4
Anatomic impairment
Base element
Faulty posture
during
movement
Movement impairment
Biomechanical
element
Pain
Inability to run
Impairment
Choice of
intervention –
stabilization of
biomechanical
element
Disability
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Stabilization Exercises
 Dynamic activities that attempt to limit and control
excessive movement.
 Focus on increasing short muscles through static
stretching, followed by active contraction of
antagonist.
 Activity should be based on the direction in which
the segment is susceptible to excessive motion.
 Supportive devices (taping, bracing) may be
necessary initially.
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Closed-Chain Exercises
Rationale
Muscular cocontraction,
decreased shear
forces, increased joint
compression
Lower Extremity
Squats, lunges, step
ups etc.
Upper Extremity
Pushups, modified
pushups, weight
bearing with hands on
table
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Open-Chain Stabilization
Particularly effective
in late stages of
rehabilitation
Sitting, prone, and
supine activities
combined with arm
reaching and leg lifts
can be used from
early to advanced
stages of stabilization
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Ballistic Exercises
Produces cocontraction about a
joint through triphasic
muscle activation.
Results in
synchronous
activation of agonists
and antagonists.
Rapid flexion &
extension of the hip
through a small range
elicits co-activation of
agonist & antagonist .
Slow movement
produces reciprocal
activation of same
group(s).
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Exercise Dosage
Depends on purpose of exercise
Signs of fatigue (e.g., substitution) alters
performance and may be indicative of loss of
desired stabilization
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Life Span Issues
 Flexibility remains stable
through age 8
 Declines until ages 11–15
 Mobilizations, generally
not used in children
(except for some CNS
disorders)
 Static stretching (as
compared to PNF, etc.)
may be less susceptible
to contraction-induced
injury for the elderly
 Declining ROM, joint
capsule tensile strength,
articular water content,
bone fragility should be
considered when treating
the elderly
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Adjunctive Agents
Superficial heat
Deep heat
Taking advantage of collagen’s response to
increased intramuscular temperature.
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Summary
 Immobilization has detrimental effects on soft tissues,
bone, and insertion sites.
 Effects are result of specific adaptations.
 Time required to restore structural and mechanical
properties can be twice that of the immobilization period.
 Joint ROM should be differentiated from muscle ROM.
 Contractile and non-contractile tissues limit joint mobility.
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Summary (cont.)
 PROM – Mobility without muscle contraction.
 AAROM – Some muscle activity.
 AROM – Uses active muscle contraction.
 Joint mobilization is indicated when capsular
restriction is a key finding.
 Various devices (home and clinical) can be used
to assist in mobility exercises.
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Summary (cont.)
 Mobility exercise prescription depends on the
specific goal of the activity and the environment
in which it will be performed.
 Hypermobility can be as disabling as
hypomobility.
 Stabilization exercises may be incorporated.
 Adjunctive agents (heat, etc.) can be used to
enhance mobility activities.
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