peripheral joint mobilization - 반드시 이해해야 하는 관절가동법의 생리학 - 대박정리!!

[문형철]

통증이 발생하면 4가지를 찾아야

1. 손상부위 lesion

2. muscle pain(spasm, Trp, myofascial pain) and muscle dysfunction

3. neural tissue pain

4. joint pain and dysfunction

관절통은 염증, hypomobility, hypermobility

mobilizing exercise

rom exercise

stretching 

joint mobilization

관절생체역학의 기초(클릭하여 반드시 읽은 후)

각관절의 관절가동, 수기저항운동, 자가운동, 기능적 운동의 정리(클릭해보세요)

1. shoulder girdle complex의 관절가동

2. elbow complex의 관절가동

3. wrist, hand and finger의 관절가동

칼텐본-에반스 정형도수치료 원리

panic bird..

Joint mobilization refers to manual therapy techniques that are used to modulate pain and treat joint dysfunctions that limit range of motion (ROM) by specifically addressing the altered mechanics of the joint. The altered joint mechanics may be due to pain and muscle guarding, joint effusion, contractures or adhesions in the joint capsules or supporting ligaments, or malalignment or subluxation of the bony surfaces.

- 관절가동은 수기치료테크닉으로 통증조절과 관절의 변형된 역학에 의해서 제한된 rom을 야기하는 관절기능부전을 치료함. 

- 변형된 관절 역학은 통증, 반사성근수축(근육 보호), 관절부종, 관절낭의 구축, 유착 또는 인대나 부정렬, 아탈구 등에 의해서 발생할 수 있음. 

 Joint mobilization stretching techniques differ from other forms of passive or self-stretching (described in Chapter 4) in that they specifically address restricted capsular tissue by replicating normal joint mechanics while minimizing abnormal compressive stresses on the articular cartilage in the joint.14,27 

- 관절가동 스트레칭 테크닉은 수동적인 형태나 자가스트레칭과는 구별됨. 

To use joint mobilization for treatment effectively, the practitioner must know and be able to examine the anatomy,

arthrokinematics, and pathology of the neuromusculoskeletal system and to recognize when the techniques are indicated or when other techniques would be more effective for regaining lost motion. Indiscriminate use of joint mobilization techniques, when not indicated, could lead to potential harm to the patient’s joints. 

- 적응증이 아닐때, 무분별한 관절가동테크닉 사용은 환자의 관절을 해롭게 할 수 있음. 

- 치료사는 해부학, arthorkinematic, 신경근 시스템의 병리를 잘 알아야 하고, 관절가동 테크닉이 적응증일때 또는 다른 테크닉이 좀더 효과적인 치료법인지를 잘 알아야 함. 

We assume that prior to learning the joint mobilization techniques presented here the student or therapist has had (or will be concurrently taking) a course in orthopedic examination and eval‎uation and therefore will be able to choose appropriate, safe techniques for treating the patient’s functional limitation. The reader is referred to several resources for additional study of eval‎uation procedures.5,14,16,17 

- 관절가동 테크닉을 배우기 전에 정형외과적 검사, 평가 등의 코스를 거쳐야 환자의 기능적 제한 치료를 안전하게 시행할수 있음. 

When indicated, joint mobilization is a safe, effective means of restoring or maintaining joint play within a joint and can also be used for treating pain.14

- 적절한 적응증일때, 관절가동테크닉은 관절기능을 개선하는데 안전하고 효과적이고, 통증을 조절할 수 있음. 

DEFINITIONS OF TERMS

1. Mobilization/Manipulation

Mobilization and manipulation are two words that have come to have the same meaning18 and are therefore interchangeable. They are passive, skilled manual therapy techniques applied to joints and related soft tissues at varying speeds and amplitudes using physiological or accessory motions for therapeutic purposes.2 The varying speeds and amplitudes could range from a small-amplitude force applied at high velocity to a large-amplitude force applied at slow velocity; that is, there is a continuum of intensities and speeds at which the technique could be applied.2

- 가동과 manipulation은 같은 의미임. 

- 수동적이고 숙련된 수기치료테크닉으로 관절과 관련 조직에 생리학적 또는 보조적 움직임을 이용한 다양한 스피드와 진폭을 적용하는 치료법임. 

- 다양한 스피드와 진폭은 작은 진폭힘과 높은 속도~큰 진폭힘과 낮은 속도등이 있음. 

2. Self-Mobilization (Auto-mobilization)

Self-mobilization refers to self-stretching techniques that specifically use joint traction or glides that direct the stretch force to the joint capsule. Self-mobilization techniques are described in the chapters on specific regions of the body.

- 자가 가동법은 자가스트레칭 테크닉으로 관절낭에 직접적인 당김힘을 적용하는 관절 당김 또는 활주를 이용함. 

3. Mobilization with Movement

Mobilization with movement (MWM) is the concurrent application of sustained accessory mobilization applied by a therapist and an active physiological movement to end range applied by the patient. Passive end-of-range overpressure, or stretching, is then delivered without pain as a barrier. The techniques are always applied in a pain-free direction and are described as correcting joint tracking from a positional fault .20,21 Brian Mulligan of New Zealand originally described these techniques.21

- 움직임을 동반한 가동법은 치료사에 의해서 지속적인 부가적 가동의 적용과 관절의 end range까지 적용된 환자 스스로의 능동적 생리적 움직임을 적용함. 

- 수동적 과도한 압력의 끝범위 또는 스트레칭은 장벽에서 통증이 없는 상태로 적용하는 것임. 

- 이 테크닉은 통증이 없는 방향과 올바른 관절 트래킹을 적용함. 

4. Physiological Movements

Physiological movements are movements the patient can do voluntarily (e.g., the classic or traditional movements, such as flexion, abduction, and rotation). The term  is used when these motions of the bones are described.

- 생리적 움직임은 환자가 자발적으로 움직일 수 있는 굴곡, 신전, 내전외전, 회전 등의 전형적인 움직임을 말함. 

-  osteokinematic 용어는 여기에 사용함.

5. Accessory Movements

Accessory movements are movements in the joint and surrounding tissues that are necessary for normal ROM but that cannot be actively performed by the patient.22 Terms that relate to accessory movements are component motions and joint play.

- 부가적인 움직임은 정상 rom에 부가적인 움직임임. 

1) Component motions are those motions that accompany active motion but are not under voluntary control. The term is often used synonymously with accessory movement. For example, motions such as upward rotation of the scapula and rotation of the clavicle, which occur with shoulder flexion, and rotation of the fibula, which occurs with ankle motions, are component motions.

2) Joint play describes the motions that occur between the joint surfaces and also the distensibility or “give”in the joint capsule, which allows the bones to move. The movements are necessary for normal joint functioning through the ROM and can be demonstrated passively, but they cannot be performed actively by the patient.25 The movements include distraction, sliding,

compression, rolling, and spinning of the joint surfaces. The term arthrokinematics is used when these motions of the bone surfaces within the joint are described.

- 관절 플레이는 관절낭에 팽창성을 주는 치료적 행위. 

- distraction, sliding, compression, rolling, spinning 등

- arthrokinematics 용어는 여기에 적합함. 

N O T E : Procedures to distract or slide the joint surfaces to decrease pain or restore joint play are the fundamental joint mobilization techniques described in this text.

6. Thrust

Thrust is a high-velocity, short-amplitude motion such that the patient cannot prevent the motion.17,25 The motion is performed at the end of the pathological limit of the joint and is intended to alter positional relationships, snap adhesions, or stimulate joint receptors.25 Pathological limit means the end of the available ROM when there is restriction.

- 쓰러스트는 높은 속도, 낮은 진폭의 움직임으로 환자는 움직임을 제한할 수 없는 테크닉. 

- 쓰러스트는 관절의 병리적 한계의 끝에서 시행하고, 위치관계, 유착 등을 변화시키고, 관절 수용기를 자극함. 

7. Manipulation Under Anesthesia

Manipulation under anesthesia is a medical procedure used to restore full ROM by breaking adhesions around a joint while the patient is anesthetized. The technique may be a rapid thrust or a passive stretch using physiological or accessory movements.

- 마취하에서 가동

- 마취하에서 가동법은 마취상태에서 관절의 full rom회복 도모하는 것. 이 테크닉은 쓰러스트 또는 수동적 스트레칭을 이용함. 

8. Muscle Energy 근에너지 기법

Muscle energy techniques use active contraction of deep muscles that attach near the joint and whose line of pull can cause the desired accessory motion. The technique requires the therapist to provide stabilization to the segment on which the distal aspect of the muscle attaches. A command for an isometric contraction of the muscle is given that causes accessory movement of the joint. These techniques are not described in this text.

- 근에넌지 기법은 심부근육의 능동적 수축을 이용함. PIR

BASIC CONCEPTS OF JOINT

MOTION: ARTHROKINEMATICS

1. Joint Shapes 관절의 형태

The type of motion occurring between bony partners in a joint is influenced by the shape of the joint surfaces. The shape may be described as ovoid or seller .14,29 

# In ovoid joints one surface is convex, the other is concave(Fig. 5.1A).

# In sellar joints, one surface is concave in one direction and convex in the other, with the opposing surface convex and concave, respectively; similar to a horseback rider being in complementary opposition to the shape of a saddle (Fig. 5.1B).  

2. Types of Motion 움직임의 타입

As a bony lever moves about an axis of motion, there is also movement of the bone surface on the opposing bone surface in the joint. 

# The movement of the bony lever is called swing and is classically described as flexion, extension, abduction, adduction, and rotation. The amount of movement can be measured in degrees with a goniometer and is called ROM.

# Motion of the bone surfaces in the joint is a variable combination of rolling and sliding, or spinning.14,23,29

These accessory motions allow greater angulation of the bone as it swings. For the rolling, sliding, or spinning to occur, there must be adequate capsule laxity or joint play.

- 관절에서 뼈표면의 움직임은 Rolling, sliding, spinning의 조합임

- 이러한 rolling, sliding, spinning이 일어나는 적절한 관절 이완 또는 관절 움직임이 일어나야 함. 

1) Roll

Characteristics of one bone rolling on another (Fig. 5.2) are as follows. 

참고) Rolling and sliding

- rolling은 새로운 지점이 반대측 면의 새로운 지점을 만나는 것

- sliding은 하나의 지점이 반대측 면의 새로운 지점을 만나는 것

rolling

# The surfaces are incongruent.

# New points on one surface meet new points on the opposing surface.

# Rolling results in angular motion of the bone (swing).

# Rolling is always in the same direction as the swinging bone motion whether the surface is convex (Fig. 5.3A) or concave (Fig. 5.3B).

# Rolling, if it occurs alone, causes compression of the surfaces on the side to which the bone is swinging and separation on the other side. Passive stretching using bone angulation alone may cause stressful compressive forces to portions of the joint surface, potentially leading to joint damage.

# In normally functioning joints, pure rolling does not occur alone but in combination with joint sliding and spinning. 

- 실제 관절움직임 동안 순수한 rolling은 홀로 일어나지 않으며 sliding and spinning이 조합되어 일어남. 

2) Slide/Translation

Characteristics of one bone sliding (translating) across another include the following.

# For a pure slide, the surfaces must be congruent, either flat (Fig. 5.4A) or curved (Fig. 5.4B).

# The same point on one surface comes into contact with the new points on the opposing surface. 

# Pure sliding does not occur in joints because the surfaces are not completely congruent.

# The direction in which sliding occurs depends on whether the moving surface is concave or convex. Sliding is in the opposite direction of the angular movement of the bone if the moving joint surface is convex (Fig. 5.5A). Sliding is in the same direction

as the angular movement of the bone if the moving surface is concave (Fig. 5.5B).

- 순수한 sliding은 일어나지 않음

- 관절가동시 특히 angular movement가 일어날때, sliding의 방향은 관절의 볼록, 오목면에 따라 다름. 

3) Combined Roll-Sliding in a Joint

# The more congruent the joint surfaces are, the more sliding there is of one bony partner on the other with movement.

# The more incongruent the joint surfaces are, the more rolling there is of one bony partner on the other with movement.

# When muscles actively contract to move a bone, some of the muscles may cause or control the sliding movement of the joint surfaces. For example, the caudal sliding motion of the humeral head during shoulder abduction is caused by the rotator cuff muscles, and the posterior sliding of the tibia during knee flexion is caused by the hamstring muscles. If this function is lost, the resulting abnormal joint mechanics may cause microtrauma and joint dysfunction.

# The joint mobilization techniques described in this chapter use the sliding component of joint motion to restore joint play and reverse joint hypomobility. Rolling (passive angular stretching) is not used to stretch tight joint capsules because it causes joint compression.

- 관절면이 좀더 잘 일치하면 sliding이 잘 일어남

- 관절면이 잘 일치하지 않으면, rolling이 좀더 잘 일어남. 

- 근육이 능동적으로 수축하면서 뼈를 움직일때, 어떤 근육은 관절의 sliding을 잘 일으킴. 예를들어 어깨 외전시 상완골두의 caudal sliding 움직임은 회전근개 근육에 의해서 야기됨. 무릎 굴곡시 경골의 post sliding은 햄스트링 근육에 의해서 일어남. 

- sliding 테크닉은 오십견과 같은 단단한 관절낭의 저운동성을 잘 회복하게 함. 

- 오십견과 같은 단단한 관절낭의 경우에 rolling(passive angular stretching)기법은 사용하지 않아야 함. 왜냐하면 관절의 부딪힘을 야기하기 때문

N O T E : When the therapist passively moves the articulating surface using the slide component of joint motion, the technique is called translatoric glide, translation, or simply glide.14 It is used to control pain when applied gently or to stretch the capsule when applied with a stretch force.

4) Spin 회전

Characteristics of one bone spinning on another include the following.

# There is rotation of a segment about a stationary mechanical axis (Fig. 5.6).

# The same point on the moving surface creates an arc of a circle as the bone spins.

# Spinning rarely occurs alone in joints but in combination with rolling and sliding.

# Three examples of spin occurring in joints of the body are the shoulder with flexion/extension, the hip with

flexion/extension, and the radiohumeral joint with pronation/supination (Fig. 5.7).

- 회전은 정지된 역학적 축에서 일어남

- spin은 위아래 같은면에서 회전적 힘이 만나는 것임. 

- 스핀은 홀로 일어나지 않고 rolling과 sliding의 조합으로 일어남. 

- 인체에서 세가지 형태의 스핀이 일어남. 어깨, 고관절, 팔꿈치..

Passive-Angular Stretching Versus Joint-Glide Stretching

Passive-angular stretching procedures,27 as when the bony lever is used to stretch a tight joint capsule, may cause increased pain or joint trauma because:

- 수동적인 각 스트레칭 테크닉은 뼈지레를 이용할때 타이트한 관절낭에 통증, 손상을 일으킬 수 있음. 

- 레버의 사용은 관절에 가해지는 힘을 과도하게 증폭하기 때문

- 과도한 힘은 관절압박부하를 초래하여 문제를 일으킴

- slide없이 일어나는 roll은 정상관절 역학을 반복할 수 없기 때문.

# The use of a lever significantly magnifies the force at the joint.

# The force causes excessive joint compression in the direction of the rolling bone (see Fig. 5.3).

# The roll without a slide does not replicate normal joint mechanics.

Joint glide (mobilization) stretching procedures, as when the translatoric slide component of the bones is used to stretch a tight capsule, are safer and more selective because:

- 관절 활주가동 스트레칭은 좀더 안전함. 

- slide관절가동은 관절연골의 압박을 일으키기 않을 수 있음. 

# The force is applied close to the joint surface and controlled at an intensity compatible with the pathology.

# The direction of the force replicates the sliding component of the joint mechanics and does not compress the cartilage.

# The amplitude of the motion is small yet specific to the restricted or adherent portion of the capsule or ligaments. Thus, the forces are selectively applied to the desired tissue. 

Other Accessory Motions that Affect the Joint

1. Compression 압박

Compression is the decrease in the joint space between bony partners.

- 압박은 관절면을 감소시키는 것임. 

# Compression normally occurs in the extremity and spinal joints when weight bearing.

# Some compression occurs as muscles contract, which provides stability to the joints.

# As one bone rolls on the other (see Fig. 5.3), some compression also occurs on the side to which the bone is angulating.

# Normal intermittent compressive loads help move synovial fluid and thus help maintain cartilage health.

# Abnormally high compression loads may lead to articular cartilage changes and deterioration.23

- 비정상적인 높은 압박부하는 관절연골을 손상시킬 수 있음. 

2. Traction/Distraction

Traction and distraction are not synonymous. Traction is a longitudinal pull. Distraction is a separation, or pulling apart.

- traction과 distraction은 동의어가 아님

- traction은 종축으로 당기는 힘이고, distraction은 분리 또는 당김으로 관절을 떨어뜨리는 힘.

# Separation of the joint surfaces (distraction) does not always occur when a traction force is applied to the long axis of a bone. For example, if traction is applied to the shaft of the humerus, it results in a glide of the joint surface (Fig. 5.8A). Distraction of the glenohumeral joint requires a pull at right angles to the glenoid fossa (Fig. 5.8B).

# For clarity, whenever there is pulling on the long axis of a bone, the term long-axis traction is used. Whenever the surfaces are to be pulled apart, the term distraction, joint traction, or joint separation is used.

- 어깨 관절에서 traction은 관절면에서 gliding을 일으킴.  disctraction은 올바른 각도로 당기는 것이 필요함. 

N O T E : For joint mobilization techniques, distraction is used to control or relieve pain when applied gently or to stretch the capsule when applied with a stretch force. A slight distraction force is used when applying gliding techniques.

Effects of Joint Motion

Joint motion stimulates biological activity by moving synovial fluid, which brings nutrients to the avascular articular cartilage of the joint surfaces and intra-articular fibrocartilage of the menisci.23 Atrophy of the articular cartilage begins soon after immobilization is imposed on joints.1,7,8

- 관절움직임은 활액의 움직임을 통해 생물학적 활성을 자극하여, 무혈관성 관절연골과 반달연골에 영양을 공급함.

- 관절연골의 위축은 관절에 immobilization이 발생한 후 즉시 나타나기 시작함. 

Extensibility and tensile strength of the articular and periarticular tissues are maintained with joint motion. With

immobilization there is fibrofatty proliferation, which causes intra-articular adhesions as well as biochemical changes in tendon, ligament, and joint capsule tissue, which in turn causes joint contractures and ligamentous weakening.1

- 관절과 관절주위 조직의 신장과 장력은 관절움직임과 함께 유지됨. 

- immobilization과 함께 fibrofatty 증식이 발생하는데, 이는 관절내의 유착뿐 아니라 힘줄, 인대, 관절낭조직의 생화학적 변화를 초래하여 관절 구축과 인대약화를 초래함. 

Afferent nerve impulses from joint receptors transmit information to the central nervous system and therefore provide awareness of position and motion. With injury or joint degeneration, there is a potential decrease in an important source of proprioceptive feedback that may affect an individual’s balance response.30 

- 관절 수용기로부터 전달되는 구심성 신경은 중추신경으로 정보를 전달하고 관절움직임과 위치 알아차림을 제공함. 

- 관절 손상 또는 퇴행성 변화와 함께, 중요한 고유수용감각기능이 감소되어 개인의 평형반응에 영향을 미침. 

Joint motion provides sensory input relative to32,33:

# Static position and sense of speed of movement (type I receptors found in the superficial joint capsule) 

- 정적인 위치, 움직임 속도 감각은 관절낭 표층에 존재하는 type 1 수용기가 담당.

# Change of speed of movement (type II receptors found in deep layers of the joint capsule and articular fat pads)

- 움직임 속도변화는 관절낭 심층과 관절지방패드에 존재하는 type 2 수용기가 담당

# Sense of direction of movement (type I and III receptors; type III found in joint ligaments)

- 움직임 방향 감각은 type 1 and 3수용기가 담당함. type 3 수용기는 인대에 풍부하게 존재함. 

# Regulation of muscle tone (type I, II, and III receptors)

- 근육의 긴장성 조절은 type 1, 2, 3 수용기가 담당

# Nociceptive stimuli (type IV receptors found in the fibrous capsule, ligaments, articular fat pads, periosteum, and walls of blood vessels)

- 통증자극은 관절낭, 인대, 관절 지방패드, 골막, 혈관벽에 풍부하게 존재하는 type4수용기가 담당함. 

INDICATIONS FOR JOINT MOBILIZATION - 관절가동의 적응증

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.17

- 통증성 관절, 반사성 근수축에 의한 근육통은 부드러운 관절가동테크닉으로 신경생리학과 기계적 효과를 자극하여 치료할 수 있음. 

1) Neurophysiological Effects

Small-amplitude oscillatory and distraction movements are used to stimulate the mechanoreceptors that may inhibit the transmission of nociceptive stimuli at the spinal cord or brain stem levels.25,29

- 작은 진폭의 진동과 distraction움직임은 기계적 수용기를 자극하여 통증전달을 억제할수 있음. 

2) Mechanical Effects

Small-amplitude distraction or gliding movements of the joint are used to cause synovial fluid motion, which is the vehicle for bringing nutrients to the avascular portions of the articular cartilage (and intra-articular fibrocartilage when present). Gentle joint-play techniques help maintain nutrient exchange and thus prevent the painful and degenerating effects of stasis when a joint is swollen or painful and cannot move through the ROM.

- 작은 진폭 distraction 또는 활주움직임은 활액움직임을 야기하고, 이는 무혈관성 관절연골에 영양을 공급하는 차량역할을 함. 

- 관절 부종 또는 통증으로 rom이 제대로 되지 않을때, 부드러운 관절가동 테크닉은 영양교환을 유지하게 하여 통증과 퇴행성 변화를 막아줌. 

N O T E : The small-amplitude joint techniques used to treat pain, muscle guarding, or muscle spasm should not place stretch on the reactive tissues (see sections on Contraindications and Precautions).

2. Reversible Joint Hypomobility

Reversible joint hypomobility can be treated with 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.14,17

- 가역적인 관절 저운동성은 점차적으로 증가하는 관절가동 테크닉으로 관절낭과 인대를 늘려 치료할 수 있음. 

- 지속적인 또는 진동성 스트레칭 힘은 짧아진 조직을 기계적으로 늘리는데 사용됨. 

3. Positional Faults/Subluxations

Malposition of one bony partner with respect to its opposing surface may result in limited motion or pain. This can occur with a traumatic injury, after periods of immobility, or with muscle imbalances. The malpositioning 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.21 Manipulations are used to reposition an obvious subluxation, such as a pulled elbow or capitate-lunate subluxation.

- 아탈구, 관절의 비정상 위치는 제한된 움직임과 통증을 야기함. 

- 이는 외상성 손상, immobility, 근육불균형으로 일어날 수 있음. 

- 움직임을 동반한 관절가동은 rom동안 환자가 능동적으로 움직여 뼈의 재정렬을 만들어냄. 

- 관절가동테크닉은 분명한 아탈구를 제자리로 돌려 놓은 것임. 

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.

- 움직임 제한을 초래하는 질환은 관절가동 테크닉으로 치료하여 가능한 움직임 또는 기계적 제한을 되돌림. 

- distraction or glide의 크기는 환자의 반응과 질병상태에 의해서 결정됨. 

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.

- 관절을 일정기간 동안 기능적으로 움직이지 못할때, 관절은 non stretch 활주 또는 distraction 테크닉으로 치료하여 제한된 움직임을 회복하고 퇴행성변화를 막을 수 있음. 

LIMITATIONS OF JOINT MOBILIZATION TECHNIQUES

Mobilization techniques cannot change the disease process of disorders such as rheumatoid arthritis or the inflammatory

process of injury. In these cases, treatment is directed toward minimizing pain, maintaining available joint play, and reducing the effects of any mechanical limitations (see Chapter 11).

- 관절가동 테크닉은 류마티스 관절염이나 조직손상 상태일때 질병과정을 변화시킬 수 없음. 

- 통증을 줄이고, 관절움직임을 유지하고, 역학적 움직임 제한을 줄일 수 있는 것임. 

The skill of the therapist affects the outcome. The techniques described in this text are relatively safe if directions are followed and precautions are heeded; but if these techniques are used indiscriminately on patients not properly examined and screened for such maneuvers or if they are applied too vigorously for the condition, joint trauma or hypermobility may result.

- 치료사의 기술은 결과에 영향을 미침. 테크닉은 ....

CONTRAINDICATIONS AND PRECAUTIONS

The only true contraindications to stretching techniques are hypermobility, joint effusion, and inflammation.

- 관절가동의 부적응증 3가지 : 과운동성, 관절부종, 염증

1. Hypermobility

# The joints of patients with potential necrosis of the ligaments or capsule should not be stretched. 

# Patients with painful hypermobile joints may benefit from gentle joint-play techniques if kept within the limits of motion. Stretching is not done.

- 통증이 있는 과움직임 관절은 gentle joint play가 도움이 될 수 있음. 

- 인대나 관절의 괴사가능성이 있는 경우 관절가동은 시행해서는 안됨. 

2. Joint Effusion

There may be joint swelling (effusion) due to trauma or disease. Rapid swelling of a joint usually indicates bleeding in the joint and may occur with trauma or diseases such as hemophilia. Medical intervention is required for aspiration of the blood to minimize its necrotizing effect on the articular cartilage. Slow swelling (more than 4 hours) usually indicates serous effusion (a buildup of excess synovial fluid) or edema in the joint due to mild trauma, irritation, or a disease such as arthritis. 

- 빠르게 증가하는 관절부종은 특히 관절가동의 부적응증임. 

# Do not stretch a swollen joint with mobilization or passive stretching techniques. The capsule is already on a stretch by being distended to accommodate the extra fluid. The limited motion is from the extra fluid and muscle response to pain, 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 may also help improve fluid flow while maintaining available joint play.

# If the patient’s response to gentle techniques results in increased pain or joint irritability, the techniques were applied too vigorously or should not have been done with the current state of pathology.

- 관절내에 빠른 부종은 혈종때문임

- 관절내 느린 부종은 활액이 과도해진 것임. 

- 관절 삼출물이 있는 경우 관절가동, 수동적 스트레칭 테크닉을 시행해서는 안됨. 

- 부드러운 진동 움직임은 통증을 줄이고, 활액흐름을 도와 치유를 촉진할 수 있음. 

- 만약 환자에게 부드러운 진동테크닉을 시행하여 통증이 증가하거나 염증이 증가하면 이 테크닉은 분명하게 잘못된 것임. 

3. Inflammation

Whenever inflammation is present, stretching increases pain and muscle guarding and results in greater tissue damage. Gentle oscillating or distraction motions may temporarily inhibit the pain response. See Chapter 10 for an

appropriate approach to treatment when inflammation is present.

- 염증이 있을때, 스트레칭은 통증과 반사성근육보호 반응을 악화시키고, 조직손상을 악화시킬 수 있음. 

- 부드러운 진동 또는 distraction 움직임은 통증반응을 줄여줌. 

Conditions Requiring Special Precautions for Stretching

In most cases, joint mobilization techniques are safer than passive angular stretching, in which the bony lever is used to stretch tight tissue and joint compression results. Mobilization may be used with extreme care in the following conditions if the signs and the patient’s response are favorable.

스트레칭을 위한 주의사항

- 대부분 경우, 관절가동 테크닉은 수동적 각도 스트레칭보다는 안전함. 

# Malignancy 악성종양

# Bone disease detectable on radiographs 뼈 골절

# Unhealed fracture (depends on the site of the fracture and stabilization provided) 치유되지 않은 골절

# Excessive pain (determine the cause of pain and modify treatment accordingly) 과도한 통증

# Hypermobility in associated joints (associated joints must be properly stabilized so the mobilization force is not transmitted to them) 관절의 과운동성

# Total joint replacements (the mechanism of the replacement is self-limiting, and therefore the mobilization gliding techniques may be inappropriate) 

# 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)

# 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 rupture tissue and result in instabilities) 

# Elderly individuals with weakened connective tissue and diminished circulation (gentle techniques within the tolerance of the tissue may be beneficial to increase mobility)

PROCEDURES FOR APPLYING PASSIVE JOINT MOBILIZATION TECHNIQUES

1. Examination and Eval‎uation

If the patient has limited or painful motion, examine and decide which tissues are limiting function and the state of pathology. Determine whether treatment should be directed primarily toward relieving pain or stretching a joint or soft tissue limitation.5,17

- 환자가 통증으로 움직임 제한이 있다면, 병리가 발생한 제한된 기능을 가진 조직이 정확히 결정되어야 함. 

- 어떤 치료를 시행할 것인지 결정은 ....

2. Quality of pain

The quality of pain when testing the ROM helps determine the stage of recovery and the dosage of techniques used for treatment (see Fig. 10.2). 

- rom검사를 시행할때, 통증의 상태는 치료를 위한 테크닉의 크기와 양을 결정할 수 있음. 

# If pain is experienced before tissue limitation—such as the pain that occurs with muscle guarding after an acute injury or during the active stage of a disease—gentle pain-inhibiting joint techniques may be used. The same techniques can also help maintain joint play (see next section on Grades or Dosages of Movement). Stretching under these circumstances is contraindicated.

- 만약 통증이 급성 손상으로 인한 염증기에 발생하는 반사성 근수축때문에 발생한다면, 부드러운 통증억제 테크닉이 시행될 수 있음. 

- 이러한 테크닉은 관절 움직임을 유지하는데 도움이 됨. 

# If pain is experienced concurrently with tissue limitation—such as the pain and limitation that occur when damaged tissue begins to heal—the limitation is treated cautiously. Gentle stretching techniques specific to the tight structure are used to improve movement gradually yet not exacerbate the pain by reinjuring the tissue.

- 만약 통증이 조직손상후 증식기때문에 발생하는 것이라면, 부드러운 스트레칭 테크닉이 시행되어 점차적으로 움직임을 회복하고 조직재손상을 막을 수 있음. 

# If pain is experienced after tissue limitation is met because of stretching of tight capsular or periarticular tissue, the stiff joint can be aggressively stretched with joint-play techniques and the periarticular tissue with the stretching techniques described in Chapter 4.

- 만약 통증이 조직제한 이후에 단단한 관절낭, 관절주위조직의 강직성 관절이라면 좀더 적극적인 관절가동을 포함한 스트레칭 테크닉이 필요함. 

3. Capsular Restriction

The joint capsule is limiting motion and should respond to mobilization techniques if the following signs are present.

- 관절낭은 움직임을 제한하는데, 관절가동테크닉은 아래의 신호반응을 살펴야 함. 

# The passive ROM for that joint is limited in a capsular pattern (these patterns are described for each peripheral joint under the respective sections on joint problems in Chapters 17 through 22).

# There is a firm capsular end-feel when overpressure is applied to the tissues limiting the range.

# There is decreased joint-play movement when mobility tests (articulations) are performed.

# An adhered or contracted ligament is limiting motion if there is decreased joint play and pain when the fibers of the ligament are stressed; ligaments often respond to joint mobilization techniques if applied specific to their line of stress.

- 관절의 수동적 rom은 관절낭 패턴에서 제한됨. 

- 과도한 압력이 제한된 범위에서 적용될때 단단한 관절낭 끝 느낌이 있음.

- 움직임 검사를 시행할때, 감소된 관절움직임이 있음.

- 감소된 관절움직임과 통증이 있다면 인대섬유에 부하가 주어질때, 인대의 유착, 구축은 움직임을 제한함. 인대는 관절가동 테크닉에 때때로 잘 반응함. 

4. Subluxation or Dislocation

Subluxation or dislocation of one bony part on another and loose intra-articular structures that block normal motion may respond to thrust techniques. Some of the simpler manipulations are described in appropriate sections in this text. Others require more advanced training and are beyond the scope of this book.

- 쓰러스트 테크닉은 아탈구, 탈구로 정상움직임 제한이 발생했을때 적응증이 될 수 있음. 

Grades or Dosages of Movement

Two systems of grading dosages for mobilization are used.14,17

1. Graded Oscillation Techniques (Fig. 5.9)

Dosages

Grade I: Small-amplitude rhythmic oscillations are performed at the beginning of the range.

- 작은 진폭의 리드믹한 진동테크닉이 움직임 시작범위에서 시행

Grade II: Large-amplitude rhythmic oscillations are performed within the range, not reaching the limit.

- 큰 진폭의 리드믹한 진동테크닉이 생리적 제한범위이내의 범위에서 시행.

Grade III: Large-amplitude rhythmic oscillations are performed up to the limit of the available motion and are stressed into the tissue resistance.

- 큰 진폭의 리드믹한 진동테크닉이 생리적 제한범위를 넘어서 조직에 저항스트레스가 가해진 범위에서 시행

Grade IV: Small-amplitude rhythmic oscillations are performed at the limit of the available motion and stressed into the tissue resistance.

- 작은 진폭의 리드믹한 진동테크닉이 조직저항이 가해지는 스트레스범위끝에서 시행

Grade V: A small-amplitude, high-velocity thrust technique is performed to snap adhesions at the limit of the available motion. Thrust techniques used for this purpose require advanced training and are beyond the scope of this book. 

- 일명 쓰러스트 테크닉

- 작은 진폭, 높은 속도의 쓰러스트 테크닉은 유착이 진행된 범위에서 스냅을 이용하여 시행

Uses

# Grades I and II are primarily used for treating joints limited by pain. The oscillations may have an inhibitory effect on the perception of painful stimuli by repetitively stimulating mechanoreceptors that block nociceptive pathways at the spinal cord or brain stem levels.25,34 These nonstretch motions help move synovial fluid to improve nutrition to the cartilage.

- 단계 1,2 진동테크닉은 통증에 의해서 제한된 관절을 치료함. 

- 진동테크닉은 통증성 자극이 척수를 따라 뇌간으로 전달되는 것을 차단함. 

- 스트레칭되지 않는 움직임은 활액움직임을 돕고, 연골에 영양개선을 줌. 

# Grades III and IV are primarily used as stretching maneuvers.

- 단계 3, 4 진동테크닉은 스트레칭된 상태에서 시행됨. 

Techniques

The oscillations may be performed using physiological (osteokinematic) motions or joint-play (arthrokinematic)

techniques.

- 진동테크닉은 생리적 움직임이나 관절가동에서 모두 시행가능함. 

2. Sustained Translatory Joint-Play Techniques (Fig. 5.10)

지속적 이동 관절-플레이 테크닉

- 지속적인 활주 관절가동 테크닉

Dosages

Grade I (loosen): Small-amplitude distraction is applied where no stress is placed on the capsule. It equalizes cohesive forces, muscle tension, and atmospheric pressure acting on the joint.

- 단계 1 : 작은 진폭의 distraction은 관절낭에 스트레스없이 적용함. 

- 점탄성의 힘, 근육장력, 관절에 가해지는 압력을 동일하게 적용함. 

Grade II (tighten): Enough distraction or glide is applied to tighten the tissues around the joint. Kaltenborn14 called this “taking up the slack.”

- 단계 2 : 충분한 distraction 또는 활주는 관절주위의 단단해지 조직에 적용함. 칼텐본은 taking up the slack이라고 표현함.

Grade III (stretch): A distraction or glide is applied with an amplitude large enough to place stretch on the joint capsule and surrounding periarticular structures. 

- 단계 3 : distraction 또는 활주가 큰 진폭으로 적용되어 관절낭과 관절주위조직의 늘어남이 적용되는 것임. 

Uses

Grade I distraction is used with all gliding motions and may be used for relief of pain.

- 단계 1 distraction은 통증을 줄이기 위해 활주움직임을 이용함.

Grade II distraction is used for the initial treatment to determine how sensitive the joint is. Once the joint reaction is known, the treatment dosage is increased or decreased accordingly. Gentle grade II distraction applied intermittently may be used to inhibit pain. Grade II glides may be used to maintain joint play when ROM is not allowed.

- 단계 2 distraction은 과민한 관절의 치료에 적용함. 한번 관절의 반을을 알면, 치료 dosage는 줄이거나 늘일 수 있음. 

- 부드러운 단계 2 distraction은 간헐적으로 적용하면 통증을 줄일 수 있음. 이 단계는 관절 rom이 제한이 있을때 관절 움직임을 유지할 수 있음. 

Grade III distractions or glides are used to stretch the joint structures and thus increase joint play.

- 단계 3 distraction 또는 활주는 관절구조를 스트레치하여 관절가동을 증진시킴. 

Techniques

This grading system describes only joint-play techniques that separate (distract) or glide/translate (slide) the joint surfaces.

- 이 단계적 시스템은 오직 joint play 테크닉에서 기술함. distraction, glide, slide

Comparison

When using either grading system, dosages I and II are low intensity and so do not cause a stretch force on the joint

capsule or surrounding tissue, although, by definition, sustained grade II techniques take up the slack of the tissues

whereas grade II oscillation techniques stay within the slack. Grades III and IV oscillations and grade III sustained stretch techniques are similar in intensity in that they all are applied with a stretch force at the limit of motion. The differences are related to the rhythm or speed of repetition of the stretch force.

# For clarity and consistency, when referring to dosages in this text, the notation graded oscillations means to use the dosages as described in the section on graded oscillation techniques. The notation sustained grade means to use the dosages as described in the section on sustained translatory joint-play techniques.

# The choice of using oscillating or sustained techniques depends on the patient’s response.

• When dealing with managing pain, either grade I or II oscillation techniques or slow intermittent grade I or II sustained joint distraction techniques are recommended; the patient’s response dictates the intensity and frequency of the joint-play technique.

• When dealing with loss of joint play and thus decreased functional range, sustained techniques applied in a cyclic manner are recommended; the longer the stretch force can be maintained, the greater the creep and plastic deformation of the connective tissue.

• When attempting to maintain available range by using joint-play techniques, either grade II oscillating or sustained grade II techniques can be used.

Positioning and Stabilization

# The patient and the extremity to be treated should be positioned so the patient can relax. To relax the muscles crossing the joint, techniques of inhibition (see Chapter 4) may be appropriately used prior to or between joint mobilization techniques. 

- 환자와 치료할 사지말단은 제대로 자리를 잡아야 환자는 이완할 수 있음.

- 치료하고자 하는 관절을 가로지르는 근육은 관절가동테크닉 전 또는 중간에 이완테크닉을 적용해야 함. 

# Examination of joint play and the first treatment are initially performed in the resting position for that joint so the greatest capsule laxity is possible. In some cases, the position to use is the one in which the joint is least painful. With progression of treatment, the joint is positioned at or near the end of the available range prior to application of the mobilization force. This places the restricting tissue in its most lengthened position where the stretch force can be more specific and effective.12

- 관절가동을 잘하기 위해서는 관절낭이 충분히 이완되는 resting position을 잘 찾아야 함. 

# Firmly and comfortably stabilize one joint partner, usually the proximal bone. A belt, one of the therapist’s hands, or an assistant holding the part may provide stabilization. Appropriate stabilization prevents unwanted stress to surrounding tissues and joints and makes the stretch force more specific and effective.

- 치료하고자 하는 관절을 잘 고정하기 위해 벨트를 이용할 수 있음. 

- 적절한 안정성은 관절, 조직에 스트레스를 줄이고, 최적의 효과를 낼 수 있는 힘을 제공함. 

Treatment Force and Direction of Movement

# The treatment force (either gentle or strong) is applied as close to the opposing joint surface as possible. The larger the contact surface, the more comfortable is the patient with the procedure. For example, instead of forcing with your thumb, use the flat surface of your hand. 

- 관절가동에 적용하는 힘은 부드럽거나 강함.....

# The direction of movement during treatment is either parallel or perpendicular to the treatment plane. Treatment plane was described by Kaltenborn14 as a plane perpendicular to a line running from the axis of rotation to the middle of the concave articular surface. The plane is in the concave partner, so its position is determined by the position of the concave bone (Fig. 5.11). 

- 관절가동의 방향은 관절면에 따라서 달라짐. 아래 그림 참조

# Distraction techniques are applied perpendicular to the treatment plane. The entire bone is moved so the joint surfaces are separated.

- distraction 테크닉은 치료면에 수직의 힘이 가해짐. 뼈 전체가 움직여 관절면이 분리됨

# Gliding techniques are applied parallel to the treatment plane. The direction of gliding is easily determined by using the convex-concave rule (described earlier in the chapter). If the surface of the moving bony partner is convex, the treatment glide should be opposite to the direction in which the bone swings. If the surface of the moving bony partner is concave, the treatment glide should be in the same direction (see Fig. 5.5).

- 활주 테크닉은 치료면에 수평으로 힘이 가해짐. 활주의 방향은 볼록-오목 규칙에 의해서 쉽게 결정됨.

- 만약 움직이려는 상대뼈의 면이 볼록하다면 활주방향은 반대 방향이어야 함. 

- 만약 움직이려는 상대뼈의 면이 오목하다면 활주방향은 같은 방향이어야 함. 

# The entire bone is moved so there is gliding of one joint surface on the other. The bone should not be used as a lever; it should have no arcing motion (swing), which would cause rolling and thus compression of the joint surfaces.

Initiation and Progression of Treatment (Fig. 5.12)

1. The initial treatment is the same whether treating to decrease pain or increase joint play. The purpose is to determine joint reactivity before proceeding.Use a sustained grade II distraction of the joint surfaces with the joint held in resting position or the position of greatest relaxation.14 Note the immediate joint response relative to irritability and range.

- 진동 테크닉의 첫단계는 grade 2임. 시행후 통증이 증가하거나 염증이 발생하면... 비슷하거나 통증 호전이 일어난다면 다음단계로 진행

2. The next day, eval‎uate joint response or have the patient report the response at the next visit.

• If there is increased pain and sensitivity, reduce the amplitude of treatment to grade I oscillations.

• If the joint is the same or better, perform either of the following: Repeat the same maneuver if the goal of treatment is to maintain joint play, or progress the maneuver to stretching techniques if the goal of treatment is to increase joint play.

3. To maintain joint play by using gliding techniques when ROM techniques are contraindicated or not possible for a period of time, use sustained grade II or grade II oscillation techniques.

4. To progress the stretch technique, move the bone to the end of the available ROM, then apply a sustained grade III distraction or glide technique. Progressions include prepositioning the bone at the end of the available range and rotating it prior to applying grade III distraction or glide techniques. The direction of the glide and rotation is dictated by the joint mechanics. For example, laterally rotate the humerus as shoulder abduction is progressed; medially rotate the tibia as knee flexion is progressed.

5. Hints

• Warm the tissue around the joint prior to stretching. Modalities, massage, or gentle muscle contractions increase the circulation and warm the tissues.

• Muscle relaxation techniques and oscillation techniques may inhibit muscle guarding and should be alternated with the stretching techniques, if necessary.

• When using grade III gliding techniques, a grade I distraction should be used with it. A grade II or III distraction should not be used with a grade III glide to avoid excessive trauma to the joint.

• If gliding in the restricted direction is too painful, begin gliding mobilizations in the painless direction. Progress to gliding in the restricted direction when mobility improves a little and it is not painful.

• When applying stretching techniques, move the bony partner through the available range of joint play first, that is, “take up the slack.” When tissue resistance is felt, apply the stretch force against the restriction.

• Incorporate MWM techniques (described later in the chapter) as part of the total approach to treatment. 

Speed, Rhythm, and Duration of Movements

1. Oscillations

# Grades I and IV are usually rapid oscillations, like manual vibrations. 

# Grades II and III are smooth, regular oscillations at 2 or 3 per second for 1 to 2 minutes.

# 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.

- 진동테크닉 1단계와 4단계는 빠른 진동을 이용함

- 진동테크닉 2단계와 3단계는 1-2분동안 초당 2-3회 부드럽게 진동

- 진동 속도의 변화는 목표하는 효과가 달라짐. 예를들어 통증을 줄이기 위해서는 작은 진폭으로 빠른 스피드로 적용함. 반사성 근수축을 줄이려면 늦은 스피드로 시행해야 함. 

Sustained

# For painful joints, apply 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.

- 통증성 관절을 위해 간헐적 distraction을 7-10초 적용하고, 몇초간의 휴식을 적용함. 

# For restricted joints, apply a minimum of a 6-second stretch force followed by partial release (to grade I or II), then repeat with slow, intermittent stretches at 3- to 4- second intervals.

- 제한된 관절을 위해 최소한 6초 스트레치 힘을 단계 1-2힘으로 시행함. 그리고 나서 천천히, 간헐적 스트레치를 3-4초간격으로 시행함. 

Patient Response

# Stretching maneuvers usually cause soreness. Perform the maneuvers on alternate days to allow the soreness to decrease and tissue healing to occur between stretching sessions. The patient should perform ROM into any newly gained range during this time. If there is increased pain after 24 hours, the dosage (amplitude) or duration of treatment was too vigorous. Decrease the dosage or duration until the pain is under control. 

- 스트레칭법은 일반적으로 soreness를 야기함. 

- 만약 통증이 24시간 지속된다면 강도와 시간은 너무 과한 것임. 

The patient’s joint and ROM should be reassessed after treatment and again before the next treatment. Alterations in treatment are dictated by the joint response.

- 치료가 적용된 후 환자의 rom은 다시 재평가하고 다음단계를 시행함. 

Total Program

Mobilization techniques are one part of a total treatment program when there is decreased function. If muscles or connective tissues are also limiting motion, inhibition and passive stretching techniques are alternated with joint mobilization during the same treatment session. Therapy should also include appropriate ROM, strengthening, and functional exercises so the client learns effective control and use of the gained mobility (Box 5.1).

- 관절가동테크닉은 환자의 기능부전이 있을때, 전체적인 프로그램의 한가지가 되어야 함.

- 만약 근육이나 결합조직이 움직임을 제한한다면, 수동적 스트레칭 테크닉은 관절가동과 교대로 진행됨. 

- 치료는 적절한 rom, 근력강화, 기능적 운동 등을 포함해야 환자는 적절한 움직임을 회복함. 

기능회복을 위한 일련의 과정

1. 조직을 warm

2. 근육 이완 - hold relax 테크닉, grade 1, 2 관절진동 테크닉

3. 관절가동 스트레치 - 조직내성 정도를 고려한 테크닉 적용

4. 관절주위조직 수동적 스트레치

5. 환자는 능동적으로 새로운 범위에서 움직임 - RI, 능동적 ROM, 기능적 활동

6. 새로운 범위의 움직임 - 자가 스트레칭, 자가 가동법, 능동적 저항을 이용한 ROM, 새로운 범위에서 기능적 활동

MOBILIZATION WITH MOVEMENT: PRINCIPLES OF APPLICATION

Brian Mulligan’s concept of mobilization with movement (MWM) is the natural continuance of progression in the development of manual therapy from active self-stretching exercises, to therapist-applied passive physiological movement, to passive accessory mobilization techniques.20 Mobilization with movement is the concurrent application of pain-free accessory mobilization with active and/or passive physiological movement.21 Passive end-range overpressure or stretching is then applied without pain as a barrier. These techniques are applicable when:

- 브라이언 멀리건의 움직임을 동반한 관절가동법은 능동적 자가스트레칭 운동-치료사가 적용하는 수동적 생리적 움직임, 수동적 부움직임 테크닉의 조합임. 

- 움직임을 동반한 관절가동법은 통증이 없는 부수적인 관절가동이 능동적, 수동적 움직임속에서 일어나는 것임. 

- 수동적 끝범위 과압력 또는 스트레칭은 장벽에서 통증없이 적용되어야 함. 

# No contraindication for manual therapy exists (described earlier in the chapter).

# A full orthopedic scanning examination has been completed, and eval‎uation of the results indicate local musculoskeletal

pathology.5

# A specific biomechanical analysis reveals localized loss of movement and/or pain associated with function.17

# No pain is produced during or immediately after application of the technique.19

Principles of MWM in Clinical Practice

# One or more comparable signs are identified during the examination.17 A comparable sign is a positive test sign that can be repeated after a therapeutic maneuver to determine the effectiveness of the maneuver. For example, a comparable sign may include loss of joint play movement, loss of ROM, or pain associated with movement during specific functional activities such as lateral elbow pain with resisted wrist extension, painful restriction of ankle dorsiflexion, or pain with overhead reaching.

# A passive joint mobilization is applied as described in the previous section following the principles of Kaltenborn.14 This accessory glide or distraction performed parallel or perpendicular to the treatment plane must be pain-free.21

# Utilizing knowledge of joint anatomy and mechanics, a sense of tissue tension, and sound clinical reasoning, the therapist investigates various combinations of parallel or perpendicular accessory glides to find the pain-free direction and grade of accessory movement. This may be a glide, spin, distraction, or combination of movements.

# While the therapist sustains the pain-free accessory mobilization, the patient is requested to perform the comparable sign. The comparable sign should now be significantly improved; that is, there should be increased ROM, and the motion should be free of the original pain.21

# The therapist must continuously monitor the patient’s reaction to ensure no pain is produced. Failure to improve the comparable sign would indicate that the therapist has not found the correct direction of accessory mobilization or the grade of movement or that the technique is not indicated.

# The previously restricted and/or painful motion or activity is repeated 6 to 10 times by the patient while the therapist continues to maintain the appropriate accessory mobilization. Further gains are expected with repetition during a treatment session, particularly when pain-free passive overpressure is applied to achieve end-range loading.

Pain as the Guide

Successful MWM techniques should render the comparable sign painless while significantly improving function during the application of the technique. Self-treatment is often possible using MWM principles with sports-type adhesive tape and/or the patient providing the mobilization component of the MWM concurrent with the active physiological movement.9 Having restored articular function with MWMs, the therapist progresses the client through the ensuing rehabilitation sequences of the recovery of muscular power, endurance, and neural control. Sustained improvements are necessary to justify ongoing intervention.

Techniques

Techniques applicable to the extremity joints are described throughout this text in the treatment sections for various conditions (see Chapters 17 through 22). 

Theoretical Framework

Mulligan postulated a positional fault model to explain the results gained through his concept. Alternately, inappropriate joint tracking mechanisms due to an altered instantaneous axis of rotation and neurophysiological response models have also been considered.9,19,20,22 For further details of the application of the Mulligan concept as it applies to the spine and extremities, refer to Manual Therapy, “NAGS,” “SNAGS,” “MWMs,” Etc.21

Focus on Evidence

Early research on the MWM approach confirm‎s its benefits; however, the mechanism by which it affects the musculoskeletal

system, whether mechanical or physiological, has yet to be fully determined.3,15,24,26,28,31 A study by Paungmail et al.26 measured a significant reduction in pain, increased grip strength, and increased sympathetic nervous system response immediately following MWM for chronic lateral epicondylalgia compared with a placebo intervention, results that were similar to studies of spinal manipulation. They interpreted this to imply that there is a multisystem response to manipulation whether the spine or

the elbow is manipulated.

[비누방울]

Graded Oscillation Techniques과 Sustained Translatory Joint-Play Techniques의 단계(grade)가 어떻게 구별되는지 또 어떻게 적용할 수 있는지 아직 이해가 잘 안됩니다, 교수님^^;

[문형철]

아... 이해가 안되는군요 ㅎㅎㅎㅎㅎㅎ

[김영환PT]

휴.. 어렵군요 여러번 읽어봐야 되겠습니다
좋은 자료 감사드립니다~~^^

[gait1004]

ㅎㅎㅎㅎㅎㅎ

[봉황]

정말 좋네요. 감사합니다.

[김종훈]

감사합니다. 꾸벅